The clinical significance of blood lactate levels in evaluation of adult patients with veno-arterial extracorporeal membrane oxygenation

Abstract

Background Veno-arterial ECMO is a life-supporting procedure that can be done to the patients with cardiogenic shock which is associated with hyperlactatemia. The objective of this study was to detect the validity of serial measurements of arterial lactate level in differentiating hospital mortality and neurological outcome after VA-ECMO support for adult patients with cardiogenic shock. All consecutive patients ≥ 18 years admitted with cardiogenic shock and supported with VA-ECMO between 2015 and 2019 in our tertiary care hospital were retrospectively studied. Results The study included 106 patients with a mean age of 40.2 ± 14.4 years, a mean BMI of 26.5 ± 7 and mostly males (69.8%). The in-hospital mortality occurred in 56.6% and acute cerebral strokes occurred in 25.5% of the enrolled patients. The non-survivors and the patients with acute cerebral strokes had significantly higher arterial lactate levels at pre-ECMO initiation, post-ECMO peak and after 24 h of ECMO support compared to the survivors and those without strokes, respectively. The peak arterial lactate ≥ 14.65 mmol/L measured after ECMO support had 81.7% sensitivity and 89.1% specificity for predicting hospital mortality [AUROC 0.889, p < 0.001], while the arterial lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 88.3% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC 0.93, p < 0.001]. The peak lactate ≥ 15.15 mmol/L measured after ECMO support had 70.8% sensitivity and 69% specificity for predicting cerebral strokes [AUROC 0.717, p < 0.001], while the lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 79.2% sensitivity and 72.4% specificity for predicting cerebral strokes [AUROC 0.779, p < 0.001]. Progressive hyperlactatemia (OR = 1.427, 95% CI 1.048–1.944, p = 0.024) and increasing SOFA score after 48 h (OR = 1.819, 95% CI 1.374–2.409, p < 0.001) were significantly associated with in-hospital mortality after VA-ECMO support. Post hoc analysis detected a significantly high frequency of hypoalbuminemia in the non-survivors and in the patients who developed acute cerebral strokes during VA-ECMO support. Conclusion Progressive hyperlactatemia after VA-ECMO initiation for adult patients with cardiogenic shock is a sensitive and specific predictor of hospital mortality and acute cerebrovascular strokes. According to our results, we could recommend early VA-ECMO initiation to achieve adequate circulatory support and better outcome.

Outcomes of Transferred Adult Venovenous and Venoarterial Extracorporeal Membrane Oxygenation Patients: A Single Center Experience

“…Recently, a observation in the Danish population revealed that the lower levels of lactate was associated to higher survival rate with a good neurological outcome ( 14 ). A recent study included 106 patients revealed that the progressive hyperlactatemia after VA-ECMO initiation for adult patients with cardiogenic shock is a sensitive and specific predictor of hospital mortality ( 15 ). Another study with 72 patients with cardiac arrest demonstrated that the metabolic state, expressed as level of lactate just before VA-ECMO initiation seems more predictive of outcome than cardiopulmonary resuscitation duration or absence of return of spontaneous circulation ( 16 ).…”

The Value of Combining Carbon Dioxide Gap and Oxygen-Derived Variables with Lactate Clearance in Predicting Mortality after Resuscitation of Septic Shock Patients

“…Our study showed that both the survivors and nonsurvivors had similar initial lactate levels, but, after resuscitation, lactate clearance was evident in the survivors. Progressive hyperlactatemia has been associated with mortality and other negative clinical outcomes in septic and nonseptic critically ill patients [3,4,10,29,[32][33][34]. Despite the proven beneficial role of lactate clearance in guiding [35][36][37].…”

SAVE score with lactate modification predicts in-hospital mortality in patients with ongoing cardiac arrest during VA-ECMO cannulation

“…This is likely due to the L-SAVE score’s inclusion of lactate which is an indicator of tissue perfusion, 9 and thus may serve as a proxy for quality of CPR. 10–15 In fact, when PC patients were excluded, mortality increased by about 10% between NoCA and PECA groups, and another 10% between PECA and OGCA groups. The L-SAVE is thus superior due to its enhanced ability to discriminate between groups.…”

“…Lactate, included in L-SAVE, represents quality of tissue perfusion 9 and thus serves as a proxy for quality of cardiopulmonary resuscitation (CPR). 10–15…”