Blood Lactate as a Reliable Marker for Mortality of Pediatric Refractory Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation
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.
KeywordsExtracorporeal membrane oxygenation Pediatric Lactate Mortality
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.
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.
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.
- 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 CrossRefPubMedPubMedCentralGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedPubMedCentralGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedPubMedCentralGoogle Scholar
- 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 CrossRefPubMedPubMedCentralGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar
- 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 CrossRefPubMedGoogle Scholar