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Nygaard U, Dungu KHS, von Linstow ML, Lundstrøm K, Zhang H, Vissing NH. Lactate as a Screening Tool for Critical Illness in a Pediatric Emergency Department. Pediatr Emerg Care 2023; 39:735-738. [PMID: 36190394 DOI: 10.1097/pec.0000000000002860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Lactate has in some pediatric emergency departments (PEDs) gained acceptance as a screening tool for critical illness, with cut-off values of 2.0 to 2.5 mmol/L. We aimed to investigate if lactate could predict the need of acute resuscitation in patients in a PED. PATIENTS AND METHODS This retrospective observational cohort study included patients aged 0 to 17 years admitted to the PED at Copenhagen University Hospital in Denmark from January 1, 2019 to January 1, 2021. Patients were included if they had lactate measured as part of their routine blood sampling because of acute PED evaluation. Area under the receiver operating characteristic (ROC) curve (AUC) was calculated to assess the ability of lactate to predict the need of acute resuscitation. In patients without need of acute resuscitation, we calculated the lactate upper limit as the 95th percentile, and significant predictors were included in a multiple linear regression model. RESULTS A total of 1355 children were included. Fourteen (1%) children with a need of acute resuscitation had a median lactate of 1.7 mmol/L (interquartile range, 1.4-2.3) versus 1.6 mmol/L (interquartile range, 1.3-2.1) in children without need of resuscitation ( P > 0.05). The AUC for lactate to predict acute resuscitation was 0.56 (95% confidence interval, 0.54-0.59). In children without need of acute resuscitation, the 95th percentile of lactate was 3.2 mmol/L, and 392 (29.8%) had lactate greater than 2.0 mmol/L. Increasing age and venous sampling were associated with lower lactate. Lactate was not associated with sex, pediatric early warning score, or duration of hospital admission. The 95th percentile of lactate after inhaled beta-2-agonists was 5.0 mmol/L. CONCLUSIONS In children evaluated in a PED, lactate achieved a low AUC, suggesting a poor ability of predicting acute resuscitation. In children without need of acute resuscitation, the 95th percentile for lactate was 3.2 mmol/L, higher than the generally accepted cut-off values. This is important to recognize to avoid concern in otherwise clinically stable children. Our data did not support the use of lactate as a screening tool for early recognition of critical illness in a PED.
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Affiliation(s)
| | - Kia Hee Schultz Dungu
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marie-Louise von Linstow
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kaare Lundstrøm
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - He Zhang
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nadja Hawwa Vissing
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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The diagnostic value of laboratory tests in detecting solid organ injuries in pediatric patients with blunt abdominal trauma: A prospective, observational study. Am J Emerg Med 2022; 57:133-137. [DOI: 10.1016/j.ajem.2022.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/23/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
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3
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How Important Are Arterial Blood Gas Parameters for Severe Head Trauma in Children? JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1016696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Guyther J, Cantwell L. Big Tests in Little People. Emerg Med Clin North Am 2021; 39:467-478. [PMID: 34215397 DOI: 10.1016/j.emc.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Can laboratory tests that are routinely used in adult patients also be used in pediatric patients? Does the current literature support the routine use of troponin, brain natriuretic peptide, D-dimer, and lactate in children? Adult problems such as acute coronary syndrome and pulmonary embolism are rare in pediatrics, and there is a paucity of literature on how blood tests commonly used to help diagnose these conditions in adults play a role in the diagnosis and management of children. This article presents the literature about 4 common blood tests and examines the clinical applications of each.
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Affiliation(s)
- Jennifer Guyther
- Department of Emergency Medicine, Department of Pediatrics, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Lauren Cantwell
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Palo Alto, CA 94304, USA
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Uyur Yalçin E, Erdogan F, Topal E, Seçim S, Sezer Yamanel RG. Relationship Between Lactate Levels and Length of Hospital Stay in Infants with Lower Respiratory Tract Infection. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2021; 34:68-72. [PMID: 34143684 DOI: 10.1089/ped.2021.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Increased lactate concentrations are directly related to the severity of shock and mortality rates. There are limited data regarding the prognostic value of lactate among lower respiratory tract infections. We aimed to investigate the impact of lactate levels on admission on the clinical outcomes of children with lower respiratory tract infections. Methods: We performed a retrospective study of hospitalized patients aged 1-12 months. We recorded data on patient demographics, clinical, laboratory, treatment, and outcomes. The primary outcome measure was the length of hospital stay, and the secondary outcome was transfer to the pediatric intensive care unit (PICU) and/or mortality rates. Results: A total of 304 infants were included in the study. There were 198 infants with lactate levels of >2 mmol/L. Lactic acidosis was present in 6 infants, with a mean hospital stay of 8 ± 3 days. Only 1 (0.3%) patient required intubation, and 5 (1.6%) were transferred to the PICU. The overall mortality rate was 0%. Lactate levels (≤2 and >2 mmol/L) were not related to the length of hospital stay, transfer to PICU/discharge, and the need for intubation (P = 0.16, 0.8, and 0.46, respectively). The length of hospital stay was not correlated with lactate levels on admission (r = 0.01, P = 0.84), pCO2 (r = 0.03, P = 0.52), pH (r = 0.07, P = 0.19), C-reactive protein (r = 0.06, P = 0.28), and oxygen saturation (r = -0.02, P = 0.72). Conclusions: Lactate levels on admission did not predict the length of hospital stay in children with lower respiratory infections and were not related to the need for transfer to the intensive care unit. We suggest using lactate levels in combination with clinical, laboratory, and physical examination findings as predictors of disease severity.
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Affiliation(s)
- Emek Uyur Yalçin
- Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Furkan Erdogan
- Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Esra Topal
- Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Selda Seçim
- Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Rabia Gönül Sezer Yamanel
- Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Diseases Training and Research Hospital, Istanbul, Turkey
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Ko Y, Kim JH, Hwang K, Lee J, Huh Y. Comparison of Base Deficit and Vital Signs as Criteria for Hemorrhagic Shock Classification in Children with Trauma. Yonsei Med J 2021; 62:352-358. [PMID: 33779089 PMCID: PMC8007427 DOI: 10.3349/ymj.2021.62.4.352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Base deficit (BD) is superior to vital signs in predicting trauma outcomes in adults. The authors aimed to compare BD and vital signs as criteria for the four-tiered hemorrhagic shock classification in children with trauma. MATERIALS AND METHODS We retrospectively reviewed the data of 1046 injured children who visited a Korean academic hospital from 2010 through 2018. These children were classified separately based on BD (class I, BD ≤2.0 mmol/L; II, 2.1-6.0 mmol/L; III, 6.1-10 mmol/L; and IV, ≥10.1 mmol/L) and vital signs (<13 years: age-adjusted hypotension and tachycardia, and Glasgow Coma Scale; 13-17 years: the 2012 Advanced Trauma Life Support classification). The two methods were compared on a class-by-class basis regarding the outcomes: mortality, early transfusion (overall and massive), and early surgical interventions for the torso or major vessels. RESULTS In total, 603 children were enrolled, of whom 6.6% died. With the worsening of BD and vital signs, the outcome rates increased stepwise (most p<0.001; only between surgical interventions and vital signs, p=0.035). Mortality more commonly occurred in BD-based class IV than in vital signs-based class IV (58.8% vs. 32.7%, p=0.008). Early transfusion was more commonly performed in BD-based class III than in vital signs-based class III (overall, 73.8% vs. 53.7%, p=0.007; massive, 37.5% vs. 15.8%, p=0.001). No significant differences were found in the rates of early surgical interventions between the two methods. CONCLUSION BD can be a better predictor of outcomes than vital signs in children with severe hemorrhagic shock.
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Affiliation(s)
- Yura Ko
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyungjin Hwang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jisook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea.
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Weber B, Lackner I, Braun CK, Kalbitz M, Huber-Lang M, Pressmar J. Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research. Front Pediatr 2021; 9:622753. [PMID: 33816396 PMCID: PMC8010656 DOI: 10.3389/fped.2021.622753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Severe trauma is the most common cause of mortality in children and is associated with a high socioeconomic burden. The most frequently injured organs in children are the head and thorax, followed by the extremities and by abdominal injuries. The efficient and early assessment and management of these injuries is essential to improve patients' outcome. Physical examination as well as imaging techniques like ultrasound, X-ray and computer tomography are crucial for a valid early diagnosis. Furthermore, laboratory analyses constitute additional helpful tools for the detection and monitoring of pediatric injuries. Specific inflammatory markers correlate with post-traumatic complications, including the development of multiple organ failure. Other laboratory parameters, including lactate concentration, coagulation parameters and markers of organ injury, represent further clinical tools to identify trauma-induced disorders. In this review, we outline and evaluate specific biomarkers for inflammation, acid-base balance, blood coagulation and organ damage following pediatric polytrauma. The early use of relevant laboratory markers may assist decision making on imaging tools, thus contributing to minimize radiation-induced long-term consequences, while improving the outcome of children with multiple trauma.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany.,Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Jochen Pressmar
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
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Raineau M, DuracherGout C. Afflux massif de victimes pédiatriques. ANESTHÉSIE & RÉANIMATION 2021. [PMCID: PMC7718588 DOI: 10.1016/j.anrea.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Toute crise sanitaire (épidémie, pandémie, actes terroristes, catastrophes naturelles ou faits de guerre) doit être anticipée par la mise en place d’un plan local, régional mais aussi national adapté aux enfants compte tenu de leur vulnérabilité. La faible expérience des équipes associée à une littérature pauvre nous oblige à extrapoler les concepts appliqués à l’adulte et à la médecine de guerre alors que les particularités anatomo-physiologiques liés à l’âge imposent des lésions et des stratégies de prise en charge spécifiques. Le shock index ajusté sur l’âge (SIPA) est un bon reflet de l’état de choc hémorragique ainsi qu’un bon indicateur des besoins de transfusion, d’admission en soins critiques, de ventilation et de mortalité chez les enfants traumatisés et pourrait être utile au triage. L’afflux de victimes pédiatriques reste un défi organisationnel, médical et humain. L’optimisation de la prise en charge repose sur une mutualisation des connaissances et une implication des différents acteurs (pédiatre, urgentiste, anesthésiste, réanimateur et chirurgien) afin de maintenir la qualité des soins. Il est important d’homogénéiser l’organisation et la formation en ciblant une communication multimodale, en s’appuyant sur des recommandations argumentées et des outils innovants qui s’inspirent de ceux qui ont été utilisés durant la récente pandémie (place du numérique). La simulation (procédurale, humaine, numérique, de masse) est un outil nécessaire et efficace pour l’entraînement régulier des équipes afin de faire face à ces situations exceptionnelles.
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Yamashiro KJ, Galganski LA, Grayson JK, Johnson MA, Beyer CA, Spruce MW, Caples CM, Trappey AF, Wishy AM, Stephenson JT. Does the pediatric hemodynamic cliff exist in response to hemorrhagic shock? J Pediatr Surg 2020; 55:2543-2547. [PMID: 32900511 DOI: 10.1016/j.jpedsurg.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/21/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The paradigm that children maintain normal blood pressure during hemorrhagic shock until 30%-45% hemorrhage is widely accepted. There are minimal data supporting when decompensation occurs and how a child's vasculature compensates up to that point. We aimed to observe the arterial response to hemorrhage and when mean arterial pressure (MAP) decreased from baseline in pediatric swine. METHODS Piglets were hemorrhaged in 20% increments of their total blood volume to 60%. MAP and angiograms of the thoracic aorta (TA) and abdominal arteries were obtained. Percent change in area of the vessels from baseline was calculated. RESULTS Piglets (n = 8) had a differential vasoconstriction starting at 20% hemorrhage (celiac artery 36.3% [31.4-44.6] vs TA 16.7% [10.7-19.1] p = 0.0012). At 40% hemorrhage, the differential vasoconstriction favored shunting blood away from the abdominal visceral branches to the TA (celiac artery 54.7% [36.9-60.6] vs TA 29.5% [23.9-36.2] p = 0.0056 superior mesenteric artery 46.7% [43.9-68.6] vs TA 29.5% [23.9-36.2] p = 0.0100). This was exacerbated at 60% hemorrhage. MAP decreased from baseline at 20% hemorrhage (66.4 ± 6.0 mmHg vs 41.4 ± 10.4 mmHg, p < 0.0001), and worsened at 40% and 60% hemorrhage. CONCLUSION In piglets, a differential vasocontriction shunting blood proximally occurred in response to hemorrhage. This did not maintain normal MAP at 20%, 40% or 60% hemorrhage. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Kaeli J Yamashiro
- Department of Surgery, University of California-Davis, Sacramento, CA; Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA.
| | - Laura A Galganski
- Department of Surgery, University of California-Davis, Sacramento, CA
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA; Department of Emergency Medicine, University of California-Davis, Sacramento, CA
| | - Carl A Beyer
- Department of Surgery, University of California-Davis, Sacramento, CA; Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA
| | - Marguerite W Spruce
- Department of Surgery, University of California-Davis, Sacramento, CA; Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA
| | - Connor M Caples
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA; Department of Vascular Surgery, University of California-Davis, Sacramento, CA
| | - A Francois Trappey
- Department of Surgery, University of California-Davis, Sacramento, CA; Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA
| | - Andrew M Wishy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA; Department of Vascular Surgery, University of California-Davis, Sacramento, CA
| | - Jacob T Stephenson
- Department of Surgery, University of California-Davis, Sacramento, CA; Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA
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Is lactic acidosis predictive of outcomes in pediatric diabetic ketoacidosis? Am J Emerg Med 2019; 38:329-332. [PMID: 31704063 DOI: 10.1016/j.ajem.2019.158449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/13/2019] [Accepted: 09/14/2019] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The objective of this study was to investigate the significance and prevalence of lactic acidosis in pediatric diabetic ketoacidosis (DKA) presenting to the emergency department. METHODS A retrospective cohort study of children (age ≤ 21 years) presenting to a tertiary care emergency department in DKA from December 1, 2015 to December 1, 2018. Patients needed to have DKA requiring admission to the pediatric intensive care unit and have had a lactate level collected while in the emergency department to be included. RESULTS 92 patients resulting in 113 encounters had DKA and a lactate level collected in the emergency department. The mean lactate level was 3.5 mmol/L (±SD 2.1). 72 (63.7%) encounters had lactic acidosis (p < 0.001). There was no significant association between the presence of lactic acidosis and pediatric intensive care unit length of stay (p = 0.321), hospital length of stay (p = 0.426), morbidity (p = 0.552) and mortality (p = 1.000). Initial glucose levels were significantly higher in the patients presenting with lactic acidosis (p = 0.001). CONCLUSIONS Lactic acidosis is a common finding in pediatric DKA patients presenting to the emergency department. Serum lactate alone should not be used as an outcome predictor in pediatric DKA.
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The impact of admission serum lactate on children with moderate to severe traumatic brain injury. PLoS One 2019; 14:e0222591. [PMID: 31536567 PMCID: PMC6752785 DOI: 10.1371/journal.pone.0222591] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022] Open
Abstract
Background Lactate is used to evaluate the prognosis of adult patients with trauma. However, the prognostic significance of admission serum lactate in the setting of pediatric traumatic brain injury (TBI) is still unclear. We aim to investigate the impact of admission lactate on the outcome in children with moderate to severe TBI. Methods This retrospective study was conducted in a tertiary pediatric hospital between May 2012 and Jun 2018 included children with an admission Glasgow Coma Scale (GCS) of ≤13. Two hundred and thirteen patients were included in the analysis and 45 patients died in hospital. Results Admission lactate and glucose were significantly higher in non-survivors than those in survivors (P < 0.05). Admission lactate was positively correlated with admission glucose and negatively correlated with GCS in all patients (n = 213), subgroup of isolated TBI (n = 112) and subgroup of GCS ≤ 8 (n = 133), respectively. AUCs of lactate could significantly predict the mortality and were higher than those of glucose in all patients, subgroup of isolated TBI and subgroup of GCS ≤ 8, respectively. Multivariate logistic regression showed that admission lactate (Adjusted OR = 1.189; 95% CI: 1.002–1.410; P = 0.047) was independently associated with mortality, while admission glucose (Adjusted OR = 1.077; 95% CI: 0.978–1.186; P = 0.133) wasn’t an independent risk factor of death. Elevated admission lactate (> 2 mmol/L) was associated with death, reduced 14-day ventilation-free days, 14-day ICU-free days and 28-day hospital-free days. Conclusions Admission serum lactate can effectively predict the mortality of children with moderate to severe TBI. Elevated admission lactate is associated with death, reduced ventilator-free, ICU-free, and hospital-free days. Admission serum lactate could be used as a prognostic biomarker of mortality in children with moderate to severe TBI.
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Ng ZM, Hong WJ, Chong SL, Allen JC, Loh LE, Low DCY, Lee JH. Correlation of arterial blood gas markers and lactate levels with outcomes in pediatric traumatic brain injury. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817704208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Various physical markers have been used to predict outcome of traumatic brain injury in children. However, the utility of metabolic alterations for prognostication has been poorly described. Thus, we aim to correlate arterial blood gas markers and lactate levels with outcomes in children with moderate to severe traumatic brain injury. Methods: This is a retrospective cohort study that included all patients <16 years old who presented to the Emergency Department with moderate to severe traumatic brain injury (Glasgow Coma Scale ⩽13). Serial arterial blood gas results and lactate levels in the first five days of admission to a pediatric intensive care unit (PICU) were reviewed. Primary outcome was in-hospital mortality. Secondary outcomes were 28-day ventilator-free and PICU-free days. A stepwise logistic regression analysis in conjunction with receiver operating characteristic analysis were used to identify variables that were associated with in-hospital mortality. Secondary outcomes were analyzed using multiple linear regression. Results: Among the 43 patients analyzed, more than half of the patients (60%) had severe traumatic brain injury (Glasgow Coma Scale 8). Twenty-seven of the 43 (65%) patients underwent neurosurgical intervention and overall mortality was 9/43 (20.9%). The worst base excess and lactate levels of Day 2 of PICU stay were found to be most predictive for mortality with maximal area-under-curve (95% confidence interval) of 0.967 (0.906, 1.000). Worst lactate level on day 2 of PICU stay was also found to be associated with ventilator-free days and PICU-free days. Conclusion: In children with moderate to severe traumatic brain injury, base excess and lactate on Day 2 of PICU stay were predictors of mortality, duration of mechanical ventilation and length of PICU stay.
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Affiliation(s)
- Zhi Min Ng
- Department of Pediatric Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Wei Jie Hong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital; Duke-NUS Medical School, Singapore
| | - John C Allen
- Center for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Lik Eng Loh
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital; Duke-NUS Medical School, Singapore
| | - David Chyi Yeu Low
- Department of Neurosurgery, KK Women’s and Children’s Hospital; Duke-NUS Medical School, Singapore
| | - Jan Hau Lee
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital; Duke-NUS Medical School, Singapore
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Cobianchi L, Peloso A, Filisetti C, Mojoli F, Sciutti F. Serum lactate level as a useful predictor of clinical outcome after surgery: an unfulfilled potential? J Thorac Dis 2016; 8:E295-7. [PMID: 27162686 DOI: 10.21037/jtd.2016.03.61] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Lorenzo Cobianchi
- 1 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, General Surgery Department, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 2 "V. Buzzi" Children Hospital, Division of Pediatric Surgery, University of Pavia, PhD School Milan, Italy ; 3 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 4 Anestesia e Rianimazione 2, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Andrea Peloso
- 1 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, General Surgery Department, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 2 "V. Buzzi" Children Hospital, Division of Pediatric Surgery, University of Pavia, PhD School Milan, Italy ; 3 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 4 Anestesia e Rianimazione 2, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Claudia Filisetti
- 1 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, General Surgery Department, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 2 "V. Buzzi" Children Hospital, Division of Pediatric Surgery, University of Pavia, PhD School Milan, Italy ; 3 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 4 Anestesia e Rianimazione 2, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Francesco Mojoli
- 1 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, General Surgery Department, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 2 "V. Buzzi" Children Hospital, Division of Pediatric Surgery, University of Pavia, PhD School Milan, Italy ; 3 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 4 Anestesia e Rianimazione 2, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Fabio Sciutti
- 1 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, General Surgery Department, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 2 "V. Buzzi" Children Hospital, Division of Pediatric Surgery, University of Pavia, PhD School Milan, Italy ; 3 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, IRCCS Foundation Policlinico San Matteo, Pavia, Italy ; 4 Anestesia e Rianimazione 2, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
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Is lactate an effective clinical marker of outcome for children with major trauma? - A literature review. Int Emerg Nurs 2016; 28:39-45. [PMID: 27160352 DOI: 10.1016/j.ienj.2016.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/07/2016] [Accepted: 04/01/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The assessment and treatment of children with major injury is fraught with difficulty - differences in anatomy and physiology mean that children that have suffered trauma can be over or under assessed. In recent years, there has been an increase in the use of biochemical markers, such as haematocrit, to assist the clinician in determining severity of injury. This paper examines the evidence surrounding lactate as a marker in paediatric trauma. METHOD A literature search was completed on Medline, CINAHL, Ovid and Science. 63 papers were initially identified - 41 papers were rejected after reading the abstracts. Of the 22 remaining papers - 6 had a paediatric focus, 16 were adult - of these 12 were rejected as not primary studies. Ten papers were fully critically reviewed - of these only one article related to paediatric patients and trauma. RESULTS The literature shows that an elevated lactate in a trauma patient is strongly correlated to severity of injury, length of stay and morbidity and mortality. However, one elevated lactate may be misleading and lactate clearance - that is the time when lactate levels return to normal, is just as important in the assessment of the severely injured. However, from this literature review it is clear that there is very little evidence for the relationship between lactate levels and trauma in children and that more studies are required.
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