A recent pediatric prospective, observational, cohort study (n=1,299), similar to previous adult studies, evaluated whether an elevated screening serum lactate >36 mg/dL (>4 mmol/L) was associated with increased mortality in pediatric patients.5 The primary outcome was in-hospital, all-cause mortality within 30 days. The overall mortality was 1.9 percent (25 of 1,299). In patients with lactates >36 mg/dL, the mortality was 4.8 percent (5 of 103) versus 1.7 percent (20 of 1,196) in the group <36 mg/dL. While the mortality in the hyperlactatemia group (>36 mg/dL) was higher, the difference in mortality was not nearly as robust as in the adult literature. For this reason, screening serum lactates in children should not be routine. More important, a serum lactate in the 18–36 mg/dL group (2–4 mmol/L) should not falsely reassure the practitioner that a child is not sick, as there were a number of deaths in this group.
Explore This IssueACEP Now: Vol 36 – No 07 – July 2017
While screening pediatric patients for sepsis with serum lactates is not routine, there are data to suggest that trending lactates for clearance is associated with less persistent organ dysfunction at 48 hours.6
Conclusion: Serum lactate measurements in children do not provide the robust sepsis risk stratification demonstrated in the adult literature. While hyperlactatemia (>4 mmol/L) may suggest a sicker patient, it is very important to recognize that a normal or intermediate lactate level should not falsely reassure you that a child is not sick.
Question 2: Do prophylactic antibiotics decrease the likelihood of drowning-associated pneumonias in children?
In general, the data are scarce and based on a mixture of adult and pediatric patients. One of the earliest studies on this topic was a retrospective study of 91 consecutive children and adults (ages 1 to 79).7 Of these patients, 81 of 91 (89 percent) survived, and they appeared to have a variety of presentations, with 33 patients requiring intubation. The data are very limited, and the authors noted, “More patients died who received prophylactic antibiotic therapy [7 of 54 (13.0 percent)] than did those from whom such therapy was withheld until gram staining, culture, and the clinical course suggested the presence of active infection [2 of 36 (5.6 percent)].” There was one patient unaccounted for and no mention of statistical significance. They did not mention the patients’ ages or the severity of illness for patients who received prophylactic antibiotics.
An older retrospective study of 40 patients, with 33 of the patients younger than 17 years, found that prophylactic antibiotics given to 31 of 40 patients “had no apparent benefit” in the patient population.8 An additional retrospective study of 125 submersion victims included an unspecified breakdown of children versus adults and found no significant benefit from prophylactic antibiotics.9