Some syndicated media has “Shark Week”. We have Sepsis Week!
The current generation of sepsis care is defined not just by our quixotic quest for simplified early warning tools, but also, more than anything, by lactate levels. In someways, lactate is our friend – no more central catheter placement solely for measurement of central venous oxygenation. However, the ease of use of checking a lactate level also means we apply it indiscriminately. The lactate has become the D-dimer of infection – increasingly weakly predictive, the more we rely upon it.
This is a snapshot of the performance of lactate levels in pediatric sepsis. This is an observational registry of patients evaluated in the Emergency Department of a pediatric hospital, consisting of 1,299 patients in whom clinically suspected sepsis resulted in a lactate order. These authors hypothesized that, as in adults, a lactate level of 36mg/dL (4mmol/L) would portend increased mortality.
And, naturally, they were correct. However, its predictive value was virtually nil. There were 103 patients with lactate elevated above their cut-off and 1,196 below. Only 5 of the 103 patients elevated lactate suffered 30-day mortality. Then, of the 1,196 below the cut-off, 20 suffered 30-day mortality. A mortality of 4.8% is higher than 1.7%, but the sensitivity is only 20% – and the specificity of 92.3% with such a low prevalence of the primary outcome means over 95% of elevated lactate levels are “false positives”.
There are some limitations here, however, that could have a substantial effects on the outcomes. There is a selection bias inherent to eligibility in which lactates were likely ordered only on the most ill-appearing patients. The effect of this would be to improve the apparent performance characteristics of the test in the study population. However, then, it is likely the patients with elevated lactate levels received more aggressive treatment than if the treating clinicians were blinded to the result. The effect of this would be a mortality benefit in the population with elevated lactate, worsening the apparent test characteristics.
But, hairs split aside, these pediatric results are grossly similar to those in adults. An elevated lactate is a warning signal, but should hardly be relied upon.
“Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children”
https://www.ncbi.nlm.nih.gov/pubmed/28068437