Lactate clearance for initiating and weaning off extracorporeal membrane oxygenation in a child with regressed left ventricle after arterial switch operation

Singh, Sarvesh Pal; Chauhan, Sandeep; Bisoi, AK; Sahoo, Manoj Kumar

doi:10.4103/0971-9784.173046

Cited by 7 publications

(10 citation statements)

References 6 publications

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“…The imbalance between production and clearance of lactate causes higher lactate levels and LC may prognosticate the mortality in patients on extracorporeal circulatory support. It has also been correlated with survival, in post-cardiac arrest, after the return of spontaneous circulation with the help of ECMO [ 6 ]. Li et al [ 5 ] noticed that fluctuations in lactate values following the ECMO implantation can presage in-hospital mortality in post-cardiac surgery patients.…”

Section: Discussionmentioning

confidence: 99%

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Does lactate clearance prognosticates outcomes in ECMO therapy: a retrospective observational study

et al. 2018

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BackgroundECMO support is a final treatment modality for patients in the refractory cardiogenic arrest and postcardiotomy cardiogenic shock with an utmost importance. Eventhough it is linked to high mortality, its usage gains popularity worldwide. We assessed the fluctuation of lactate levels and the clearance of lactate during the ECMO therapy and its prognostic role on mortality.MethodsData were gathered on all patients receiving ECMO therapy longer than 48 h between January 2015 and December 2017 retrospectively. Blood lactate had been recorded before ECMO implantation and at specific time points during ECMO support as a routine procedure. In this study, the Lactate clearance at specific time points (Lactate clearance-1) and the duration that lactate cleared more than 10% of the initial lactate level (Lactate clearance-2) was measured. Statistical analysis included Mann Whitney U-test and ROC-curves to predict 30-day mortality.ResultsFourty-eight patients underwent ECMO therapy for refractory cardiogenic shock resulting in 70.8% mortality. The lactate levels before and after ECMO therapy as well as the dynamic changes were significantly correlated with mortality variable. With AUC calculation, LC-2 has a strong discrimination (AUC = 0.97) on 30-day survivors and nonsurvivors. LAE-LBE (AUC = 0.785), L48-LBE (AUC = 0.706) showed moderate predictive power on 30-day mortality.ConclusionsChanges in lactate levels after ECMO implantation is an important tool to assess effective circulatory support and it is found superior to single lactate measurements as a prognostic sign of mortality in our study. Based on our results, an early insertion of ECMO before lactate gets high was suggested. Serial changes on lactate levels and calculation of its clearance may be superior to single lactate on both effective circulatory support and as prognostic prediction. LC-2 showed a strong discrimination on 30-day mortality.

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Section: Discussionmentioning

confidence: 99%

“…Lactate is mainly cleared by the liver, skeletal and cardiac myocytes, and proximal tubule kidney cells. It is claimed that the cause of hyperlactatemia in patients who get stabilized via ECMO support is the decrease in lactate clearance rather than increased production of lactate as in sepsis without hemodynamic instability [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

Does lactate clearance prognosticates outcomes in ECMO therapy: a retrospective observational study

et al. 2018

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“…12 In a case report from our institute, we measured lactate level, calculated lactate clearance at 6 and 18 hour after initiation of ECMO in a child who underwent arterial switch operation for TGA, and concluded that increased lactate clearance predicts successful weaning from ECMO. 13 A high-peak inotropic score predicted mechanical support in children requiring ECMO support, following fulminant myocarditis. 14,15 In our study, we found that while on ECMO, decreasing trend of vasoactive inotropic score over the first 5 days was associated with successful weaning and significantly improved survival on VA-ECMO (p value 0.003).…”

Section: Discussionmentioning

confidence: 99%

Outcome of Cardiac ECMO in Children Less than 1 Year Age Undergoing Corrective Cardiac Surgery

Singh

Sengupta

Sahu

et al. 2020

Journal of Cardiac Critical Care TSS

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Extracorporeal membrane oxygenation (ECMO) has emerged as an effective mechanical support device to support both respiratory and cardiac function following cardiac surgery. The use of ECMO is more common among children who undergo complex surgical procedures. The objective of this study was to observe the outcomes of children subjected to central venoarterial (VA) ECMO after congenital cardiac surgery and identify the factors influencing survival in these children. Twenty children, below the age of 1 year, who underwent corrective cardiac surgery and were placed on ECMO support within first 48 hours of biventricular repair, from July 2018 to June 2019, were included in this study. ECMO was initiated either in the operating room (either preoperative decision or unable to come off cardiopulmonary bypass [CPB]) or in the intensive care unit (low-cardiac output syndrome). The maintenance and weaning from ECMO was done as per institute protocol. At the initiation of ECMO, the flows were maintained between 100 and 150 mL/kg/min. The flows were decreased if it was possible to maintain normal perfusion with lesser flows. Out of 20 children, 12 children were less than or equal to 2 months of age. The 30-day survival was 45% and all the children were alive at 4 months after discharge from hospital. A negative cumulative fluid balance (CFB) of more than 50 mL/kg in the first 48 hours, decreasing lactate and inotropic score, and improving ventricular function in the first 3 days of ECMO were associated with improved survival. The following factors were correlated with decreased survival: aortic cross-clamp time (AOCX T) more than 106 minutes, higher initial ECMO flows (75 vs. 52%), ECMO duration more than 4 days, increased transfusion of blood and blood products, urine output < 1.06 ± 0.81/kg/h (in the first 48 h), and increasing trend of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

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“…Lactate was the second best diagnostic discriminator of myocardial injury with an optimal “cutoff” value of >2 mmol/L at immediately after aortic declamping (AUC, 0.89 [±SE 0.04, 95% CI: 0.80–0.96]; sensitivity 83.33%; specificity 80%; likelihood ratio (+) 4.16) [ Figure 8 ]. [ 29 30 31 ] cTn-I was the third best diagnostic discriminator of myocardial injury with an optimal “cutoff” value of > 2.1 ng/mL at immediately after aortic declamping (AUC, 0.88 [±SE 0.04, 95% CI: 0.80–0.95]; sensitivity 81.25%; specificity 80%; likelihood ratio (+) 4.06) [ Figure 8 ]. CK-MB was the fourth best diagnostic discriminator of myocardial injury with an optimal “cutoff” value of > 58 log units/mL after coming off bypass before decannulation (AUC, 0.85 [±SE 0.05, 95% CI: 0.78–0.94]; sensitivity 77.08%; specificity 80%; likelihood ratio (+) 3.85) [ Table 4 and Figure 8 ].…”

Section: Discussionmentioning

confidence: 99%

Short-term prognostic value of perioperative coronary sinus-derived-serum cardiac troponin-I, creatine kinase-MB, lactate, pyruvate, and lactate-pyruvate ratio in adult patients undergoing open heart surgery

et al. 2016

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Objectives:To investigate the release pattern of different cardiac metabolites and biomarkers directly from the coronary sinus (CS) and to establish the diagnostic discrimination limits of each marker protein and metabolites to evaluate perioperative myocardial injury in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB).Patients and Methods:Sixty-eight patients undergoing first mitral and/or aortic valve replacements with/without coronary artery bypass grafting and Bentall procedure under CPB and blood cardioplegic arrest were studied. All cardiac metabolites and biomarkers were measured in serial CS-derived blood samples at pre-CPB, immediate post aortic declamping, 10 minutes post-CPB and 12 hrs post-CPB.Results:Receiver operating characteristic curve analysis of cardiac biomarkers indicated lactate-pyruvate ratio as the superior diagnostic discriminator of myocardial injury with an optimal “cut-off” value >10.8 immediately after aortic declamping (AUC, 0.92; 95% CI: 0.85-0.98). Lactate was the second best diagnostic discriminator of myocardial injury with an optimal “cut-off” value >2mmol/l at immediately after aortic declamping (AUC, 0.89; 95% CI: 0.80-0.96). Cardiac troponin-I was the third best diagnostic discriminator of myocardial injury with an optimal “cut-off” value >2.1ng/ml at immediately after aortic declamping (AUC, 0.88; 95% CI: 0.80-0.95). Creatine kinase-MB was the fourth best diagnostic discriminator of myocardial injury with an optimal “cut-off” value >58 log units/ml prior to decanulation (AUC, 0.85; 95% CI: 0.78-0.94).Conclusions:Measurable cardiac damage exists in all patients undergoing cardiac surgery under cardioplegic arrest. The degree of myocardial injury is more in patients with poor ventricular function and those requiring longer aortic clamp time. CS-derived lactate-pyruvate ratio, lactate, cTn-I served as superior diagnostic discriminators of peri-operative myocardial damage.

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Lactate clearance for initiating and weaning off extracorporeal membrane oxygenation in a child with regressed left ventricle after arterial switch operation

Cited by 7 publications

References 6 publications

Does lactate clearance prognosticates outcomes in ECMO therapy: a retrospective observational study

Does lactate clearance prognosticates outcomes in ECMO therapy: a retrospective observational study

Outcome of Cardiac ECMO in Children Less than 1 Year Age Undergoing Corrective Cardiac Surgery

Short-term prognostic value of perioperative coronary sinus-derived-serum cardiac troponin-I, creatine kinase-MB, lactate, pyruvate, and lactate-pyruvate ratio in adult patients undergoing open heart surgery

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