Association Between Initial Emergency Department Lactate and Use of Vasoactive Medication in Children With Septic Shock

Lactate Levels as a Predictor of Emergency Department Revisits in Infants With Acute Bronchiolitis

OBJECTIVE

This study aimed to identify predictive biomarkers for unscheduled emergency department (ED) revisits within 24 hours of discharge in infants diagnosed with acute bronchiolitis (AB).

METHODS

A retrospective observational study was conducted on infants diagnosed with AB who visited 3 emergency medical centers between January 2020 and December 2022. The study excluded infants with comorbidities, congenital diseases, and prematurity and infants who revisited the ED after 24 hours of discharge. Demographic data, vital signs, and laboratory results were collected from the medical records. Univariable and multivariable logistic regression analyses were performed on factors with P of less than 0.1 in univariable analysis. Receiver operator curve analysis was used to assess the accuracy of lactate measurements in predicting ED revisits within 24 hours of discharge.

RESULTS

Out of 172 participants, 100 were in the revisit group and 72 in the discharge group. The revisit group was significantly younger and exhibited higher lactate levels, lower pH values, and higher pCO 2 levels compared to the discharge group. Univariable logistic regression identified several factors associated with revisits. Multivariable analysis found that only lactate was a variable correlated with predicting ED revisits (odds ratio, 18.020; 95% confidence interval [CI], 5.764-56.334). The receiver operator curve analysis showed an area under the curve of 0.856, with an optimal lactate cutoff value of 2.15.

CONCLUSION

Lactate value in infants diagnosed with AB were identified as a potential indicator of predicting unscheduled ED revisits within 24 hours of discharge. The predictive potential of lactate levels holds promise for enhancing prognosis prediction, reducing health care costs, and alleviating ED overcrowding. However, given the study's limitations, a more comprehensive prospective investigation is recommended to validate these findings.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Lactate Measurements and Their Association With Mortality in Pediatric Severe Sepsis in India: Evidence That 6-Hour Level Performs Best

PURPOSE

To investigate association of static and dynamic lactate indices with early mortality (within 48 hours of admission), as well as need for vasopressors and mechanical ventilation in pediatric severe sepsis/shock. To explore optimal cutoffs of lactate indices. We hypothesized that dynamic indices are superior to static indices in predicting early mortality.

METHODS

This prospective cohort study involved children (aged <14 years) admitted in emergency department, tertiary care teaching hospital in North India with severe sepsis/shock (2015-2016). Arterial lactate was measured at admission (X0) and after 6 hours (X6). Primary outcome of the measurement was early mortality. Association between lactate indices- lactate at 0 hours (Lac0), lactate after 6 hours (Lac6), time-weighted average (LacTW), delta (ΔLac), clearance (LacCl%) and early mortality, need for vasopressors, and mechanical ventilation-was assessed using Student t test/Mann-Whitney test. Area under the receiver operating characteristic curve (AUROC) for early mortality deduced for all lactate indices and compared with reference (Lac0). Optimal cutoffs (maximizing both sensitivity and specificity) and their positive predictive value (PPV) and negative predictive value (NPV) were determined.

RESULTS

During the study period, 116 children were assessed. Septic shock was present at admission in 56.9% children; 50% of children died during the next 48 hours. Lac0, Lac6, and LacTW were significantly higher, and LacCl% was lower in nonsurvivors versus survivors (all P < .001). Lac6 (0.837 [0.76-0.91]) had significantly higher AUROC (95% confidence interval) than Lac0 (0.77; P = .03). Abnormal lactate metrics (higher Lac0, Lac6, LacTW, and lower LacCl%) were associated with vasopressors need and mechanical ventilation. On logistic regression, Lac6 emerged as an independent predictor of early mortality as well as vasopressor and mechanical ventilation need. The optimal cutoff of Lac6 for identifying early mortality with good sensitivity, specificity, PPV, and NPV was ≥2.65 (76, 85, 83, 78).

CONCLUSIONS

Lactate6 is the best marker associated with early mortality and higher level of care in severe sepsis/septic shock in resource-poor regions.

The efficacy of dopamine versus epinephrine for pediatric or neonatal septic shock: a meta-analysis of randomized controlled studies

INTRODUCTION

The efficacy of dopamine versus epinephrine for pediatric or neonatal septic shock remains controversial. We conduct a meta-analysis to explore the influence of dopamine versus epinephrine on shock reversal for pediatric or neonatal septic shock.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through July 2019 for randomized controlled trials (RCTs) assessing the efficacy and safety of dopamine versus epinephrine for pediatric or neonatal septic shock.

RESULTS

Three RCTs are included in the meta-analysis. Overall for pediatric or neonatal septic shock, dopamine and epinephrine reveal comparable shock reversal within 1 h (risk ratios (RR) = 0.61; 95% CI = 0.16 to 2.31; P = 0.47), mortality (RR = 1.16; 95% CI = 0.87 to 1.55; P = 0.30), heart rate (standard mean differences (SMD) = 0.03; 95% CI = -0.28 to 0.34; P = 0.85), systolic blood pressure (SMD = -0.18; 95% CI = -0.69 to 0.33; P = 0.49), mean arterial pressure (SMD = -0.15; 95% CI = -1.64 to 1.34; P = 0.84) and adverse events (RR = 1.00; 95% CI = 0.94 to 1.07; P = 0.91).

CONCLUSIONS

Dopamine and epinephrine show the comparable efficacy for the treatment of pediatric or neonatal septic shock.

Management of Children With Fever at Risk for Pediatric Sepsis: A Prospective Study in Pediatric Emergency Care

Objective: To study warning signs of serious infections in febrile children presenting to PED, ascertain their risk of having sepsis, and evaluate their management. Design: Prospective observational study. Setting: A single pediatric emergency department (PED). Participants: Febrile children, aged 1 month-16 years, with >= 1 warning signs of sepsis. Interventions and Main outcome measures: Clinical characteristics, including different thresholds for tachycardia and tachypnoea, and their association with (1) delivery of pediatric sepsis 6 (PS6) interventions, (2) final diagnosis of invasive bacterial infection (IBI), (3) the risk for pediatric intensive care unit (PICU) admission, and (4) death. Results: Forty-one percent of 5,156 febrile children had warning signs of sepsis. 1,606 (34%) children had tachypnoea and 1,907 (39%) children had tachycardia when using APLS threshold values. Using the NICE sepsis guidelines thresholds resulted in 1,512 (32%) children having tachypnoea (kappa 0.56) and 2,769 (57%) children having tachycardia (kappa 0.66). Of 1,628 PED visits spanning 1,551 disease episodes, six children (0.4%) had IBI, with one death (0.06%), corresponding with 256 children requiring escalation of care according to sepsis guideline recommendations for each child with IBI. There were five additional PICU admissions (0.4%). 121 (7%) had intravenous antibiotics in PED; 39 children (2%) had an intravenous fluid bolus, inotrope drugs were started in one child. 440 children (27%) were reviewed by a senior clinician. In 4/11 children with IBI or PICU admission or death, PS6 interventions were delivered within 60 min after arriving. 1,062 (65%) visits had no PS6 interventions. Diagnostic performance of vital signs or sepsis criteria for predicting serious illness yielded a large proportion of false positives. Lactataemia was not associated with giving iv fluid boluses (p = 0.19) or presence of serious bacterial infections (p = 0.128). Conclusion: Many febrile children (41%) present with warning signs for sepsis, with only few of them undergoing investigations or treatment for true sepsis. Children with positive isolates in blood or CSF culture presented in a heterogeneous manner, with varying levels of urgency and severity of illness. Delivery of sepsis care can be improved in only a minority of children with IBI or admitted to PICU.

Lactate clearance prognosticates outcome in pediatric septic shock during first 24 h of intensive care unit admission

This study was undertaken to examine the clinical utility of lactate clearance as an indicator of mortality in pediatric septic shock, and to compare the performance of lactate clearance at 6, 12, and 24 h for predicting in-hospital and 60-day mortality. Pediatric patients with septic shock were prospectively studied. Vital signs, laboratory values, Pediatric Risk of Mortality Score, and pediatric logistic organ dysfunction score were obtained at presentation (hour 0), hour 6, hour 24 and over the first 72 h of hospitalization. Lactate clearance was obtained at 6, 12, and 24 h of hospital admission. Therapy received, outcome parameters of mortality, and duration of hospitalization were recorded. The primary outcome variable of 60-day mortality rate was 31.25%. Only lactate clearance at 6 and 24 h was significantly associated with mortality, with odds of 0.97 (95% CI, 0.951-981; p < 0.001) and 0.975 (95% CI, 0.964-0.986; p < 0.001), respectively. Approximately there was a 24% decrease in likelihood of mortality for each 10% increase in lactate clearance at 24 h. At a threshold value of 10% 6-h lactate clearance had a sensitivity of 0.948 and specificity of 0.571, while at a threshold of 20% 24-h lactate clearance had a sensitivity of 0.922 and specificity of 0.629. The comparison of clearance at 6 and 24 h using receiver operating characteristic showed that former was "fair" (area under the curve = 0.753) and later was "good" (area under the curve = 0.81) in predicting mortality in pediatric septic shock.

Conclusion

We concluded that optimal lactate clearance in pediatric septic shock both during the early presentation and after the initial "golden hours" is associated with lower in-hospital and 60-day mortality. Further, 24-h lactate clearance appears superior to 6 h lactate clearance in predicting mortality in such patients.