Karthikeyan, C (2013) Serum Lactate Level - Predictor of Outcome in Pediatric Septic Shock. Masters thesis, Coimbatore Medical College, Coimbatore.
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Abstract
INTRODUCTION: Critical care medicine has remarkably improved in past few decades. Newer antibiotics are being introduced daily. Even then, sepsis is one of the leading causes of death worldwide. Sepsis related deaths are more common in developing nations like India. Epidemiology of sepsis is changing. The reasons for this change are infections which were previously fatal are now controlled by use of effective antibiotics and immunization. Yet new infections are on the rise. Increased utilization of invasive devices and technology has led to health care associated infections. Various biochemical indicators are used to diagnose, prognosticate and to guide treatment in children with septic shock. OXYGEN DELIVERY: The main function of cardio respiratory system is to maintain delivery of oxygen and nutrients to the body tissues and remove the end products of metabolism. When there is reduced oxygen supply, tissue demands could not be met and this results in low central venous oxygen saturation. Anaerobic metabolism occurs when there is prolonged tissue hypoxia leading to the production of lactic acid. Adequate supply of oxygen to tissues depends on 1. Adequate oxygen content in the blood. 2. Cardiac output with sufficient blood flow to organs.3. Adequate blood flow according to local tissue metabolic demand. 4. Ability to utilize oxygen by the mitochondria Oxygen content in blood is determined by the concentration of hemoglobin and percentage of hemoglobin that is saturated with oxygen. Adequate blood flow to the tissues is determined by cardiac output and local tissue demand. Cardiac output is the amount of blood that flows through tissues in 1 minute. Cardiac output is determined by stroke volume and heart rate. Stroke volume is the amount of blood pumped by the heart with each beat. Heart rate is the number of contractions by heart each minute. OBJECTIVES OF THE STUDY: 1. To determine the association between serum lactate level and mortality in pediatric septic shock. 2. To determine whether serial determination of serum lactate level is a predictor of outcome in pediatric septic shock. 3. To determine the association between organ dysfunction, presence of anemia, malnutrition, diagnosis and outcome in pediatric septic shock. DISCUSSION: The total number of children with septic shock admitted during the study period were 55 in number. Among them 30 were boys and 25 were girls. Anemia was observed in 38 cases. Undernutrition was observed in 40 cases. There were 31 survivors and 24 non survivors. Mortality was 43.6%. Bronchopneumonia (65.5%) was the most cause of septic shock in our study followed by acute diarrhoeal disease (14.5%), meningitis (12.7%), urosepsis (5.5%). This is comparable to study by Kolski et al in which bronchopneumonia was the common infection. This is also comparable to study by Kana Ram Jat et al in which bronchopneumonia accounted for 73.3% cases. Mortality in our study was 43.6%. This is comparable to observations by Kana Ram Jat et al. Mortality was 50% in their study. In children with urosepsis, E coli was the causative organism. Organ dysfunction other than cardiovascular dysfunction was observed in 36(65.5%) cases. This is comparable to study by Kana Ram Jat et al in which organ dysfunction was observed in 66.7% of cases. Respiratory dysfunction (50%) was the most common next to cardiovascular organ system dysfunction. From ROC analysis, the optimal cut off value for lactate measured at 0 to 3 hours was ≥ 41 mg/dl (4.55 mmol/l). For lactate measured at 24 hours, the optimal cut off value was ≥ 39.2 mg/dl (4.35 mmol/l). Both initial and lactate at 24 hours were significantly high in non survivors (p < 0.001). The association between lactate measured at 0 to 3 hours and outcome was significant. Also there was significant association between lactate measured at 24 hours and outcome. Initial lactate level of > 41 mg/dl had sensitivity of 87% and specificity of 95.8%. Lactate level at 24 hours had sensitivity of 90% and specificity of 95.8%. High lactate level, presence of organ dysfunction and under nutrition were independently associated with poor outcome. In our study, initial lactate level of ≥ 41mg/dl (4.55 mmol/l) and 24 hours lactate level of ≥ 39.2 mg/dl (4.35 mmol / l) was significantly associated with poor outcome. This is comparable to previous study conducted by Kana Ram Jat et al in which lactate ≥ 5 mmol/l or 45 mg/dl was significantly associated with poor outcome. In contrast to our study, Duke et al reported lactate level of ≥ 3 mmol/l was a significant predictor of outcome. But in the study conducted by Duke et al, children with sepsis were the study population. Barat Ramakrishna et al studied children with pneumonia and reported a cut off > 2mmol/l. CONCLUSION: Septic shock is a common cause for mortality and morbidity in children. Early recognition and goal directed therapy is necessary to prevent complications. Our study demonstrated high serum lactate was associated with higher mortality. Serial determination of serum lactate levels was a better predictor of poor outcome.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Serum Lactate Level ; Predictor ; Pediatric Septic Shock. |
| Subjects: | MEDICAL > Paediatrics |
| Depositing User: | Ravindran C |
| Date Deposited: | 10 Apr 2018 06:38 |
| Last Modified: | 17 Dec 2018 15:46 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/6923 |
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