Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit

Abdulrahman Özel; Esra Nur İlbeği; Servet Yüce

doi:10.4266/acc.003528

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Original Article Trauma Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit: Abdulrahman Özel¹, Esra Nur İlbeği¹, Servet Yüce²; Acute and Critical Care 2025;40(1):87-94.
DOI: https://doi.org/10.4266/acc.003528
Published online: February 18, 2025

¹Pediatric Intensive Care Unit, Department of Pediatrics, Bağcılar Training and Research Hospital, University of Health Sciences Türkiye, Istanbul, Türkiye

²Department of Public Health, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye

Corresponding author: Abdulrahman Özel Pediatric Intensive Care Unit, Department of Pediatrics, Bağcılar Training and Research Hospital, University of Health Sciences Turkiye, Merkez district, Dr. Sadık Ahmet St, No. 5, 34200 Bagcilar/Istanbul, Türkiye Tel: +90-53-1205-8253 Fax Email: dr.abdulrahman.ozel@gmail.com

• Received: August 26, 2024 • Revised: October 16, 2024 • Accepted: November 18, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
KEY MESSAGES
NOTES
REFERENCES

Abstract

Background
This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.
Methods
This retrospective study at tertiary center’s pediatric intensive care unit from January 2020 to June 2024 aimed to characterize trauma patients and assess admission lactate levels' prognostic value.
Results
A total of 190 critically ill pediatric trauma patients were included in the study. The mortality rate was 7.9%, with most deaths occurring within the first 48 hours of admission. Initial lactate levels ≥6.9 mmol/L demonstrated moderate predictive power (area under the curve [AUC], 0.878) for mortality. Pediatric Risk of Mortality III (PRISM III) score showed good predictive ability (AUC, 0.922), while Pediatric Trauma Scores exhibited variable predictive performance (AUC, 0.863). Higher initial lactate levels were significantly associated with severe brain injury, the need for intubation, and an increased incidence of thoracic or abdominal injuries.
Conclusions
Initial lactate levels and PRISM III score are effective predictors of mortality in critically ill pediatric trauma patients. Lactate levels ≥5 mmol/L upon admission should prompt close monitoring and consideration of aggressive management strategies.
Key Words: accidental injuries; child mortality; critical care; lactate; multiple trauma

INTRODUCTION

Injuries resulting from trauma surpass all other critical illnesses in children and have become a significant public health issue [1]. Recent reports from Türkiye indicate that trauma and poisoning are among the leading causes of child mortality, with 1,275 children succumbing to these causes in 2022 [2].

In developing countries, the number of pediatric trauma centers is limited or nonexistent, which results in the initial management of pediatric trauma patients being conducted by emergency clinicians who are not specialized in pediatrics [3]. Children, who have different physiology from adults and unique characteristics for each age group, present challenges for clinicians in emergency settings [4]. The care provided by specialized teams in pediatric trauma centers has a significant positive impact on mortality and morbidity [4,5]. Therefore, there is a clear need for simple predictive markers for emergency department staff who may lack sufficient knowledge and experience in the physiological characteristics of children, rather than complex pediatric trauma scores.

Lactate is a byproduct of glucose and pyruvate metabolism [6]. Under anaerobic conditions, pyruvate, the end product of glycolysis, is converted into lactate by the enzyme lactate dehydrogenase, and lactate participates in cellular energy production through various mechanisms [7]. Elevated blood lactate levels can result from increased anaerobic metabolism, hyperadrenergic states, impaired hepatic clearance, and mitochondrial dysfunctions [8].

In critical care, lactate levels and lactic acidosis (LA) have been associated with poor outcomes or mortality in conditions such as sepsis, dehydration, shock, and post-cardiac arrest [9,10]. Unlike studies in adults, research on the importance of LA in pediatric trauma patients is limited [6,11,12]. One study examined the relationship between LA and severe pediatric injury, while another investigated the association between initial lactate levels and lactate clearance with mortality [11,12]. Both studies suggest that initial lactate levels could serve as an early indicator of poor outcomes for clinicians evaluating pediatric trauma patients in emergency settings.

In light of this information, it is evident that there is a need for quick and simple tests to predict poor clinical outcomes in the evaluation of pediatric trauma patients. This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.

MATERIALS AND METHODS

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approved by the non-interventional clinical studies ethics board of University of Health Sciences Türkiye, Bağcılar Training and Research Hospital (No. 2024-07-03-056). Informed consent was obtained from the parents of all patients prior to admission and during all procedures. This retrospective, observational, single-center study aimed to examine the general characteristics of trauma patients admitted to the pediatric intensive care unit (PICU) of University of Health Sciences Turkiye, Bağcılar Training and Research Hospital, between January 2020 and June 2024, and to evaluate the prognostic significance of venous lactate levels at the time of admission.

All patients admitted to our eight-bed PICU with diagnoses of falls from height, ground-level falls, bicycle falls, natural disaster injuries, near-drowning, and penetrating injuries were included in the study. Pediatric trauma patients initially treated in other centers outside our emergency department, as well as children with chronic metabolic, cardiological, or endocrinological diseases that could affect lactate levels, and those who underwent resuscitation before or at the time of the first encounter in the emergency department, were excluded from the study.

Data on patients' demographic characteristics, trauma characteristics, affected organ systems, need for endotracheal intubation and/or presence of hypotension at the first encounter, need for massive transfusion (defined as transfusion exceeding 40 ml/kg within 24 hours), continuous renal replacement therapy (CRRT), and therapeutic plasma exchange (TPE) requirements, as well as mortality and morbidity information, were obtained from the hospital information system. The need for surgery was defined as interventions performed within the first week under operating room conditions, excluding minor procedures such as simple laceration repairs and tube thoracostomy. Additionally, clinical and laboratory findings at the first encounter, including systolic arterial blood pressure and venous blood gas, were recorded. Patients were divided into four groups based on lactate levels: normal (<2.5 mmol/L), mild (2.5–5 mmol/L), moderate (5–10 mmol/L), and severe LA (≥10 mmol/L) [13,14]. The presence of morbidity was defined as the presence of newly developed mental or motor retardation, epilepsy, need for tracheostomy and limb loss at the time of discharge from the PICU.

The Pediatric Trauma Score (PTS) [15] and Pediatric Glasgow Coma Scale (pGCS) [16] were calculated based on vital signs and neurological examination findings at the first encounter in the emergency department. The Pediatric Risk of Mortality III (PRISM III) score was calculated using data from the first 24 hours of examination [17].

Statistical Analysis

Data were analyzed using the SPSS software version 29.0 (IBM Corp.). Pearson's chi-square test was used to evaluate the relationships between demographic parameters, lactate groups, and mortality. Fisher's exact test and odds ratios were calculated to examine the relationships between mortality rates and types of trauma. Independent t-tests, one-way analysis of variance (ANOVA), and Kruskal-Wallis tests were used to assess the relationships between trauma types, complications, lactate levels, and clinical evaluation tools. The area under the curve (AUC) and receiver operating characteristic curve analysis were performed to evaluate the predictive power of lactate, PTS, and PRISM III scores for mortality and morbidity. In addition, logistic regression analysis was performed for parameters predicting mortality. For these analyses, all parameters predicting mortality were first subjected to univariate analysis, and then a multivariate regression model was created with the parameters that were significant in the univariate analysis. All statistical analyses were assessed at a significance level of P<0.05.

RESULTS

A total of 190 patients with a mean age of 7±5 years were included. The mortality rate was 7.9%, with 15 deaths (Figure 1). Head trauma was present in 54.2% of patients, significantly higher in non-survivors (93.3% vs. 51.4%, P=0.002). Subarachnoid hemorrhage, pneumocephalus, brain edema, and intracranial hematoma were more common in the non-survivor group (P<0.001 for each). In non-survivors, thoracic and abdominal trauma rates were 80% and 66.7%, respectively, both significantly higher than in survivors (P=0.041, P=0.002) (Table 1).

Of all patients at initial evaluation, hypotension was observed in 7.4% (14/190) and endotracheal intubation was performed in 30% (57/190), both significantly more frequent in non-survivors (P<0.001). The need for TPE and CRRT rates were both higher in non-survivors (P<0.001, P=0.008) (Table 1).

Average lactate levels were 3.22±2.87 mmol/L. Patients were categorized as follows: 48.9% with lactate <2.5 mmol/L, 36.8% with 2.5–5 mmol/L, 10.5% with 5-10 mmol/L, and 3.7% with >10 mmol/L. Higher lactate levels were significantly associated with increased mortality (P<0.001), with all patients having lactate >10 mmol/L not surviving. Most deaths in this group occurred within the first 48 hours (P<0.001). Higher lactate levels were also linked to increased morbidity (P<0.001). Elevated lactate levels were associated with more head and thoracic injuries (P=0.004, P=0.033), hypotension (P=0.004), and need for intubation (P<0.001). TPE was more frequent with higher lactate levels (P=0.003) (Table 2).

Predictive models showed robust performance. A lactate cutoff ≥6.9 mmol/L had 73.3% sensitivity and 97.7% specificity (AUC, 0.878). PRISM III scores >12 had 86.7% sensitivity and 88.6% specificity (AUC, 0.922). PTS <3 had 73.3% sensitivity and 93.7% specificity (AUC, 0.863) (Figure 2A). For morbidity, lactate levels ≥3.35 mmol/L had 45.9% sensitivity and 74.5% specificity (AUC, 0.606). PRISM III scores ≥4 showed 70.3% sensitivity and 59.5% specificity (AUC, 0.634). PTS ≤8 had 70.3% sensitivity and 58% specificity (AUC, 0.710) (Figure 2B). In the logistic regression analysis performed for factors predicting mortality, the presence of hypotension at the initial encounter (P=0.031), pGCS <8 (P=0.030), and lactate >5 mmol/L (P=0.007) were identified as independent predictors of mortality (Table 3).

DISCUSSION

Clinicians in emergency departments face challenges with pediatric patients due to age-related physiological differences and distinct treatment approaches compared to adults. Objective biomarkers are needed to predict clinical deterioration and facilitate timely intervention for critically ill pediatric patients [9]. While lactate levels are well-studied in adults for predicting trauma severity and poor outcomes, research on their role in pediatric trauma is limited [1]. The recent inclusion of lactate in the Phoenix score for pediatric sepsis underscores its importance in identifying critical conditions in children [14], likely raising clinician awareness.

The goal of identifying mortality predictors in pediatric trauma patients is to develop early intervention strategies and provide warning signs for timely action. Ramanathan et al. [12] found a lactate level of ≥4.7 mmol/L as a good predictor for severe injury, though with a low sensitivity of 26.7%. Çeleğen and Çeleğen [11] identified ≥12.9 mmol/L as the best cutoff for predicting mortality, but with low specificity (33.3%). A review article suggested a cutoff of 6.5 mmol/L for PICU patients, though this included a broader range of pediatric illnesses [6]. In our study, a lactate level of ≥6.9 mmol/L was a strong predictor of mortality (sensitivity, 73.3%; specificity, 97.7%; AUC, 0.878), showing a strong correlation with mortality. Although lactate's predictive performance was slightly lower than PRISM III score, it remains a valuable tool. PRISM III score involves age-dependent parameters and subjective clinical findings, requiring a 24-hour observation period [18], whereas lactate levels are simple, inexpensive, and quickly obtainable, providing objective data without interpretation.

In our study, a significant relationship was found between LA and head trauma. Additionally, we observed a significant correlation LA and the presence of severe brain injury, indicated by GCS between 3 and 8. A study investigating the relationship between traumatic brain injury (TBI) and LA demonstrated that post-TBI, lactate production increases in peripheral tissues, serving as an energy source for the brain, and its utilization by undamaged brain tissue also increases [19].

It is well known that increased anaerobic metabolism in tissues, resulting in lactic acid production, is a fundamental mechanism due to hypoxia and hypoperfusion [7]. Contrary to popular belief, LA results not only from increased production but also from the body's exceeded capacity to clear it, known as the "anaerobic threshold" [20]. Supporting this view, an exercise study in children showed a weak correlation between lactate and anaerobic metabolism increases, concluding that children have a higher anaerobic threshold compared to adults [21]. In our study, the presence of hypotension and the need for intubation at the initial encounter were statistically associated with high lactate levels. Regression analysis further demonstrated that hypotension, severe TBI (indicated by pGCS<8), and lactate levels above 5 mmol/L were significant predictors of mortality. These findings suggest that both respiratory impairment and hypoperfusion contribute to elevated lactate levels, which are in turn linked to more severe injuries. The independent significance of these three factors in the regression model highlights their combined impact on patient prognosis.

Moreover, patients with lactate levels above 5 mmol/L had a higher incidence of thoracic and abdominal injuries, reinforcing the role of lactate as an important marker of trauma severity. It is known that the majority of lactate is cleared by the liver, with a smaller amount excreted by the kidneys [6,7]. We hypothesize that the impact on the respiratory system and on organs like the liver and intestines, which play crucial roles in lactate clearance, exacerbates LA.

The majority of pediatric trauma cases result in mortality within the first 24 hours of hospital admission [22]. In our study, approximately half of the deaths occurred within the first 48 hours. This discrepancy can be attributed to our study cohort comprising patients admitted to the PICU, excluding those who expired in the emergency department before transfer to our unit could occur. Another notable finding is that five out of the seven patients who died within the first 48 hours had initial lactate levels exceeding 10 mmol/L. Early deaths in trauma cases are frequently due to primary causes such as TBI and intracranial hemorrhage, while later deaths are often secondary to sepsis and multiple organ dysfunction syndrome [23]. Our study found a significant relationship between the need for TPE and lactate levels during PICU follow-up. However, the early mortality of patients with lactate levels above 10 mmol/L prevented us from reaching sufficient numbers to evaluate the need for TPE and CRRT.

To our knowledge, our study is the first to examine the relationship between initial lactate levels and morbidity in pediatric trauma patients. We found that the best cutoff point for predicting morbidity was an initial lactate level of 3.35 mmol/L or higher, though it emerged as a weak predictor (AUC, 0.606; sensitivity, 45.9%; specificity, 74.5%). The moderate to weak performance of other scoring systems and lactate in our study suggests a need for more quantitative morbidity predictors in pediatric trauma [24,25].

Our study has several limitations. The most significant is the lack of information regarding whether patients received intravenous fluid therapy before arriving at the emergency department. However, in our country, critically ill patients are usually transported to the nearest hospital, which reduces the time from injury to hospital admission. Therefore, even if pre-hospital intravenous fluid therapy was administered, we believe the amount was likely minimal or none, leaving the initial lactate measurements largely unaffected. Additionally, patients who received initial treatment at other emergency departments were excluded from our study. Another limitation is that our study is retrospective and single-centered. Despite these limitations, our study yielded significant findings. Notably, it is the first to investigate the relationship between lactate levels and both mortality and morbidity in critically ill pediatric trauma patients.

Pediatric trauma patients represent a critical population requiring specialized monitoring and treatment in pediatric trauma centers overseen by pediatricians and pediatric surgeons. In settings where such facilities are not available, rapid identification of high-risk pediatric trauma patients using simple and cost-effective tests is crucial. Our study identifies initial lactate levels in pediatric trauma patients as a valuable predictor, particularly for mortality. However, its predictive utility for morbidity appears limited.

KEY MESSAGES

▪ Initial lactate levels in pediatric trauma patients serve as a valuable predictor of mortality, with higher levels correlating strongly with increased risk of death.

▪ Initial lactate measurements can be used as a simple and cost-effective tool for early identification of critical pediatric trauma patients, especially in settings where specialized pediatric trauma centers are not available.

▪ While lactate levels are effective in predicting mortality, their utility in predicting morbidity is limited. This suggests the need for better quantitative predictors in pediatric trauma care.

NOTES

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: all authors. Data curation: all authors. Formal analysis: AÖ, SY. Methodology: AÖ, ENI. Project administration: AÖ. Writing–original draft: AÖ, SY. Writing–review & editing: all authors. All authors read and agreed to the published version of the manuscript.

Figure 1.

Study flowchart. PICU: pediatric intensive care unit.

Figure 2.

(A) Receiver operating characteristic (ROC) analysis for predicting mortality. Lactate levels ≥6.9 mmol/L had 73.3% sensitivity and 97.7% specificity (area under the curve [AUC], 0.878). Pediatric Risk of Mortality Score III (PRISM III) scores >12 had 86.7% sensitivity and 88.6% specificity (AUC, 0.922). Pediatric Trauma Score (PTS) <3 had 73.3% sensitivity and 93.7% specificity (AUC, 0.863). (B) ROC analysis for predicting morbidity. Lactate levels ≥3.35 mmol/L had 45.9% sensitivity and 74.5% specificity (AUC, 0.606). PRISM III scores ≥4 showed 70.3% sensitivity and 59.5% specificity (AUC, 0.634). PTS ≤8 had 70.3% sensitivity and 58.0% specificity (AUC, 0.710).

Table 1.

Comparison of key parameters between non-survivors and survivors

Parameter	Non-survivor (n=15)	Survivor (n=175)	P-value
Head injury	14 (93.3)	90 (51.4)	0.002^a)
Subarachnoid hemorrhage	11 (73.3)	20 (11.4)	<0.001^a)
Pneumocephaly	10 (66.7)	46 (26.3)	<0.001^a)
Brain edema	6 (40.0)	18 (10.3)	<0.001^a)
Intracranial hematoma	13 (86.7)	73 (41.7)	<0.001^a)
Thoracic injury	12 (80.0)	92 (52.6)	0.041^a)
Pneumothorax	7 (46.7)	59 (33.7)	0.312^a)
Lung contusion	11 (73.3)	82 (46.9)	0.049^a)
Abdominal injury	10 (66.7)	49 (28.0)	0.002^a)
Splenic laceration	8 (53.3)	21 (12.0)	<0.001^a)
Liver laceration	3 (20.0)	24 (13.7)	0.503^a)
Intestinal perforation	0	4 (2.3)	0.554^a)
Renal laceration	3 (20.0)	10 (5.7)	0.035^a)
TPE	3 (20.0)	7 (4.0)	0.008^a)
CRRT	4 (26.7)	6 (3.4)	<0.001^a)
Hypotension	8 (53.30)	6 (3.4)	<0.001^a)
Need for massive transfusion	1 (6.7)	4 (2.3)	0.309^a)
Need for surgery	1 (6.7)	62 (35.4)	0.023^a)
Lactate group			<0.001^a)
<2.5 mmol/L	2 (13.3)	91 (52.0)
2.5–5 mmol/L	2 (13.3)	68 (38.9)
5–10 mmol/L	4 (26.7)	16 (9.1)
>10 mmol/L	7 (46.7)	0
PTS	1.5±3.7	6.9±3.0	<0.001^b)
pGCS	4.1±2.9	12.6±3.5	<0.001^b)
PRISM III score	34.9±21.1	5.0±7.2	<0.001^b)
Lactate level (mmol/L)	9.5±5.7	2.7±1.6	<0.001^b)

Values are presented as number (%) or mean±standard deviation.

TPE: therapeutic plasma exchange; CRRT: continuous renal replacement therapy; PTS: Pediatric Trauma Score; pGCS: Pediatric Glasgow Coma Scale; PRISM III: Pediatric Risk of Mortality III.

^a)Pearson chi-square test;

^b)Independent samples t-test.

Table 2.

Relationship between lactate levels and clinical features, treatment requirements, morbidity, and mortality

Parameter	Lactate <2.5 mmol/L (n=93)	Lactate 2.5–5 mmol/L (n=70)	Lactate 5–10 mmol/L (n=20)	Lactate >10 mmol/L (n=7)	P-value^a)
Mortality
Non-survivor	2 (2.1)	2 (2.8)	4 (20)	7 (100)	<0.001
Time of death					<0.001
Within 48 hours	0	0 (0)	2 (10)	5 (71)
2–7 days	1 (1.1)	2 (2.8)	1 (5)	2 (28.5)
After 7 days	1 (1.1)	0 (0)	1 (5)	0
Morbidity	15 (16.1)	14 (20)	8 (40)	0	<0.001
Head injury	45 (48.3)	37 (52.8)	15 (75)	7 (100)	0.004
Subarachnoid hemorrhage	10 (10.8)	9 (12.9)	5 (25.0)	7 (100)	<0.001
Pneumocephaly	24 (25.8)	17 (24.3)	10 (50.0)	5 (71.4)	0.009
Brain edema	5 (5.4)	10 (14.3)	6 (30.0)	3 (42.9)	<0.001
Intracranial hematoma	35 (37.6)	33 (47.1)	12 (60.0)	8 (85.7)	0.034
Thoracic injury	50 (53.8)	37 (52.8)	10 (50)	7 (100)	0.033
Abdominal injury	21 (22.5)	22 (31.4)	12 (60)	4 (57.1)	0.06
Hypotension	3 (3.2)	4 (5.7)	4 (20)	3 (42.8)	0.004
pGCS <8	7 (7.5)	12 (17.1)	10 (50)	6 (85.7)	<0.001
Intubation	17 (18.2)	21 (30)	12 (60)	7 (100)	<0.001
Need for surgery	29 (31.2)	27 (38.6)	7 (35)	0	0.081
TPE	0	7 (10)	2 (10)	1 (14.2)	0.003
CRRT	2 (2.1)	4 (5.7)	2 (10)	2 (28.5)	0.072

Values are presented as number (%).

pGCS: Pediatric Glasgow Coma Scale; TPE: therapeutic plasma exchange; CRRT: continuous renal replacement therapy.

^a)Pearson chi-square test.

Table 3.

Logistic regression analysis for the prediction of mortality

Parameter	B	SE	Wald	Significance	Exp(B)
Head injury	1.645	1.940	0.719	0.396	5.183
Thoracic injury	0.154	1.208	0.016	0.899	1.166
Abdominal injury	1.573	1.090	2.082	0.149	4.820
Hypotension	2.908	1.346	4.666	0.031	18.317
Intubation	0.085	1.542	0.003	0.956	1.089
pGCS <8	2.768	1.277	4.695	0.030	15.927
Lactate >5 mmol/L	2.086	0.775	7.243	0.007	8.056
Constant	–8.018	2.915	7.564	0.006	0

SE: standard error; pGCS: Pediatric Glasgow Coma Scale.

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Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit

Acute Crit Care. 2025;40(1):87-94. Published online February 18, 2025

DOI: https://doi.org/10.4266/acc.003528

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Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit

Figure 1. Study flowchart. PICU: pediatric intensive care unit.

Figure 2. (A) Receiver operating characteristic (ROC) analysis for predicting mortality. Lactate levels ≥6.9 mmol/L had 73.3% sensitivity and 97.7% specificity (area under the curve [AUC], 0.878). Pediatric Risk of Mortality Score III (PRISM III) scores >12 had 86.7% sensitivity and 88.6% specificity (AUC, 0.922). Pediatric Trauma Score (PTS) <3 had 73.3% sensitivity and 93.7% specificity (AUC, 0.863). (B) ROC analysis for predicting morbidity. Lactate levels ≥3.35 mmol/L had 45.9% sensitivity and 74.5% specificity (AUC, 0.606). PRISM III scores ≥4 showed 70.3% sensitivity and 59.5% specificity (AUC, 0.634). PTS ≤8 had 70.3% sensitivity and 58.0% specificity (AUC, 0.710).

Figure 1.

Figure 2.

Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit

Parameter	Non-survivor (n=15)	Survivor (n=175)	P-value
Head injury	14 (93.3)	90 (51.4)	0.002^a)
Subarachnoid hemorrhage	11 (73.3)	20 (11.4)	<0.001^a)
Pneumocephaly	10 (66.7)	46 (26.3)	<0.001^a)
Brain edema	6 (40.0)	18 (10.3)	<0.001^a)
Intracranial hematoma	13 (86.7)	73 (41.7)	<0.001^a)
Thoracic injury	12 (80.0)	92 (52.6)	0.041^a)
Pneumothorax	7 (46.7)	59 (33.7)	0.312^a)
Lung contusion	11 (73.3)	82 (46.9)	0.049^a)
Abdominal injury	10 (66.7)	49 (28.0)	0.002^a)
Splenic laceration	8 (53.3)	21 (12.0)	<0.001^a)
Liver laceration	3 (20.0)	24 (13.7)	0.503^a)
Intestinal perforation	0	4 (2.3)	0.554^a)
Renal laceration	3 (20.0)	10 (5.7)	0.035^a)
TPE	3 (20.0)	7 (4.0)	0.008^a)
CRRT	4 (26.7)	6 (3.4)	<0.001^a)
Hypotension	8 (53.30)	6 (3.4)	<0.001^a)
Need for massive transfusion	1 (6.7)	4 (2.3)	0.309^a)
Need for surgery	1 (6.7)	62 (35.4)	0.023^a)
Lactate group			<0.001^a)
<2.5 mmol/L	2 (13.3)	91 (52.0)
2.5–5 mmol/L	2 (13.3)	68 (38.9)
5–10 mmol/L	4 (26.7)	16 (9.1)
>10 mmol/L	7 (46.7)	0
PTS	1.5±3.7	6.9±3.0	<0.001^b)
pGCS	4.1±2.9	12.6±3.5	<0.001^b)
PRISM III score	34.9±21.1	5.0±7.2	<0.001^b)
Lactate level (mmol/L)	9.5±5.7	2.7±1.6	<0.001^b)

Parameter	Lactate <2.5 mmol/L (n=93)	Lactate 2.5–5 mmol/L (n=70)	Lactate 5–10 mmol/L (n=20)	Lactate >10 mmol/L (n=7)	P-value^a)
Mortality
Non-survivor	2 (2.1)	2 (2.8)	4 (20)	7 (100)	<0.001
Time of death					<0.001
Within 48 hours	0	0 (0)	2 (10)	5 (71)
2–7 days	1 (1.1)	2 (2.8)	1 (5)	2 (28.5)
After 7 days	1 (1.1)	0 (0)	1 (5)	0
Morbidity	15 (16.1)	14 (20)	8 (40)	0	<0.001
Head injury	45 (48.3)	37 (52.8)	15 (75)	7 (100)	0.004
Subarachnoid hemorrhage	10 (10.8)	9 (12.9)	5 (25.0)	7 (100)	<0.001
Pneumocephaly	24 (25.8)	17 (24.3)	10 (50.0)	5 (71.4)	0.009
Brain edema	5 (5.4)	10 (14.3)	6 (30.0)	3 (42.9)	<0.001
Intracranial hematoma	35 (37.6)	33 (47.1)	12 (60.0)	8 (85.7)	0.034
Thoracic injury	50 (53.8)	37 (52.8)	10 (50)	7 (100)	0.033
Abdominal injury	21 (22.5)	22 (31.4)	12 (60)	4 (57.1)	0.06
Hypotension	3 (3.2)	4 (5.7)	4 (20)	3 (42.8)	0.004
pGCS <8	7 (7.5)	12 (17.1)	10 (50)	6 (85.7)	<0.001
Intubation	17 (18.2)	21 (30)	12 (60)	7 (100)	<0.001
Need for surgery	29 (31.2)	27 (38.6)	7 (35)	0	0.081
TPE	0	7 (10)	2 (10)	1 (14.2)	0.003
CRRT	2 (2.1)	4 (5.7)	2 (10)	2 (28.5)	0.072

Parameter	B	SE	Wald	Significance	Exp(B)
Head injury	1.645	1.940	0.719	0.396	5.183
Thoracic injury	0.154	1.208	0.016	0.899	1.166
Abdominal injury	1.573	1.090	2.082	0.149	4.820
Hypotension	2.908	1.346	4.666	0.031	18.317
Intubation	0.085	1.542	0.003	0.956	1.089
pGCS <8	2.768	1.277	4.695	0.030	15.927
Lactate >5 mmol/L	2.086	0.775	7.243	0.007	8.056
Constant	–8.018	2.915	7.564	0.006	0

Table 1. Comparison of key parameters between non-survivors and survivors

Values are presented as number (%) or mean±standard deviation.

TPE: therapeutic plasma exchange; CRRT: continuous renal replacement therapy; PTS: Pediatric Trauma Score; pGCS: Pediatric Glasgow Coma Scale; PRISM III: Pediatric Risk of Mortality III.

Pearson chi-square test;

Independent samples t-test.

Table 2. Relationship between lactate levels and clinical features, treatment requirements, morbidity, and mortality

Values are presented as number (%).

pGCS: Pediatric Glasgow Coma Scale; TPE: therapeutic plasma exchange; CRRT: continuous renal replacement therapy.

Pearson chi-square test.

Table 3. Logistic regression analysis for the prediction of mortality

SE: standard error; pGCS: Pediatric Glasgow Coma Scale.