Association Between Serum Lactate and Unsatisfactory Outcomes in Critically Ill Children in the Immediate Post-operative Period of Liver Transplantation.

Jaime Fernández-Sarmiento,Karen Moreno-Medina,Julián Augusto Palomar Dominguez,Hernando Mulett,María Angélica Wilches-Cuadros,Lorena Acevedo,Ricardo Hernandez-Sarmiento,Nicolás Molano,Jairo Rivera,Claudia Salinas

doi:10.3389/fped.2021.796504

Abstract

ObjectivesSerum lactate is a useful biomarker of tissue perfusion in critically ill patients. We evaluated the behavior of serum lactate in children in the pediatric intensive care unit (PICU) immediately after liver transplantation and its association with surgical complications, graft dysfunction and 90-day mortality.Materials and MethodsA prospective observational study carried out between November 2009 and December 2019. Multidisciplinary PICU at the University Children's Hospital, Fundación Cardioinfantil-IC, Bogotá, Colombia.Measurements and Main ResultsPatients between 1 month and 18 years of age who were in the immediate post-operative period following living-donor or cadaveric liver transplantation were included. A total of 145 patients with a median age of 14 months (IQR 8–60) met the inclusion criteria. Biliary atresia was the main diagnosis in 56.5% of the cases. A serum lactate level > 3.0 mmol/L on admission to the PICU was associated with biliary complications (AUC 0.73 95% CI 0.54–0.93; p = 0.05) and mortality (AUC 0.72 95% CI 0.63–0.8; p = 0.01). A lactate level > 2 mmol/L after 6 h in the PICU was associated with mortality (AUC 0.70 95% CI 0.54–0.83; p = 0.02). Higher lactate levels and lack of clearance were associated with the presence of tardus et parvus waveforms (p = 0.001) on liver Doppler, primary dysfunction (p < 0.001), arterial thrombosis (p < 0.001) and neurological complications (p = 0.04). There was an inverse correlation between admission lactate and the volume of fluids administered during surgery (rho = 0.36; p < 0.001). A total procedure time > 350 min, along with a vasopressor score > 7 and elevated lactate, were associated with worse outcomes (p < 0.001).ConclusionsIn post-operative pediatric liver transplant patients, the level of serum lactate is associated with post-operative surgical complications and mortality.

Highlights

Acute and chronic liver failure in childhood has an almost 90% mortality rate without transplantation [1, 2]
We evaluated the behavior of serum lactate in children in the pediatric intensive care unit (PICU) immediately after liver transplantation and its association with surgical complications, graft dysfunction and 90-day mortality
We found that a serum lactate level > 3.0 mmol/L on PICU admission had an 80% sensitivity and 65% specificity (AUC 0.73; CI 0.54–0.93, p = 0.05) for predicting biliary complications, venous or arterial thrombosis (62% sensitivity and 64% specificity; AUC 0.58; CI 0.40–0.77; p = 0.4), and 90day mortality (76% sensitivity and 65% specificity, AUC 0.72; CI 0.63–0.81; p = 0.01)

Summary

Introduction

Acute and chronic liver failure in childhood has an almost 90% mortality rate without transplantation [1, 2]. Liver transplantation has developed significantly over the last 40 years and is the definitive solution for various liver diseases which lead to cirrhosis [3]. Biliary atresia is the most common cholestatic disease in children and is responsible for ∼40% of liver transplant cases in children [2, 4, 5]. Complications of liver transplantation are frequent and, due to the complexity of the procedure, are largely determined by each center’s level of experience. In the first 90 days, biliary tract complications were reported in 13.6%, and in the first year, acute cellular rejection occurred in 34.7% [1]

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