Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

Biancari, Fausto; Fiore, Antonio; Jónsson, Kristján; Gatti, Giuseppe; Zipfel, S.; Ruggieri, Vito Giovanni; Perrotti, Andréa; Bounader, Karl; Loforte, Antonio; Lechiancole, Andrea; Saeed, Diyar; Lichtenberg, Artur; Pol, Marek; Spadaccio, Cristiano; Pettinari, Matteo; Mogianos, Krister; Alkhamees, Khalid; Mariscalco, Giovanni; El-Dean, Zein; Settembre, Nicla; Welp, Henryk; Fux, Thomas; Juvonen, Tatu; Dalén, Magnus

doi:10.3390/jcm8122218

Cited by 15 publications

(17 citation statements)

References 13 publications

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“…This is consistent with a previous study that reported a MAP of 80 (IQR, 68‐91) mmHg in 49 successfully weaned patients 6 . Several studies have shown a close association between high pre‐ECMO lactate level and mortality in patients receiving ECMO for cardiac causes 13‐15 ; however, only one study has reported the prognostic value of arterial lactate at time of weaning from ECMO 16 . Biancari et al observed that a cut‐off level of arterial blood lactate ≥ 1.6 mmol/L at weaning was predictive of hospital mortality.…”

Section: Discussionsupporting

confidence: 91%

“…The cumulative survival for patients who met the weaning criteria and patients failing to meet criteria at first attempt was 85% (95% CI, 64%-94%) and 17% (95% CI, 3%-41%), respectively, (P < .001) however, only one study has reported the prognostic value of arterial lactate at time of weaning from ECMO. 16 Biancari et al observed that a cut-off level of arterial blood lactate ≥ 1.6 mmol/L at weaning was predictive of hospital mortality. In our population, there was no significant difference in arterial lactate level and pH at the time of weaning between patients fulfilling the weaning criteria and patients failing the criteria.…”

Section: Ta B L E 2 Outcome Variables F I G U R Ementioning

confidence: 99%

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A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure

Mørk

Frederiksen

Nielsen

et al. 2021

Acta Anaesthesiol Scand

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Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is commonly used to provide haemodynamic support for patients with severe cardiac failure. However, timing ECMO weaning remains challenging. We aimed to examine if an integrative weaning approach based on predefined haemodynamic, respiratory and echocardiographic criteria is associated with successful weaning.Methods: All patients weaned from ECMO between April 2017 and April 2019 at Aarhus University Hospital, Denmark, were consecutively enrolled. Predefined haemodynamic, respiratory and echocardiographic criteria were assessed before and during ECMO flow reduction. A weaning attempt was commenced in haemodynamic stable patients and patients remaining stable at minimal flow were weaned from ECMO. Comparisons were made between patients who met the criteria for weaning at first attempt and patients who did not meet these criteria. Patients completing a full weaning attempt with no further need for mechanical support within 24 h were defined as successfully weaned.Results: A total of 38 patients were included in the study, of whom 26 (68%) patients met the criteria for weaning. Among these patients, 25 (96%) could be successfully weaned. Successfully weaned patients were younger and had less need for inotropic support and ECMO duration was shorter. Fulfilling the weaning criteria was associated with successful weaning and both favourable 30-d survival and survival to discharge. Conclusion:An integrative weaning approach based on haemodynamic, respiratory and echocardiographic criteria may strengthen the clinical decision process in predicting successful weaning in patients receiving ECMO for refractory cardiac failure. Editorial CommentThis report concerns testing of a standardized protocol to wean patients of venoarterial ECMO, based on haemodynamic, respiratory and echocardiographic assessment. Among those who fulfilled the entry criteria for weaning, 96% were successfully separated from ECMO. Notable limitations are small sample size and a lack of comparison group receiving nonprotocolized weaning. The results support meticulous systematic assessment of patients on VA-ECMO to facilitate timely and successful weaning. How to cite this article: Mørk SR, Frederiksen CA, Nielsen RR, et al. A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure. Acta Anaesthesiol Scand.

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Section: Discussionsupporting

confidence: 91%

Section: Ta B L E 2 Outcome Variables F I G U R Ementioning

confidence: 99%

A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure

Mørk

Frederiksen

Nielsen

et al. 2021

Acta Anaesthesiol Scand

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“…In a recent large multi-centric study of post-cardiotomy cardiac failure treated with VA-ECMO, lactate level >1.6 mmol/L at weaning was predictive of in-hospital mortality. 24 However, weaning failure remains higher than 50% even when these criteria are fulfilled and is associated with an increase in overall mortality. [7][8] Indeed, weaning failure is associated with the use of another form of temporary mechanical circulatory support, weaning failure related shock requiring the use of high dose vasopressors and inotropes, increased arrhythmia, a greater myocardial energy imbalance, excessive peripheral vasoconstriction and subsequent organ hypo-perfusion, and mortality.…”

Section: Discussionmentioning

confidence: 99%

“…High lactate levels at weaning were predictive of in-hospital mortality in postcardiotomy patients treated with VA-ECMO. 24 VIS was used in order to homogenize data concerning vasopressor or inotrope use after VA-ECMO removal, and value ≤10 was used according to previous studies. 31 We decided to administer levosimendan before VA-ECMO weaning.…”

Section: Discussionmentioning

confidence: 99%

Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial

et al. 2021

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Aims Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in circulatory failure. The main indications are cardiogenic shock, post-cardiotomy cardiac failure, and refractory cardiac arrest. However, VA-ECMO weaning is particularly challenging, and weaning failure is reported to be as high as 50%, with increased related mortality. Levosimendan is a novel long acting effect inodilator used in cardiogenic shock and terminal heart failure decompensation. Levosimendan use in VA-ECMO patients seems to reduce weaning failure regardless of the initial aetiology and to reduce mortality when administrated early after VA-ECMO initiation. However, studies are limited to retrospective analyses and reported case series. The aim of the WEANILEVO trial is to evaluate whether administration of levosimendan before VA-ECMO weaning is associated with a reduced rates of weaning failure and recourse to other temporary circulatory support. Methods and results WEANILEVO is a randomized, prospective, multicentre, double-blind, parallel-group, controlled trial. One hundred eighty patients will be enrolled if they had acute circulatory heart failure treated with VA-ECMO and for whom weaning is expected within 48 h. The study drugs are either levosimendan (0.2 μg/kg/min for 24 h) or a placebo. The primary endpoint of the trial is the absence of VA-ECMO weaning, recourse to another VA-ECMO, or other temporary circulatory assistance or death within 7 days of VA-ECMO weaning. Conclusions Levosimendan use in VA-ECMO appears to be beneficial for reducing weaning failure and mortality. The results of WEANILEVO should significantly influence decisions regarding the use of levosimendan for VA-ECMO weaning.

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“…3 Furthermore, when assessing lactate prior to weaning off VA-ECMO, post-cardiotomy patients with lactate ⩾1.4 mmol/L had significantly higher risk of hospital mortality compared to patients with lower lactate levels. 4…”

Section: Introductionmentioning

confidence: 99%

Outcomes of end-organ function and survival with veno-arterial extracorporeal membrane oxygenation

et al. 2020

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Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a temporary therapy option for refractory cardiac or respiratory failure. Preliminary study suggests that ECMO aids in the recovery of end-organ function by maintaining systemic perfusion. Methods: A retrospective IRB approved database research and chart review was performed on patients initiated on veno-arterial (VA-) ECMO between September 2010 and April 2019. End-organ injury markers were compared between the pre-ECMO period, defined as markers recorded before ECMO initiation, and the pre-decannulation period, defined as markers prior to ECMO decannulation. Data was expressed with mean ± standard deviation, or median [quartile 1, quartile 3] and compared between Pre-ECMO and per-decannulation period. Results: Among the 159 VA-ECMO patients, 100 patients (63%) survived ECMO with mean ECMO duration 10 ± 7 days. Within the survival group, 78 patients (49%) weaned to recovery, and 22 patients (14%) weaned off to durable implantable devices. Compared to the pre-ECMO period, the pre-decannulation period significantly improved in pH (7.23 ± 0.19 vs. 7.40 ± 0.09; p < 0.001) and lactate (5.5 [2.3, 9.0] vs. 1.6 [0.9, 2.3]; p < 0.001), and serum creatinine (1.4 [1.1, 2.1] vs. 1.1 [0.8, 1.7]; p < 0.001). Significant changes were noted in ventilation parameters as well, such as FiO2 (100 [100, 100] vs. 50 [50, 50]; p < 0.001), PaO2 (88 [62, 135], 126 [87, 162]; p < 0.001) and PEEP (8.0 [5.0, 12.0] vs. 5.0 [5.0, 8.0]; p < 0.001). Conclusion: Maintaining perfusion with VA-ECMO utilization on indicated patients demonstrated improvements in end-organ functions. Survival rates of VA-ECMO patients were also optimistic.

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Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

Cited by 15 publications

References 13 publications

A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure

A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure

Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial

Outcomes of end-organ function and survival with veno-arterial extracorporeal membrane oxygenation

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