Advertisement

Pediatric Cardiology

, Volume 40, Issue 3, pp 602–609 | Cite as

Blood Lactate as a Reliable Marker for Mortality of Pediatric Refractory Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation

  • Lijun Yang
  • Yong FanEmail author
  • Ru Lin
  • Wenlong He
Original Article

Abstract

The objective of this study is to establish reliable markers for mortality in children with refractory cardiogenic shock who underwent extracorporeal membrane oxygenation. A retrospective observational cohort study was performed at academic children’s hospital for forty-three consecutive pediatric patients who required veno-arterial extracorporeal membrane oxygenation (ECMO) support with refractory cardiogenic shock from January 2011 to October 2017. 30-day mortality in this cohort was 39.5% (17/43), and successful ECMO weaning rate was 69.8%. Blood lactate was elevated before ECMO implantation and the lactate peak concentration had significant differences between survivors and non-survivors, 8.4 ± 4.3 vs 13.9 ± 6.6 mmol/L. AUC to ROC curve analysis of lactate peak was 0.745 (p < 0.05), and the best cut-off value was 14.2 mmmol/L (sensitivity: 53%, specificity: 92%). The length of lactate level > 5 mmol/L was the most significant connection to 30-day mortality. Its AUC was 0.722 (p < 0.05), and the best cut-off value was 3.3 h (sensitivity: 67%, specificity: 80%). Non-survivors had significantly higher lactate levels during 0–6 h of ECMO support, compared to survivors, which also persisted at 7–12-h, 13–24-h, and 25–48-h ECMO. However, lactate clearance at 12 h, 24 h, 48 h revealed no significant differences between survivors and non-survivors based on 30-day mortality. Lactate peak and the duration of high lactate concentration before ECMO were reliable markers for 30-day mortality of pediatric patients with refractory cardiogenic shock. Static lactate values after ECMO implantation were associated with mortality while dynamic lactate value was not. Ensuring adequate ECMO support after cannulation and early diagnostic and intervention should be implemented to normalize the lactate level.

Keywords

Extracorporeal membrane oxygenation Pediatric Lactate Mortality 

Notes

Acknowledgements

My deepest gratitude goes first and foremost to Professor Ru Lin, for her constant encouragement and guidance. Second, I would like to express my thanks to my colleagues who have contributed to this article.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

The ethical standards of the institutional research committee granted permission to access and analyze the data with a waiver of informed consent because this is a retrospective analysis of the collected data.

References

  1. 1.
    Barbaro RP, Paden ML, Guner YS, Raman L, Ryerson LM, Alexander P, Nasr VG, Bembea MM, Rycus PT, Thiagarajan RR, Centers EM (2017) Pediatric Extracorporeal Life Support Organization Registry International Report 2016. ASAIO J 63:456–463.  https://doi.org/10.1097/MAT.0000000000000603 CrossRefGoogle Scholar
  2. 2.
    Brown KL, Ichord R, Marino BS, Thiagarajan RR (2013) Outcomes Following Extracorporeal Membrane Oxygenation in Children With Cardiac Disease. Pediatric Critical Care Medicine 14:S73–S83.  https://doi.org/10.1097/PCC.0b013e318292e3fc CrossRefGoogle Scholar
  3. 3.
    Gehrmann LP, Hafner JW, Montgomery DL, Buckley KW, Fortuna RS (2015) Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians. J Emerg Med 49:552–560.  https://doi.org/10.1016/j.jemermed.2015.02.010 CrossRefGoogle Scholar
  4. 4.
    Thourani VH, Kirshbom PM, Kanter KR, Simsic J, Kogon BE, Wagoner S, Dykes F, Fortenberry J, Forbess JM (2006) Venoarterial extracorporeal membrane oxygenation (VA-ECMO) in pediatric cardiac support. Ann Thorac Surg 82, 138–144; discussion 144–135.  https://doi.org/10.1016/j.athoracsur.2006.02.011 CrossRefGoogle Scholar
  5. 5.
    Rajagopal SK, Almond CS, Laussen PC, Rycus PT, Wypij D, Thiagarajan RR (2010) Extracorporeal membrane oxygenation for the support of infants, children, and young adults with acute myocarditis: a review of the Extracorporeal Life Support Organization registry. Crit Care Med 38:382–387.  https://doi.org/10.1097/CCM.0b013e3181bc8293 CrossRefGoogle Scholar
  6. 6.
    Joffe AR, Lequier L, Robertson CM (2012) Pediatric outcomes after extracorporeal membrane oxygenation for cardiac disease and for cardiac arrest: a review. ASAIO J 58:297–310.  https://doi.org/10.1097/MAT.0b013e31825a21ff CrossRefGoogle Scholar
  7. 7.
    Cooper DS, Jacobs JP, Moore L, Stock A, Gaynor JW, Chancy T, Parpard M, Griffin DA, Owens T, Checchia PA, Thiagarajan RR, Spray TL, Ravishankar C (2007) Cardiac extracorporeal life support: state of the art in 2007. Cardiol Young 17 Suppl 2, 104–115.  https://doi.org/10.1017/S1047951107001217 Google Scholar
  8. 8.
    Nichol A, Bailey M, Egi M, Pettila V, French C, Stachowski E, Reade MC, Cooper DJ, Bellomo R (2011) Dynamic lactate indices as predictors of outcome in critically ill patients. Crit Care 15:R242.  https://doi.org/10.1186/cc10497 CrossRefGoogle Scholar
  9. 9.
    Li CL, Wang H, Jia M, Ma N, Meng X, Hou XT (2015) The early dynamic behavior of lactate is linked to mortality in postcardiotomy patients with extracorporeal membrane oxygenation support: A retrospective observational study. J Thorac Cardiovasc Surg 149:1445–1450.  https://doi.org/10.1016/j.jtcvs.2014.11.052 CrossRefGoogle Scholar
  10. 10.
    Rigamonti F, Montecucco F, Boroli F, Rey F, Gencer B, Cikirikcioglu M, Reverdin S, Carbone F, Noble S, Roffi M, Banfi C, Giraud R (2016) The peak of blood lactate during the first 24 h predicts mortality in acute coronary syndrome patients under extracorporeal membrane oxygenation. Int J Cardiol 221:741–745.  https://doi.org/10.1016/j.ijcard.2016.07.065 CrossRefGoogle Scholar
  11. 11.
    Gaies MG, Jeffries HE, Niebler RA, Pasquali SK, Donohue JE, Yu S, Gall C, Rice TB, Thiagarajan RR (2014) Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries. Pediatr Crit Care Med 15:529–537.  https://doi.org/10.1097/PCC.0000000000000153 CrossRefGoogle Scholar
  12. 12.
    Rossi AF, Khan DM, Hannan R, Bolivar J, Zaidenweber M, Burke R (2005) Goal-directed medical therapy and point-of-care testing improve outcomes after congenital heart surgery. Intensive Care Med 31, 98–104.  https://doi.org/10.1007/s00134-004-2504-1 CrossRefGoogle Scholar
  13. 13.
    Prodhan P, Fiser RT, Dyamenahalli U, Gossett J, Imamura M, Jaquiss RD, Bhutta AT (2009) Outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) following refractory pediatric cardiac arrest in the intensive care unit. Resuscitation 80:1124–1129.  https://doi.org/10.1016/j.resuscitation.2009.07.004 CrossRefGoogle Scholar
  14. 14.
    Huang SC, Wu ET, Chen YS, Chang CI, Chiu IS, Wang SS, Lin FY, Ko WJ (2008) Extracorporeal membrane oxygenation rescue for cardiopulmonary resuscitation in pediatric patients. Crit Care Med 36:1607–1613.  https://doi.org/10.1097/CCM.0b013e318170b82b CrossRefGoogle Scholar
  15. 15.
    Polimenakos AC, Wojtyla P, Smith PJ, Rizzo V, Nater M, El Zein CF, Ilbawi MN (2011) Post-cardiotomy extracorporeal cardiopulmonary resuscitation in neonates with complex single ventricle: analysis of outcomes. Eur J Cardiothorac Surg 40:1396–1405. discussion 1405.  https://doi.org/10.1016/j.ejcts.2011.01.087 Google Scholar
  16. 16.
    Kumar TK, Zurakowski D, Dalton H, Talwar S, Allard-Picou A, Duebener LF, Sinha P, Moulick A (2010) Extracorporeal membrane oxygenation in postcardiotomy patients: factors influencing outcome. J Thorac Cardiovasc Surg 140:330–336 e332.  https://doi.org/10.1016/j.jtcvs.2010.02.034 CrossRefGoogle Scholar
  17. 17.
    Slottosch I, Liakopoulos O, Kuhn E, Scherner M, Deppe AC, Sabashnikov A, Mader N, Choi YH, Wippermann J, Wahlers T (2017) Lactate and lactate clearance as valuable tool to evaluate ECMO therapy in cardiogenic shock. J Crit Care 42:35–41.  https://doi.org/10.1016/j.jcrc.2017.06.022 CrossRefGoogle Scholar
  18. 18.
    Howard TS, Kalish BT, Wigmore D, Nathan M, Kulik TJ, Kaza AK, Williams K, Thiagarajan RR (2016) Association of extracorporeal membrane oxygenation support adequacy and residual lesions with outcomes in neonates supported after cardiac surgery. Pediatr Crit Care Med 17:1045–1054.  https://doi.org/10.1097/PCC.0000000000000943 CrossRefGoogle Scholar
  19. 19.
    Kolovos NS, Bratton SL, Moler FW, Bove EL, Ohye RG, Bartlett RH, Kulik TJ (2003) Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery. Ann Thorac Surg 76, 1435–1441.  https://doi.org/10.1016/s0003-4975(03)00898-1 CrossRefGoogle Scholar
  20. 20.
    Park SJ, Kim SP, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW (2014) Blood lactate level during extracorporeal life support as a surrogate marker for survival. J Thorac Cardiovasc Surg 148:714–720.  https://doi.org/10.1016/j.jtcvs.2014.02.078 CrossRefGoogle Scholar
  21. 21.
    Attana P, Lazzeri C, Chiostri M, Gensini GF, Valente S (2013) Dynamic behavior of lactate values in venous-arterial extracorporeal membrane oxygenation for refractory cardiac arrest. Resuscitation 84:e145–e146.  https://doi.org/10.1016/j.resuscitation.2013.07.007s CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Extracorporeal Circulation and Extracorporeal Life Support, Heart InstituteZhejiang University School of Medicine Children’s HospitalHangzhouPeople’s Republic of China

Personalised recommendations