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Olson TL, Kilcoyne HW, Morales-Demori R, Rycus P, Barbaro RP, Alexander PMA, Anders MM. Extracorporeal cardiopulmonary resuscitation for pediatric out-of-hospital cardiac arrest: A review of the Extracorporeal Life Support Organization Registry. Resuscitation 2024; 203:110380. [PMID: 39222833 DOI: 10.1016/j.resuscitation.2024.110380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/23/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
AIMS Current data are insufficient for the leading resuscitation societies to advise on the use of extracorporeal cardiopulmonary resuscitation (ECPR) for pediatric out-of-hospital cardiac arrest (OHCA). The aim of this study was to explore the current utilization of ECPR for pediatric OHCA and characterize the patient demographics, arrest features, and metabolic parameters associated with survival. METHODS Retrospective review of the Extracorporeal Life Support Organization Registry database from January 2020 to May 2023, including children 28 days to 18 years old who received ECPR for OHCA. The primary outcome was survival to hospital discharge. RESULTS Eighty patients met inclusion criteria. Median age was 8.8 years [2.0-15.8] and 53.8% of patients were male. OHCA was witnessed for 65.0% of patients and 46.3% received bystander cardiopulmonary resuscitation (CPR). Initial rhythm was shockable in 26.3% of patients and total CPR duration was 78 min [52-106]. Signs of life were noted for 31.3% of patients and a cardiac etiology precipitating event was present in 45.0%. Survival to discharge was 29.9%. Initial shockable rhythm was associated with increased odds of survival (unadjusted OR 4.7 [1.5-14.5]; p = 0.006), as were signs of life prior to ECMO (unadjusted OR 7.8 [2.6-23.4]; p < 0.001). Lactate levels early on-ECMO (unadjusted OR 0.89 [0.79-0.99]; p = 0.02) and at 24 h on-ECMO (unadjusted OR 0.62 [0.42-0.91]; p < 0.001) were associated with decreased odds of survival. CONCLUSIONS These preliminary data suggest that while overall survival is poor, a carefully selected pediatric OHCA patient may benefit from ECPR. Further studies are needed to understand long-term neurologic outcomes.
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Affiliation(s)
- Taylor L Olson
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC, USA.
| | - Hannah W Kilcoyne
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC, USA.
| | - Raysa Morales-Demori
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, USA.
| | - Peter Rycus
- Extracorporeal Life Support Organization, 3001 Miller Road, Ann Arbor, MI, USA.
| | - Ryan P Barbaro
- Department of Pediatrics, Division of Critical Care Medicine, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, USA.
| | - Peta M A Alexander
- Department of Pediatrics, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA.
| | - Marc M Anders
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, USA.
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Sugimoto M, Takayama W, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Otomo Y. Impact of Lactate Clearance on Clinical and Neurological Outcomes of Patients With Out-of-Hospital Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Secondary Data Analysis. Crit Care Med 2024; 52:e341-e350. [PMID: 38411442 PMCID: PMC11166734 DOI: 10.1097/ccm.0000000000006245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
OBJECTIVES Serial evaluations of lactate concentration may be more useful in predicting outcomes in patients with out-of-hospital cardiac arrest (OHCA) than a single measurement. This study aimed to evaluate the impact of lactate clearance (LC) on clinical and neurologic outcomes in patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR). DESIGN Retrospective multicenter observational study. SETTING Patients with OHCA receiving ECPR at 36 hospitals in Japan between January 1, 2013, and December 31, 2018. PATIENTS This study evaluated 1227 patients, with lactate initial assessed upon emergency department admission and lactate second measured subsequently. To adjust for the disparity in the time between lactate measurements, the modified 6-hour LC was defined as follows: ([lactate initial -lactate second ]/lactate initial ) × 100 × (6/the duration between the initial and second measurements [hr]). The patients were divided into four groups according to the modified 6-hour LC with an equivalent number of patients among LC quartiles: Q1 (LC < 18.8), Q2 (18.8 < LC < 59.9), Q3 (60.0 < LC < 101.2), and Q4 (101.2 < LC). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 30-day survival rates increased as the 6-hour LC increased (Q1, 21.2%; Q2, 36.8%; Q3, 41.4%; Q4, 53.6%; p for trend < 0.001). In the multivariate analysis, the modified 6-hour LC was significantly associated with a 30-day survival rate (adjusted odds ratio [AOR], 1.003; 95% CI, 1.001-1.005; p < 0.001) and favorable neurologic outcome (AOR, 1.002; 95% CI, 1.000-1.004; p = 0.027). CONCLUSIONS In patients with OHCA who underwent ECPR, an increase in the modified 6-hour LC was associated with favorable clinical and neurologic outcome. Thus, LC can be a criterion to assess whether ECPR should be continued.
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Affiliation(s)
- Momoko Sugimoto
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Wataru Takayama
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan
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Wang J, Ji M. The 6-hour lactate clearance rate in predicting 30-day mortality in cardiogenic shock. JOURNAL OF INTENSIVE MEDICINE 2024; 4:393-399. [PMID: 39035609 PMCID: PMC11258499 DOI: 10.1016/j.jointm.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/25/2023] [Accepted: 01/10/2024] [Indexed: 07/23/2024]
Abstract
Background Early evaluation of prognosis in cardiogenic shock (CS) is crucial for tailored treatment selection. Both lactate clearance and lactate levels are considered useful prognostic biomarkers in patients with CS. However, there is yet no literature comparing the 6-hour lactate clearance rate (Δ6Lac) with lactate levels measured at admission (L1) and after 6 h (L2) to predict 30-day mortality in CS. Methods In this observational cohort study, 95 patients with CS were treated at Department of Intensive Care Unit, Yiwu Central Hospital between January 2020 and December 2022. Of these, 88 patients met the eligibility criteria. The lactate levels were measured after admission (L1) as the baseline lactate value, and were measured after 6 h (L2) following admission. The primary endpoint of the study was survival rate at 30 days. A receiver operating characteristic curve was used for data analysis. Univariate and multivariate Cox regression analyses were performed based on Δ6Lac. Kaplan-Meier (KM) survival curves were generated to compare the 30-day survival rates among L1, L2, and Δ6Lac. Results The Δ6Lac model showed the highest area under the curve value (0.839), followed by the L2 (0.805) and L1 (0.668) models. The Δ6Lac model showed a sensitivity of 84.2% and specificity of 75.4%. The L1 and L2 models had sensitivities of 57.9% each and specificities of 89.9% and 98.6%, respectively. The cut-off values for Δ6Lac, L1, and L2 were 18.2%, 6.7 mmol/L, and 6.1 mmol/L, respectively. Univariate Cox regression analysis revealed a significant association between Δ6Lac and 30-day mortality. After adjusting for five models in multivariate Cox regression, Δ6Lac remained a significant risk factor for 30-day mortality in patients with CS. In our fifth multivariate Cox regression model, Δ6Lac remained a risk factor associated with 30-day mortality (hazard ratio [HR]=5.14, 95% confidence interval [CI]: 1.48 to 17.89, P=0.010) as well as L2 (HR=8.42, 95% CI: 1.26 to 56.22, P=0.028). The KM survival curve analysis revealed that L1 >6.7 mmol/L (HR=8.08, 95% CI: 3.23 to 20.20, P <0.001), L2 >6.1 mmol/L (HR=25.97, 95% CI: 9.76 to 69.15, P <0.001), and Δ6Lac ≤18.2% (HR=8.92, 95% CI: 2.95 to 26.95, P <0.001) were associated with a higher risk of 30-day mortality. Conclusions Δ6Lac is a better predictor for 30-day mortality in CS than lactate levels at admission. It has a predictive value equivalent to that of lactate level at 6 h after admission, making it an important surrogate indicator for evaluating the suitability as well as poor prognosis after CS treatment. We found that a cut-off value of 18.2% for Δ6Lac provided the most accurate assessment of early prognosis in CS.
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Affiliation(s)
- Junfeng Wang
- Department of Intensive Care Unit, Yiwu Central Hospital, Yiwu, Zhejiang, China
| | - Mingxia Ji
- Department of Intensive Care Unit, Yiwu Central Hospital, Yiwu, Zhejiang, China
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Bernard S, Pashun RA, Varma B, Yuriditsky E. Physiology-Guided Resuscitation: Monitoring and Augmenting Perfusion during Cardiopulmonary Arrest. J Clin Med 2024; 13:3527. [PMID: 38930056 PMCID: PMC11205151 DOI: 10.3390/jcm13123527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
Given the high morbidity and mortality associated with cardiopulmonary arrest, there have been multiple trials aimed at better monitoring and augmenting coronary, cerebral, and systemic perfusion. This article aims to elucidate these interventions, first by detailing the physiology of cardiopulmonary resuscitation and the available tools for managing cardiopulmonary arrest, followed by an in-depth examination of the newest advances in the monitoring and delivery of advanced cardiac life support.
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Affiliation(s)
| | | | | | - Eugene Yuriditsky
- Division of Cardiology, New York University Grossman School of Medicine, New York, NY 10016, USA; (S.B.); (R.A.P.)
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Choi SY, Oh SH, Park KN, Youn CS, Kim HJ, Park SH, Lim JY, Kim HJ, Bang HJ. Association between early lactate-related variables and 6-month neurological outcome in out-of-hospital cardiac arrest patients. Am J Emerg Med 2024; 78:62-68. [PMID: 38217899 DOI: 10.1016/j.ajem.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024] Open
Abstract
INTRODUCTION The role of lactate measurement in out-of-hospital cardiac arrest (OHCA) survivors remains controversial. We assessed the association between early lactate-related variables, OHCA characteristics, and long-term neurological outcome. METHODS In OHCA patients who received targeted temperature management, lactate levels were measured at 0, 12, and 24 h after the return of spontaneous circulation. We calculated lactate clearance and time-weighted cumulative lactate (TWCL), which represent the area under the time-lactate curve. The area under the receiver operating characteristic curve (AUC) and the adjusted odds ratios (AORs) of lactate-related variables for predicting 6-month poor outcome (Cerebral Performance Category 3-5) were evaluated. Interactions between lactate variables and characteristics of OHCA were evaluated by a multivariable logistic model with interaction terms and subgroup analysis. RESULTS A total of 347 OHCA patients were included. After adjustment, higher lactate levels at the three time points were associated with a poor outcome (AOR 1.10 [95% CI, 1.03-1.18], AOR 1.15 [95% CI, 1.02-1.29], and AOR 1.36 [95% CI, 1.15-1.60], respectively), while TWCL was the only lactate kinetics variable associated with a poor outcome (AOR 1.29 [95% CI, 1.12-1.49]). We identified several interactions between lactate-related variables and OHCA characteristics. In particular, the AUC of TWCL was excellent in cases of noncardiac etiology (AUC 0.92 [95% CI, 0.86-0.96] but only moderate in cardiac etiology (AUC 0.69 [95% CI, 0.62-0.75]). CONCLUSIONS Early lactate levels, especially at 24 h, and TWCL were independent predictors of neurologic outcome in these patients, whereas lactate clearance was not. The prognostic ability of lactate-related variables varied depending on the OHCA characteristics.
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Affiliation(s)
- Se Young Choi
- Department of Emergency Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang Hyun Park
- Department of Emergency Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Susur O, Yesіlaras M, Eyler Y. The Relationship Between Lactate and Lactate Clearance with In-Hospital Mortality in Unselected Emergency Department Patients. Prehosp Disaster Med 2024; 39:178-183. [PMID: 38454833 DOI: 10.1017/s1049023x24000141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Lactate is a frequently used biomarker in emergency departments (EDs), especially in critically ill patients. The aim of this study is to investigate the relationship between lactate and lactate clearance with in-hospital mortality in unselected ED patients. METHODS This study was carried out retrospectively in the ED of a tertiary hospital. Patients aged 18 years and older whose blood lactate level was obtained in the ED were included in the study. Patients whose lactate value did not have sufficient analytical accuracy, whose lactate value was recorded in the system 180 minutes after admission, who were admitted to the ED as cardiac arrest, and whose ED or hospital outcome was unknown were excluded from the study. According to the first measured lactate value, the patients were divided into three groups: < 2.0mmol/L, 2.0-3.9mmol/L, and ≥ 4.0mmol/L. Lactate clearance was calculated and recorded in patients with one-to-four hours between two lactate values. RESULTS During the five-year study period, a total of 1,070,406 patients were admitted to the ED, of which 114,438 (10.7%) received blood gas analysis. The median age of 81,449 patients included in the study was 58 years (IQR: 30, min: 18-max: 117) and 54.4% were female. The study found that non-trauma patients with a lactate level between 2.0-3.9mmol/L had a 2.5-times higher mortality risk, while those with a lactate level of ≥ 4.0mmol/L had a 20.8-times higher risk, compared to those with a lactate level < 2.0mmol/L. For trauma patients, the mortality risk was three-times higher for those with lactate levels between 2.0-3.9mmol/L and nine-times higher for those with a lactate level of ≥ 4.0mmol/L, compared to those with a lactate level < 2.0mmol/L. Among patients with a first measured lactate value ≥ 4.0mmol/L and a two-hour lactate clearance < 20%, the mortality rate was 19.7%. In addition, lactate, lactate clearance, and age were independent variables for mortality in this patient group. CONCLUSION The lactate value in unselected patients in the ED is a biomarker that can be used to predict the prognosis of the patients. In addition, lactate, lactate clearance, and age are independent predictors of mortality.
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Affiliation(s)
- Ozlem Susur
- Emergency Physician, Department of Emergency, Merkezefendi State Hospital, Manisa, Turkey
| | - Murat Yesіlaras
- Emergency Physician, Department of Emergency, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Yesim Eyler
- Emergency Physician, Department of Emergency, Tepecik Training and Research Hospital, Izmir, Turkey
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Wu X, Cap AP, Bynum JA, Chance TC, Darlington DN, Meledeo MA. Prolyl hydroxylase domain inhibitor is an effective pre-hospital pharmaceutical intervention for trauma and hemorrhagic shock. Sci Rep 2024; 14:3874. [PMID: 38365865 PMCID: PMC10873291 DOI: 10.1038/s41598-024-53945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/07/2024] [Indexed: 02/18/2024] Open
Abstract
Pre-hospital potentially preventable trauma related deaths are mainly due to hypoperfusion-induced tissue hypoxia leading to irreversible organ dysfunction at or near the point of injury or during transportation prior to receiving definitive therapy. The prolyl hydroxylase domain (PHD) is an oxygen sensor that regulates tissue adaptation to hypoxia by stabilizing hypoxia inducible factor (HIF). The benefit of PHD inhibitors (PHDi) in the treatment of anemia and lactatemia arises from HIF stabilization, which stimulates endogenous production of erythropoietin and activates lactate recycling through gluconeogenesis. The results of this study provide insight into the therapeutic roles of MK-8617, a pan-inhibitor of PHD-1, 2, and 3, in the mitigation of lactatemia in anesthetized rats with polytrauma and hemorrhagic shock. Additionally, in an anesthetized rat model of lethal decompensated hemorrhagic shock, acute administration of MK-8617 significantly improves one-hour survival and maintains survival at least until 4 h following limited resuscitation with whole blood (20% EBV) at one hour after hemorrhage. This study suggests that pharmaceutical interventions to inhibit prolyl hydroxylase activity can be used as a potential pre-hospital countermeasure for trauma and hemorrhage at or near the point of injury.
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Affiliation(s)
- Xiaowu Wu
- Blood and Shock Resuscitation, USA Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3610, JBSA Fort Sam Houston, TX, 78234-7767, USA.
| | - Andrew P Cap
- Blood and Shock Resuscitation, USA Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3610, JBSA Fort Sam Houston, TX, 78234-7767, USA
| | - James A Bynum
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Tiffani C Chance
- Department of Health and Human Services, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Daniel N Darlington
- Blood and Shock Resuscitation, USA Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3610, JBSA Fort Sam Houston, TX, 78234-7767, USA
| | - Michael A Meledeo
- Blood and Shock Resuscitation, USA Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3610, JBSA Fort Sam Houston, TX, 78234-7767, USA
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Mieritz HB, Povlsen AL, Linde L, Beske RP, Helgestad OKL, Josiassen J, Hassager C, Schmidt H, Jensen LO, Holmvang L, Møller JE, Ravn HB. DIFFERENCES IN MANAGEMENT AND PROGNOSTICATION OF CARDIOGENIC SHOCK PATIENTS IN THE PRESENCE AND ABSENCE OF OUT-OF-HOSPITAL CARDIAC ARREST. Shock 2024; 61:209-214. [PMID: 38010103 DOI: 10.1097/shk.0000000000002272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Background: The clinical spectrum of acute myocardial infarction complicated by cardiogenic shock (AMICS) varies. Out-of-hospital cardiac arrest (OHCA) can be the first sign of cardiac failure, whereas others present with various degrees of hemodynamic instability (non-OHCA). The aim of the present study was to explore differences in prehospital management and characteristics of survivors and nonsurvivors in AMICS patients with OHCA or non-OHCA. Methods: Data analysis was based on patient data from the RETROSHOCK cohort comprising consecutive AMICS patients admitted to two tertiary cardiac centers between 2010 and 2017. Results: 1,716 AMICS patients were included and 42% presented with OHCA. Mortality in OHCA patients was 47% versus 57% in the non-OHCA group. Almost all OHCA patients were intubated before admission (96%). In the non-OHCA group, prehospital intubation (25%) was associated with a better survival ( P < 0.001). Lactate level on admission demonstrated a linear relationship with mortality in OHCA patients. In non-OHCA, probability of death was higher for any given lactate level <12 mmol/L compared with OHCA. However, a lactate level >7 mmol/L in non-OHCA did not increase mortality odds any further. Conclusion: Mortality was almost doubled for any admission lactate level up to 7 mmol/L in non-OHCA patients. Above this level, mortality remained unchanged in non-OHCA patients but continued to increase in OHCA patients. Prehospital intubation was performed in almost all OHCA patients but only in one of four patients without OHCA. Early intubation in non-OHCA patients was associated with a better outcome.
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Affiliation(s)
- Hanne Beck Mieritz
- Department of Cardiothoracic Anesthesia, Odense University Hospital, Odense, Denmark
| | - Amalie Ling Povlsen
- Department of Cardiothoracic Anesthesia, Odense University Hospital, Odense, Denmark
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Rasmus Paulin Beske
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Cardiothoracic Anesthesia, Odense University Hospital, Odense, Denmark
| | | | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Vujanović V, Borovnik Lesjak V, Mekiš D, Strnad M. Dynamics of Capillary Lactate Levels in Patients with Out-of-Hospital Cardiac Arrest. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1989. [PMID: 38004038 PMCID: PMC10673385 DOI: 10.3390/medicina59111989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: An effective strategy for cardiopulmonary resuscitation should be based on tissue perfusion. Our primary aim was to determine the association between capillary lactate values and initial rhythm as well as the probability of the return of spontaneous circulation in out-of-hospital cardiac arrest patients. Materials and Methods: This prospective observational cohort study included all patients with non-traumatic out-of-hospital cardiac arrest, older than 18 years, resuscitated by a prehospital emergency medical team between April 2020 and June 2021. Capillary lactate samples were collected at the time of arrival and every 10 min after the first measurement until the time of the return of spontaneous circulation (ROSC) or, if ROSC was not achieved, at the time of declaring death on the scene. Results: In total, 83 patients were enrolled in the study. ROSC was achieved in 28 patients (33.7%), 21 were admitted to hospital (26.3%), and 6 (7.23%) of them were discharged from hospital. At discharge, all patients had Cerebral Performance Category Scale 1 or 2. Initial capillary lactate values were significantly higher in patients with a non-shockable rhythm compared to the group with a shockable rhythm (9.19 ± 4.6 versus 6.43 ± 3.81; p = 0.037). A significant difference also persisted in a second value taken 10 min after the initial value (10.03 ± 5,19 versus 5.18 ± 3.47; p = 0.019). Capillary lactate values were higher in the ROSC group and non-ROSC group at the time of restored circulation (11.10 ± 6.59 and 6.77 ± 4.23, respectively; p = 0.047). Conclusions: Capillary lactate values are significantly higher in patients with a non-shockable first rhythm in out-of-hospital cardiac arrest (OHCA). There is also a significantly different rise in capillary lactate levels in patients with ROSC.
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Affiliation(s)
- Vitka Vujanović
- Center for Emergency Medicine, Prehospital Unit, Community Healthcare Center, Cesta Proletarskih Brigad 21, 2000 Maribor, Slovenia; (V.B.L.)
| | - Vesna Borovnik Lesjak
- Center for Emergency Medicine, Prehospital Unit, Community Healthcare Center, Cesta Proletarskih Brigad 21, 2000 Maribor, Slovenia; (V.B.L.)
| | - Dušan Mekiš
- Department of Anaesthesiology, Intensive Care and Pain Management, University Clinical Centre Maribor, Ljubljanska ul. 5, 2000 Maribor, Slovenia;
- Faculty of Medicine, University of Maribor, Taborska 8, 2000 Maribor, Slovenia
| | - Matej Strnad
- Center for Emergency Medicine, Prehospital Unit, Community Healthcare Center, Cesta Proletarskih Brigad 21, 2000 Maribor, Slovenia; (V.B.L.)
- Emergency Department, University Clinical Centre Maribor, Ljubljanska ul. 5, 2000 Maribor, Slovenia
- Department of Emergency Medicine, Faculty of Medicine, University of Maribor, Taborska 8, 2000 Maribor, Slovenia
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Dusik M, Rob D, Smalcova J, Havranek S, Karasek J, Smid O, Brodska HL, Kavalkova P, Huptych M, Bakker J, Belohlavek J. Serum lactate in refractory out-of-hospital cardiac arrest: Post-hoc analysis of the Prague OHCA study. Resuscitation 2023; 192:109935. [PMID: 37574002 DOI: 10.1016/j.resuscitation.2023.109935] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/12/2023] [Accepted: 08/05/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The severity of tissue hypoxia is routinely assessed by serum lactate. We aimed to determine whether early lactate levels predict outcomes in refractory out-of-hospital cardiac arrest (OHCA) treated by conventional and extracorporeal cardiopulmonary resuscitation (ECPR). METHODS This study is a post-hoc analysis of a randomized Prague OHCA study (NCT01511666) assessing serum lactate levels in refractory OHCA treated by ECPR (the ECPR group) or conventional resuscitation with prehospital achieved return of spontaneous circulation (the ROSC group). Lactate concentrations measured on admission and every 4 hours (h) during the first 24 h were used to determine their relationship with the neurological outcome (the best Cerebral Performance Category score within 180 days post-cardiac arrest). RESULTS In the ECPR group (92 patients, median age 58.5 years, 83% male) 26% attained a favorable neurological outcome. In the ROSC group (82 patients, median age 55 years, 83% male) 59% achieved a favorable neurological outcome. In ECPR patients lactate concentrations could discriminate favorable outcome patients, but not consistently in the ROSC group. On admission, serum lactate >14.0 mmol/L for ECPR (specificity 87.5%, sensitivity 54.4%) and >10.8 mmol/L for the ROSC group (specificity 83%, sensitivity 41.2%) predicted an unfavorable outcome. CONCLUSION In refractory OHCA serum lactate concentrations measured anytime during the first 24 h after admission to the hospital were found to correlate with the outcome in patients treated by ECPR but not in patients with prehospital ROSC. A single lactate measurement is not enough for a reliable outcome prediction and cannot be used alone to guide treatment.
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Affiliation(s)
- Milan Dusik
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Daniel Rob
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Jana Smalcova
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Stepan Havranek
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Jiri Karasek
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Ondrej Smid
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Helena Lahoda Brodska
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Petra Kavalkova
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Michal Huptych
- Czech Institute of Informatics, Robotics and Cybernetics (CIIRC), Czech Technical University, Prague, Czech Republic
| | - Jan Bakker
- Erasmus MC University Medical Center, Rotterdam, Netherlands; NYU Langone and Columbia University Irving Medical Center, New York, USA; Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jan Belohlavek
- 2(nd) Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic.
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11
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Hoehne SN, Hopper K, Epstein SE. Association of point-of-care blood variables obtained from dogs and cats during cardiopulmonary resuscitation and following return of spontaneous circulation with patient outcomes. J Vet Emerg Crit Care (San Antonio) 2023; 33:223-235. [PMID: 36537864 DOI: 10.1111/vec.13267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the association of point-of-care biochemical variables obtained during CPR or within 24 hours of return of spontaneous circulation (ROSC) with patient outcomes. DESIGN Retrospective study. SETTING University teaching hospital. ANIMALS Ninety-four dogs and 27 cats undergoing CPR according to the Reassessment Campaign on Veterinary Resuscitation guidelines. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Blood gas, acid-base, electrolyte, glucose, and plasma lactate values obtained during CPR or within 24 hours of ROSC were retrospectively evaluated and are described. The blood sample type and collection time with respect to CPR initiation and ROSC were recorded. Measured variables, collection times, and species were included in a multivariable logistic regression model to estimate the odds ratio (OR) and 95% confidence interval of ROSC, sustained ROSC (≥20 min), and survival to hospital discharge. Significance was set at P < 0.05. Seventy-two venous blood samples obtained during CPR and 45 first venous and arterial blood samples obtained after ROSC were included in logistic regression analysis. During CPR, PvO2 (1.09 [1.036-1.148], P = 0.001) and venous standard base excess (SBE) (1.207 [1.094-1.331], P < 0.001) were associated with ROSC. PvO2 (1.075 [1.028-1.124], P = 0.002), SBE (1.171 [1.013-1.353], P = 0.032), and potassium concentration (0.635 [0.426-0.946], P = 0.026) were associated with sustained ROSC. Potassium concentration (0.235 [0.083-0.667], P = 0.007) was associated with survival to hospital discharge. Following ROSC, pH (69.110 [4.393-1087], P = 0.003), potassium concentration (0.222 [0.071-0.700], P = 0.010), and chloride concentration (0.805 [0.694-0.933], P = 0.004) were associated with survival to hospital discharge. CONCLUSIONS Biochemical variables such as PvO2 , SBE, and potassium concentration during CPR and pH, potassium, and chloride concentration in the postarrest period may help identify dogs and cats with lower odds for ROSC or survival to hospital discharge following CPR.
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Affiliation(s)
- Sabrina N Hoehne
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
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12
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Linde H, Bartusevicius V, Norberg Å, Klevebro F, Grip J. Frequency of blood lactate elevation following esophagectomy and its association to postoperative complications. Acta Anaesthesiol Scand 2023; 67:277-283. [PMID: 36537042 DOI: 10.1111/aas.14181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Esophagectomy is a major surgical intervention and a cornerstone in the treatment of esophageal cancer. There is clinical experience that blood lactate concentration often is elevated in the period following esophagectomy, but the incidence and clinical consequences are sparsely studied. METHODS We extracted data from all patients undergoing esophagectomy at Karolinska University Hospital 2016-2018, n = 153. Most were performed with minimally invasive technique, n = 130. Blood lactate values directly after surgery, highest value during the first night, and morning level on postoperative day one were recorded. Primary outcome was hospital length of stay and secondary outcome was a composite of postoperative infection, additional surgery, or intensive care during the hospital stay. Development of anastomotic leak was analyzed separately. RESULTS Postoperative hyperlactatemia was common as 93% of patients had peak lactate concentration >1.6 mmol/L and 27% >3.5 mmol/L in the first night following operation. Median hospital length of stay was 14 days. Blood lactate showed a weak correlation to hospital stay and intensive care the morning following surgery, but not at arrival to postoperative ward. There were no statistical differences between those with and without anastomotic leak at any of the time points. Elevated lactate in the first 12-16 h postoperatively was related to surgical factors (open technique, surgery time, and perioperative bleeding) but not to patient related factors (ASA-class, Charlson comorbidity index, sex, age) or cumulative fluid balance. CONCLUSION In conclusion, elevated blood lactate in the immediate time following esophagectomy showed a weak association to intensive care and length of stay but not anastomotic leak.
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Affiliation(s)
- Henrik Linde
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Vilhelmas Bartusevicius
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Jonathan Grip
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
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13
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Hannen LEM, Toprak B, Weimann J, Mahmoodi B, Fluschnik N, Schrage B, Roedl K, Söffker G, Kluge S, Issleib M, Blankenberg S, Kirchhof P, Clemmensen P, Sinning C, Zengin-Sahm E, Becher PM. Clinical characteristics, causes and predictors of outcomes in patients with in-hospital cardiac arrest: results from the SURVIVE-ARREST study. Clin Res Cardiol 2023; 112:258-269. [PMID: 35978110 PMCID: PMC9898362 DOI: 10.1007/s00392-022-02084-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/10/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In-hospital cardiac arrest (IHCA) is acutely life-threatening and remains associated with high mortality and morbidity. Identifying predictors of mortality after IHCA would help to guide acute therapy. METHODS We determined patient characteristics and independent predictors of 30-day in-hospital mortality, neurological outcome, and discharge/referral pathways in patients experiencing IHCA in a large tertiary care hospital between January 2014 and April 2017. Multivariable Cox regression model was fitted to assess predictors of outcomes. RESULTS A total of 368 patients with IHCA were analysed (median age 73 years (interquartile range 65-78), 123 (33.4%) women). Most patients (45.9%) had an initial non-shockable rhythm and shockable rhythms were found in 20.9%; 23.6% of patients suffered from a recurrent episode of cardiac arrest. 172/368 patients died within 30 days (46.7%). Of 196/368 patients discharged alive after IHCA, the majority (72.9%, n = 143) had a good functional neurological outcome (modified Rankin Scale ≤ 3 points). In the multivariable analysis, return of spontaneous circulation without mechanical circulatory support (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.21-0.64), invasive coronary angiography and/or percutaneous intervention (HR 0.56, 95% CI 0.34-0.92), and antibiotic therapy (HR 0.87, 95% CI 0.83-0.92) were associated with a lower risk of 30-day in hospital mortality. CONCLUSION In the present study, IHCA was survived in ~ 50% in a tertiary care hospital, although only a minority of patients presented with shockable rhythms. The majority of IHCA survivors (~ 70%) had a good neurological outcome. Recovery of spontaneous circulation and presence of treatable acute causes of the arrest are associated with better survival. Clinical Characteristics, Causes and Predictors of Outcomes in Patients with In-Hospital Cardiac Arrest: Results from the SURVIVE-ARREST Study. ABBREVIATIONS CPR, cardiopulmonary resuscitation; IHCA, In-hospital cardiac arrest; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; ROSC, return of spontaneous circulation; SBP, systolic blood pressure.
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Affiliation(s)
- Laura Erika Maria Hannen
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Betül Toprak
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,grid.452396.f0000 0004 5937 5237German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel, Lübeck, Germany
| | - Jessica Weimann
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Bahara Mahmoodi
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Nina Fluschnik
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Benedikt Schrage
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,grid.452396.f0000 0004 5937 5237German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel, Lübeck, Germany
| | - Kevin Roedl
- grid.13648.380000 0001 2180 3484Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Gerold Söffker
- grid.13648.380000 0001 2180 3484Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- grid.13648.380000 0001 2180 3484Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Issleib
- grid.13648.380000 0001 2180 3484Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,grid.452396.f0000 0004 5937 5237German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel, Lübeck, Germany
| | - Paulus Kirchhof
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,grid.452396.f0000 0004 5937 5237German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel, Lübeck, Germany ,grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Peter Clemmensen
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,grid.452396.f0000 0004 5937 5237German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel, Lübeck, Germany ,grid.10825.3e0000 0001 0728 0170Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark and Nykoebing Falster Hospital, Odense, Denmark
| | - Christoph Sinning
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,grid.452396.f0000 0004 5937 5237German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel, Lübeck, Germany ,Adult Congenital Heart Disease Section, University Heart and Vascular Centre Hamburg, Hamburg, Germany
| | - Elvin Zengin-Sahm
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,Adult Congenital Heart Disease Section, University Heart and Vascular Centre Hamburg, Hamburg, Germany
| | - Peter Moritz Becher
- grid.13648.380000 0001 2180 3484Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,grid.452396.f0000 0004 5937 5237German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel, Lübeck, Germany
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14
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Rusnak J, Schupp T, Weidner K, Ruka M, Egner-Walter S, Forner J, Bertsch T, Kittel M, Mashayekhi K, Tajti P, Ayoub M, Behnes M, Akin I. Impact of Lactate on 30-Day All-Cause Mortality in Patients with and without Out-of-Hospital Cardiac Arrest Due to Cardiogenic Shock. J Clin Med 2022; 11:jcm11247295. [PMID: 36555911 PMCID: PMC9781807 DOI: 10.3390/jcm11247295] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
In patients with cardiogenic shock (CS) due to myocardial infarction, elevated lactate levels are known to be negative predictors. Studies regarding the prognostic impact in patients with CS complicated by out-of-hospital cardiac arrest (OHCA) are limited. Two hundred and sixty-three consecutive patients with CS were included. The prognostic value of lactate on days 1, 2, 3, 4 and 8 was tested stratified by OHCA and non-OHCA. Statistical analyses included the univariable t-test, Spearman's correlation, C-statistics, Kaplan-Meier analyses, as well as multivariable mixed analysis of variance (ANOVA) and Cox proportional regression analyses. The primary endpoint of all-cause mortality occurred in 49.4% of the non-OHCA group and in 63.4% of the OHCA group. Multivariable regression models showed an association of lactate values with 30-day all-cause mortality in the non-OHCA (p = 0.024) and OHCA groups (p = 0.001). In Kaplan-Meier analyses, patients with lactate levels ≥ 4 mmol/L (log-rank p = 0.001) showed the highest risk for 30-day all-cause mortality in the non-OHCA as well as in the OHCA group. However, in C-statistics lactate on days 1 and 8 had a better discrimination for 30-day all-cause mortality in the OHCA group compared to the non-OHCA group. In conclusion, patients presenting with CS lactate levels showed a good prognostic performance, with and without OHCA. Especially, lactate levels on days 1 and 8 were more accurate in the discrimination for all-cause mortality in CS-patients with OHCA.
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Affiliation(s)
- Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
- Correspondence:
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Maximilian Kittel
- Institute for Clinical Chemistry, Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, 77933 Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, 1096 Budapest, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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15
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Ganushchak YM, Kurniawati ER, van der Horst IC, van Kuijk SM, Weerwind PW, Lorusso R, Maessen JG. Patterns of oxygen debt repayment in cardiogenic shock patients sustained with extracorporeal life support: A retrospective study. J Crit Care 2022; 71:154044. [DOI: 10.1016/j.jcrc.2022.154044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 03/04/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
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Associations between early thiamine administration and clinical outcomes in critically ill patients with acute kidney injury. Br J Nutr 2022; 128:183-191. [PMID: 34392848 DOI: 10.1017/s0007114521003111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The effects of early thiamine use on clinical outcomes in critically ill patients with acute kidney injury (AKI) are unclear. The purpose of this study was to investigate the associations between early thiamine administration and clinical outcomes in critically ill patients with AKI. The data of critically ill patients with AKI within 48 h after ICU admission were extracted from the Medical Information Mart for Intensive Care III (MIMIC III) database. PSM was used to match patients early receiving thiamine treatment to those not early receiving thiamine treatment. The association between early thiamine use and in-hospital mortality due to AKI was determined using a logistic regression model. A total of 15 066 AKI patients were eligible for study inclusion. After propensity score matching (PSM), 734 pairs of patients who did and did not receive thiamine treatment in the early stage were established. Early thiamine use was associated with lower in-hospital mortality (OR 0·65; 95 % CI 0·49, 0·87; P < 0·001) and 90-d mortality (OR 0·58; 95 % CI 0·45, 0·74; P < 0·001), and it was also associated with the recovery of renal function (OR 1·26; 95 % CI 1·17, 1·36; P < 0·001). In the subgroup analysis, early thiamine administration was associated with lower in-hospital mortality in patients with stages 1 to 2 AKI. Early thiamine use was associated with improved short-term survival in critically ill patients with AKI. It was possible beneficial role in patients with stages 1 to 2 AKI according to the Kidney Disease: Improving Global Outcomes criteria.
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17
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Costa NA, Pereira AG, Sugizaki CSA, Vieira NM, Garcia LR, de Paiva SAR, Zornoff LAM, Azevedo PS, Polegato BF, Minicucci MF. Insights Into Thiamine Supplementation in Patients With Septic Shock. Front Med (Lausanne) 2022; 8:805199. [PMID: 35155482 PMCID: PMC8832096 DOI: 10.3389/fmed.2021.805199] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Septic shock is associated with unacceptably high mortality rates, mainly in developing countries. New adjunctive therapies have been explored to reduce global mortality related to sepsis. Considering that metabolic changes, mitochondrial dysfunction and increased oxidative stress are specific disorders within the path of septic shock, several micronutrients that could act in cellular homeostasis have been studied in recent decades. Thiamine, also known as vitamin B1, plays critical roles in several biological processes, including the metabolism of glucose, synthesis of nucleic acids and reduction of oxidative stress. Thiamine deficiency could affect up to 70% of critically ill patients, and thiamine supplementation appears to increase lactate clearance and decrease the vasopressor dose. However, there is no evident improvement in the survival of septic patients. Other micronutrients such as vitamin C and D, selenium and zinc have been tested in the same context but have not been shown to improve the outcomes of these patients. Some problems related to the neutrality of these clinical trials are the study design, doses, route, timing, length of intervention and the choice of endpoints. Recently, the concept that multi-micronutrient administration may be better than single-micronutrient administration has gained strength. In general, clinical trials consider the administration of a single micronutrient as a drug. However, the antioxidant defense is a complex system of endogenous agents in which micronutrients act as cofactors, and the physiological interactions between micronutrients are little discussed. In this context, the association of thiamine, vitamin C and corticoids was tested as an adjunctive therapy in septic shock resulting in a significant decrease in mortality. However, after these initial results, no other study conducted with this combination could reproduce those benefits. In addition, the use of low-dose corticosteroids is recommended in patients with septic shock who do not respond to vasopressors, which can affect the action of thiamine. Therefore, given the excellent safety profile, good biologic rationale and promising clinical studies, this review aims to discuss the mechanisms behind and the evidence for single or combined thiamine supplementation improving the prognosis of patients with septic shock.
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Affiliation(s)
- Nara Aline Costa
- Faculty of Nutrition, Universidade Federal de Goiás (UFG), Goiânia, Brazil
| | - Amanda Gomes Pereira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | | | - Nayane Maria Vieira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Leonardo Rufino Garcia
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | | | | | - Paula Schmidt Azevedo
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Bertha Furlan Polegato
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Marcos Ferreira Minicucci
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
- *Correspondence: Marcos Ferreira Minicucci
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18
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The Value of Combining Carbon Dioxide Gap and Oxygen-Derived Variables with Lactate Clearance in Predicting Mortality after Resuscitation of Septic Shock Patients. Crit Care Res Pract 2021; 2021:6918940. [PMID: 34616571 PMCID: PMC8487837 DOI: 10.1155/2021/6918940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/21/2021] [Accepted: 09/16/2021] [Indexed: 11/17/2022] Open
Abstract
Background Achieving hemodynamic stabilization does not prevent progressive tissue hypoperfusion and organ dysfunction during resuscitation of septic shock patients. Many indicators have been proposed to judge the optimization of oxygen delivery to meet tissue oxygen consumption. Methods A prospective observational study was conducted to evaluate and validate combining CO2 gap and oxygen-derived variables with lactate clearance during early hours of resuscitation of adults presenting with septic shock. Results Our study included 456 adults with a mean age of 63.2 ± 6.9 years, with 71.9% being males. Respiratory and urinary infections were the origin of about 75% of sepsis. Mortality occurred in 164 (35.9%) patients. The APACHE II score was 18.2 ± 3.7 versus 34.3 ± 6.8 (p < 0.001), the initial SOFA score was 5.8 ± 3.1 versus 7.3 ± 1.4 (p=0.001), while the SOFA score after 48 hours was 4.2 ± 1.8 versus 9.4 ± 3.1 (p < 0.001) in the survivors and nonsurvivors, respectively. Hospital mortality was independently predicted by hyperlactatemia (OR: 2.47; 95% CI: 1.63-6.82, p=0.004), PvaCO2 gap (OR: 2.62; 95% CI: 1.28-6.74, p=0.026), PvaCO2/CavO2 ratio (OR: 2.16; 95% CI: 1.49-5.74, p=0.006), and increased SOFA score after 48 hours of admission (OR: 1.86; 95% CI: 1.36-8.13, p=0.02). A blood lactate cutoff of 40 mg/dl at the 6th hour of resuscitation (T6) had a 92.7% sensitivity and 75.3% specificity for predicting hospital mortality (AUROC = 0.902) with 81.6% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO2/CavO2 ratio cutoff of 1.4 increased the specificity to 93.2% with a sensitivity of 75.6% in predicting mortality and with 86.8% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO2 gap of 6 mmHg increased the sensitivity to 93% and increased the specificity to 98% in predicting mortality with 91% accuracy. Conclusion Combining the carbon dioxide gap and arteriovenous oxygen difference with lactate clearance during early hours of resuscitation of septic shock patients helps to predict hospital mortality more accurately.
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19
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Dong S, Qian L, Cheng Z, Chen C, Wang K, Hu S, Zhang X, Wu T. Lactate and Myocadiac Energy Metabolism. Front Physiol 2021; 12:715081. [PMID: 34483967 PMCID: PMC8415870 DOI: 10.3389/fphys.2021.715081] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/29/2021] [Indexed: 12/05/2022] Open
Abstract
The myocardium is capable of utilizing different energy substrates, which is referred to as “metabolic flexibility.” This process assures ATP production from fatty acids, glucose, lactate, amino acids, and ketones, in the face of varying metabolic contexts. In the normal physiological state, the oxidation of fatty acids contributes to approximately 60% of energy required, and the oxidation of other substrates provides the rest. The accumulation of lactate in ischemic and hypoxic tissues has traditionally be considered as a by-product, and of little utility. However, recent evidence suggests that lactate may represent an important fuel for the myocardium during exercise or myocadiac stress. This new paradigm drives increasing interest in understanding its role in cardiac metabolism under both physiological and pathological conditions. In recent years, blood lactate has been regarded as a signal of stress in cardiac disease, linking to prognosis in patients with myocardial ischemia or heart failure. In this review, we discuss the importance of lactate as an energy source and its relevance to the progression and management of heart diseases.
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Affiliation(s)
- Shuohui Dong
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Linhui Qian
- Department of Colorectal and Anal Surgery, Feicheng Hospital Affiliated to Shandong First Medical University, Feicheng, China
| | - Zhiqiang Cheng
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Chang Chen
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Kexin Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Sanyuan Hu
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Xiang Zhang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Tongzhi Wu
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA, Australia.,Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
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20
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Moustafa AA, Elhadidi AS, El-Nagar MA, Hassouna HM. Can Lactate Clearance Predict Mortality in Critically Ill Children? J Pediatr Intensive Care 2021; 12:112-117. [PMID: 37082472 PMCID: PMC10113011 DOI: 10.1055/s-0041-1730930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractSerial evaluation of blood lactate, including lactate clearance, may have greater value over single measurement at the time of presentation. The rationale of the current study was to evaluate the use of lactate clearance after 6 hours of admission to pediatric intensive care unit (PICU) as a predictor of mortality in critically ill children. A prospective observational study was conducted in a nine-bed PICU of a tertiary care teaching hospital over a period of 6 months. Lactate levels were measured in arterial blood samples of 76 patients at the time of admission and 6 hours later. According to calculated lactate clearance, patients were divided into group A (lactate clearance more than 0) which included 71% of patients and group B (lactate clearance ≤0) which included 29% of patients. Lactate level at admission was a poor predictor of mortality (area under receiver operating characteristic curve [AUC] = 0.519, p = 0.789). Lactate clearance after 6 hours of admission was a significant predictor of mortality (AUC = 0.766, p < 0.001). Using Kaplan–Meier survival curve, overall survival was significantly better among group A (p < 0.001). Using multivariate logistic regression model, lactate clearance after 6 hours (odds ratio = 0.98, 95% confidence interval [CI]: 0.96–0.99) and The Pediatric Index of Mortality 2 (PIM2) score (odds ratio = 4.7, 95% CI: 1.85–12.28) had independent prognostic significance as regard to mortality (p = 0.030, 0.001 respectively). We conclude that lactate clearance after 6 hours of admission can predict mortality in critically ill children.
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Affiliation(s)
- Azza A. Moustafa
- Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Abeer S. Elhadidi
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mona A. El-Nagar
- Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hadir M. Hassouna
- Department of Pediatrics and Pediatric Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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21
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Liu J, Yan H, Li Y. Hyperlactatemia associated with diabetic ketoacidosis in pediatric intensive care unit. BMC Endocr Disord 2021; 21:110. [PMID: 34044824 PMCID: PMC8157405 DOI: 10.1186/s12902-021-00776-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/20/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Children with diabetic ketoacidosis often have elevated lactate. In this study, we investigated the clinical variables associated with hyperlactatemia in children with diabetic ketoacidosis. METHODS We designed a single-center retrospective descriptive study of children with diabetic ketoacidosis in a pediatric intensive care unit. RESULTS Of the 107 patients with diabetic ketoacidosis included in the analysis, 61 developed hyperlactatemia. Multivariate logistic regression analysis showed that heart rate (p = 0.003),diastolic blood pressure (p = 0.001) and stage of severity (p = 0.042) were independently associated with the development of hyperlactatemia in diabetic ketoacidosis. We found that lactate level was not significantly associated with length of hospital stay (p = 0.115) or the length of time to diabetic ketoacidosis resolution (p = 0.143). CONCLUSIONS Children with diabetic ketoacidosis presenting with severer stage, elevated heart rate and higher diastolic blood pressure may be prone to hyperlactatemia. Hyperlactatemia was not associated with length of time to DKA resolution and length of hospital stay.
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Affiliation(s)
- Jingwei Liu
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Xin Min Street, 130021, Changchun, China
| | - Haibo Yan
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Xin Min Street, 130021, Changchun, China
| | - Yumei Li
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Xin Min Street, 130021, Changchun, China.
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22
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Lonsain WS, De Lausnay L, Wauters L, Desruelles D, Dewolf P. The prognostic value of early lactate clearance for survival after out-of-hospital cardiac arrest. Am J Emerg Med 2021; 46:56-62. [PMID: 33721591 DOI: 10.1016/j.ajem.2021.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Prognostication of survival after out-of-hospital cardiac arrest (OHCA) remains challenging with current guidelines recommending the prognostication no earlier than 72 h after return of spontaneous circulation (ROSC). Prognostic factors that could be used earlier after ROSC, like lactate clearance, are still being studied. OBJECTIVES This paper aims to investigate the prognostic strength of early lactate clearance for survival after OHCA. METHODS This retrospective observational single-center study focuses on patients for whom ROSC was achieved after OHCA. Patients ≥18 years admitted between September 2012 and January 2019, for which arterial serum lactate measurements were available immediately at and 3 h after hospital admission (T0 and T3), were included. RESULTS 192 patients were included. Lactate clearance at T3 (p < 0.001) was identified as an independent predictor for 24 h, 48 h and 72 h survival. Witnessed arrest, bystander CPR and initial shockable rhythm were independent significant predictors for long term survival after ROSC (1 month, 3 months and 1 year; p < 0.05), but not for 24 h survival. Age (above or below 65 years) was not significant for predicting survival. Upon combination of witnessed arrest, bystander CPR and initial shockable rhythm in a multivariate logistic regression model for long term survival, the initial rhythm was the dominant factor in the combined model, making witnessed arrest and bystander CPR redundant. CONCLUSION Lactate clearance at T3 after ROSC is associated with 24 h, 48 h and 72 h survival. Further research is needed to determine how to incorporate lactate clearance as part of a clinically useful tool to predict long term survival.
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Affiliation(s)
- Willemina Sofie Lonsain
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium; KULeuven - University, Department of Public Health and Primary Care, Leuven, Belgium
| | - Loranne De Lausnay
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium; KULeuven - University, Department of Public Health and Primary Care, Leuven, Belgium
| | - Lina Wauters
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Didier Desruelles
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Philippe Dewolf
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium; KULeuven - University, Department of Public Health and Primary Care, Leuven, Belgium.
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23
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Son SH, In YN, Md, Park JS, You Y, Min JH, Yoo I, Cho YC, Jeong W, Ahn HJ, Kang C, Lee BK. Cerebrospinal Fluid Lactate Levels, Brain Lactate Metabolism and Neurologic Outcome in Patients with Out-of-Hospital Cardiac Arrest. Neurocrit Care 2021; 35:262-270. [PMID: 33432527 DOI: 10.1007/s12028-020-01181-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND/OBJECTIVE Cerebrospinal fluid (CSF) and serum lactate levels were assessed to predict poor neurologic outcome 3 months after return of spontaneous circulation (ROSC). We compared arterio-CSF differences in the lactate (ACDL) levels between two neurologic outcome groups. METHODS This retrospective observational study involved out-of-hospital cardiac arrest (OHCA) survivors who had undergone target temperature management. CSF and serum samples were obtained immediately (lactate0), and at 24 (lactate24), 48 (lactate48), and 72 (lactate72) h after ROSC, and ACDL was calculated at each time point. The primary outcome was poor 3-month neurologic outcome (cerebral performance categories 3-5). RESULTS Of 45 patients, 27 (60.0%) showed poor neurologic outcome. At each time point, CSF lactate levels were significantly higher in the poor neurologic outcome group than in the good neurologic outcome group (6.97 vs. 3.37, 4.20 vs. 2.10, 3.50 vs. 2.00, and 2.79 vs. 2.06, respectively; all P < 0.05). CSF lactate's prognostic performance was higher than serum lactate at each time point, and lactate24 showed the highest AUC values (0.89, 95% confidence interval, 0.75-0.97). Over time, ACDL decreased from - 1.30 (- 2.70-0.77) to - 1.70 (- 3.2 to - 0.57) in the poor neurologic outcome group and increased from - 1.22 (- 2.42-0.32) to - 0.64 (- 2.31-0.15) in the good neurologic outcome group. CONCLUSIONS At each time point, CSF lactate showed better prognostic performance than serum lactate. CSF lactate24 showed the highest prognostic performance for 3-month poor neurologic outcome. Over time, ACDL decreased in the poor neurologic outcome group and increased in the good neurologic outcome group.
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Affiliation(s)
- Seung Ha Son
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | | | - Md
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea. .,Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea.
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Insool Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, 61469, Korea
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24
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Bhat JA, Masoodi SR, Bhat MH, Bhat H, Ahmad PO, Sood M. Lactic Acidosis in Diabetic Ketoacidosis: A Marker of Severity or Alternate Substrate for Metabolism. Indian J Endocrinol Metab 2021; 25:59-66. [PMID: 34386396 PMCID: PMC8323635 DOI: 10.4103/ijem.ijem_753_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/12/2020] [Accepted: 03/07/2021] [Indexed: 11/04/2022] Open
Abstract
PURPOSE The lactate level is being increasingly used as a marker of severity of illness and prognosis in multitude of critical conditions. However, its role in diabetic ketoacidosis (DKA) is not well defined. AIM To determine the prevalence and clinical importance along with the underlying role of metformin in lactic acidosis (LA) in patients admitted with DKA. METHODS A 2-year prospective and observational study involving 62 consenting in hospital DKA patients. Plasma lactate level on arrival, its clinical significance and relationship with morbidity and mortality in patients with DKA was evaluated. RESULTS The prevalence of LA (lactate ≥2.5 mmol/l) among the study cohort was found to be 55% with significant LA (≥5 mmol/l) documented in 16%. The median lactate level was 2.55 mmol/l (interquartile range, 1.70-3.20). No significant difference in the severity of LA was seen with metformin use. Lactate correlated positively with initial plasma glucose (IPG) (P = 0.001) and APACHE-II Score (P = 0.002); correlated negatively with systolic blood pressure (P = 0.003), pH (P = 0.002) and severity of DKA (P = 0.001). After controlling for AKI, APACHE II score and blood pressure, lactate continued to correlate positively with IPG (P = 0.002). No mortality or significant morbidity was documented in the entire cohort. CONCLUSIONS LA has a significant presence in patients with DKA; however, it is not associated with mortality or significant morbidity. Moreover, there was no significant difference in severity of LA with metformin use. Elevated lactate levels may be an adaptation to provide alternate substrate for metabolism in the presence of hypoinsulinemic state. The study results provide rationale for large well-designed studies evaluating in-depth clinical relationship of lactate in DKA.
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Affiliation(s)
- Javaid Ahmad Bhat
- Department of Endocrinology, Superspeciality Hospital, GMC, Srinagar, Kashmir, India
| | - Shariq Rashid Masoodi
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Moomin Hussain Bhat
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Hilal Bhat
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Peerzada Ovais Ahmad
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Mona Sood
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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25
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Gharipour A, Razavi R, Gharipour M, Modarres R, Nezafati P, Mirkheshti N. The incidence and outcome of severe hyperlactatemia in critically ill patients. Intern Emerg Med 2021; 16:115-123. [PMID: 32415561 DOI: 10.1007/s11739-020-02337-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/06/2020] [Indexed: 12/22/2022]
Abstract
This study aimed to assess the incidence, persistence, and associated mortality of severe hyperlactatemia in a large cohort of unselected critically ill patients. Also, we evaluated the association between 12 h lactate clearance, the timing of severe hyperlactatemia, and the maximum lactate levels with ICU mortality. In this retrospective, single-center study, we used data from the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Data extracted to screen 23,598 ICU patients for severe hyperlactatemia. A total of 23,598 critically ill patients were eligible for this study. Overall, ICU mortality in the 23,598 ICU patients was 12.1%. Of these, 760 patients had lactate concentration [Formula: see text] 10 mmol/L and ICU mortality in this group was 65%. Our findings confirm the association between hyperlactatemia and ICU mortality [odds ratio 1.42 (95% CI 1.35; 1.49; P < 0.001)]. Data for 12 h lactate clearance was available for 443 patients (276 nonsurvivable vs. 167 survival). 12 h lactate clearance yielded a high area under the curve (AUC) of 0.78, (95% CI 0.74 and 0.83). Severe hyperlactatemia is associated with extremely high ICU mortality in a heterogeneous ICU population. Lactate derived variables (the timing and persistence of severe hyperlactatemia, maximum level, and 12 h clearance) are shown to be associated with ICU mortality in patients with severe hyperlactatemia. Our results suggest that maximum lactate level and 12 h lactate clearance were clinically useful prognostic parameters for patients with severe hyperlactatemia.
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Affiliation(s)
- Amin Gharipour
- Business School, Griffith University, Gold Coast Campus, Australia
| | - Rouzbeh Razavi
- Department of Management and Information Systems, Kent State University, Kent, OH, USA
| | - Mojgan Gharipour
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Esfahan, Iran.
| | - Reza Modarres
- School of Medical Sciences, Griffith University, Gold Coast Campus, Australia
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26
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Moskowitz A, Andersen LW, Rittenberger JC, Swor R, Seethala RR, Kurz MC, Berg KM, Chase M, Cocchi MN, Grossestreuer AV, Liu X, Holmberg MJ, Callaway CW, Donnino MW. Continuous Neuromuscular Blockade Following Successful Resuscitation From Cardiac Arrest: A Randomized Trial. J Am Heart Assoc 2020; 9:e017171. [PMID: 32851921 PMCID: PMC7660770 DOI: 10.1161/jaha.120.017171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Neuromuscular blockade (NMB) agents are often administered to control shivering during targeted temperature management following cardiac arrest. In this study, we hypothesized that early, continuous NMB would result in a greater reduction in serum lactate levels among comatose patients after cardiac arrest. Methods and Results Randomized trial of continuous NMB for 24 hours versus usual care following cardiac arrest conducted at 5 urban centers in the United States. Adult patients who achieved return of spontaneous circulation, remained unresponsive, and underwent targeted temperature management after cardiac arrest were included. The primary outcome was change in lactate over 24 hours. A total of 83 patients were randomized, and 80 were analyzed (37 and 43 in the NMB and usual care arms, respectively). There was no significant interaction between time and treatment group with respect to change in lactate over 24 hours (median lactate change from 4.2 to 2.0 mmol/L [−2.2 mmol/L] in the NMB arm versus 4.0 to 1.7 mmol/L [−2.3 mmol/L] in the usual care arm; geometric mean difference, 1.3 [95% CI, 1.0–1.8]; P=0.07 for the interaction term). There was no difference in hospital survival (38% [NMB] versus 33% [usual care]; P=0.63) or survival with good functional outcome (30% [NMB] versus 21% [usual care]; P=0.35). There were no adverse events in either arm attributed to study interventions. Conclusions Continuous NMB compared with usual care did not reduce lactate over the first 24 hours after enrollment compared with usual care. There was no difference in overall hospital survival, hospital survival with good neurologic outcome, or adverse events. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02260258.
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Affiliation(s)
- Ari Moskowitz
- Division of Pulmonary Critical Care, and Sleep Medicine Beth Israel Deaconess Medical Center Boston MA.,Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA
| | - Lars W Andersen
- Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA.,Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University Hospital Aarhus Denmark
| | - Jon C Rittenberger
- Department of Emergency Medicine Guthrie Robert Packer Hospital Sayre PA.,Department of Emergency Medicine University of Pittsburgh PA
| | - Robert Swor
- Department of Emergency Medicine Beaumont Hospital, Royal Oak MI
| | - Raghu R Seethala
- Department of Emergency Medicine Brigham and Women's Hospital Boston MA
| | - Michael C Kurz
- Department of Emergency Medicine University of Alabama School of Medicine Birmingham AL
| | - Katherine M Berg
- Division of Pulmonary Critical Care, and Sleep Medicine Beth Israel Deaconess Medical Center Boston MA.,Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA
| | - Maureen Chase
- Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA.,Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| | - Michael N Cocchi
- Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA.,Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| | - Anne V Grossestreuer
- Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA.,Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| | - Xiaowen Liu
- Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA.,Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
| | - Mathias J Holmberg
- Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA.,Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University Hospital Aarhus Denmark
| | | | - Michael W Donnino
- Division of Pulmonary Critical Care, and Sleep Medicine Beth Israel Deaconess Medical Center Boston MA.,Center for Resuscitation Science Beth Israel Deaconess Medical Center Boston MA.,Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
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27
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Predictors of Successful Weaning From Veno-Arterial Extracorporeal Membrane Oxygenation After Coronary Revascularization for Acute Myocardial Infarction Complicated by Cardiac Arrest: A Retrospective Multicenter Study. Shock 2020; 51:690-697. [PMID: 30080744 DOI: 10.1097/shk.0000000000001220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM While veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been utilized to resuscitate and stabilize hemodynamics in patients of acute myocardial infarction (AMI) complicated by cardiac arrest (CA), it is essential to predict the possibility of weaning from ECMO to determine further strategies, including use of ventricular assist device. We aimed to determine predictors of successful weaning from VA-ECMO in the early phase of ECMO treatment. METHODS We identified consecutive patients of AMI complicated by CA treated with VA-ECMO and percutaneous coronary intervention (PCI). Clinical data within 48 h after ECMO initiation were assessed and multiple logistic regression analysis was performed to determine independent predictors of weaning outcome. RESULTS Fifty-five patients were analyzed. While 28 (51%) patients were successfully weaned from VA-ECMO, 27 (49%) failed to wean. Multivariate analysis identified post-PCI thrombolysis in myocardial infarction (TIMI) flow grade (P = 0.046), mean arterial pressure (MAP) at 4 h after ECMO initiation (P = 0.010), and serum lactate at 24 h (P = 0.015) as independent predictors of successful weaning. Left ventricular ejection fraction (LVEF) at 24 and 48 h was significantly greater in the successful weaning group (P = 0.014, P = 0.025, respectively). CONCLUSIONS Successful weaning from VA-ECMO was predicted by post-PCI TIMI flow grade, MAP at 4 h, and serum lactate at 24 h after VA-ECMO initiation in patients of AMI complicated by CA. Furthermore, in patients who failed to wean from ECMO, LVEF did not recover within 48 h. In such patients, adjunctive use of other circulatory mechanical devices must be considered.
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28
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High plasma levels of pro-inflammatory factors interleukin-17 and interleukin-23 are associated with poor outcome of cardiac-arrest patients: a single center experience. BMC Cardiovasc Disord 2020; 20:170. [PMID: 32293300 PMCID: PMC7158084 DOI: 10.1186/s12872-020-01451-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 03/29/2020] [Indexed: 12/12/2022] Open
Abstract
Background Systemic inflammation is an important feature of post-cardiac arrest syndrome (PCAS). This study was designed to determine whether the plasma concentrations of some circulating pro-inflammatory cytokines (interleukin-17 [IL-8], IL-22, IL-23 and IL-33) are of value in predicting the outcome of patients after return of spontaneous circulation (ROSC) during the post–cardiac arrest period. Methods This was a prospective observational clinical study. In total, 21 patients (survivors, n = 10; non-survivors, n = 11) who experienced cardiac arrest and successful ROSC with expected survival of at least 7 days were consecutively enrolled from January 2016 to December 2017. Of the 21 enrolled patients, ten survived were designated “survivors”. The other eleven patients died between 2 days and 1 months post ROSC. Venous blood was drawn at three time-points: baseline (< 1 h post ROSC), 2 days post ROSC and 7 days post ROSC. Plasma IL-8, IL-22, IL-23 and IL-33 were determined using commercial enzyme-linked immunosorbent assays. Results Plasma creatinine levels, but aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, were elevated in non-survivors compared with survivors. Plasma levels of IL-17, IL-22, IL-23 and IL-33 of the 21 total patients did not change at 2 or 7 days post ROSC compared to baseline. In survivors, the plasma levels of IL-17 and IL-23 at 2 or 7 days post ROSC were lower than baseline. In non-survivors, plasma levels of IL-17 increased compared with baseline. Receiver operating characteristic curve analysis showed that the plasma levels of IL-17 and IL-23 at 2 or 7 days post ROSC were able to predict the mortality of PCAS patients, and positively correlated with Acute Physiology and Chronic Health Evaluation (APACHE)-II score and time to ROSC. Conclusion These results provide the first evidence that the elevated plasma IL-17 and IL-23 levels are associated with poor outcome in PCAS patients. The role of IL-17/IL-23 axis post ROSC is worth paying attention to in PCAS patients. Trial registration Clinicaltrial.govNCT02297776, 2014-11-21.
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29
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Elfwén L, Lagedal R, Rubertsson S, James S, Oldgren J, Olsson J, Hollenberg J, Jensen U, Ringh M, Svensson L, Nordberg P. Post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest patients randomized to immediate coronary angiography versus standard of care. IJC HEART & VASCULATURE 2020; 27:100483. [PMID: 32154359 PMCID: PMC7056719 DOI: 10.1016/j.ijcha.2020.100483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 11/30/2022]
Abstract
Background Immediate coronary angiography with subsequent percutaneous coronary intervention (PCI) has the potential to reduce post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest (OHCA) patients. The aim of this study was to see if immediate coronary angiography, with potential PCI, in patients without ST-elevation on the ECG, influenced post-resuscitation myocardial function and cardiac biomarkers. Methods A secondary analysis of the Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest (DISCO) trial (ClinicalTrials.gov ID: NCT02309151). Patients with bystander-witnessed OHCA, without ST-elevations on the ECG were randomly assigned to immediate coronary angiography within two hours of cardiac arrest (n = 38) versus standard-of-care with deferred angiography (n = 40). Outcome measures included left ventricle ejection fraction (LVEF) at 24 h, peak Troponin T levels, lactate clearance and NT-proBNP at 72 h. Results In the immediate-angiography group, median LVEF at 24 h was 47% (Q1-Q3; 30–55) vs. 46% (Q1-Q3; 35–55) in the standard-of-care group. Peak Troponin-T levels during the first 24 h were 362 ng/L (Q1-Q3; 174–2020) in the immediate angiography group and 377 ng/L (Q1-Q3; 205–1078) in the standard-of-care group. NT-proBNP levels at 72 h were 931 ng/L (Q1-Q3; 396–2845) in the immediate-angiography group and 1913 ng/L (Q1-Q3; 489–3140) in the standard-of-care group. Conclusion In this analysis of OHCA patients without ST-elevation on the ECG randomized to immediate coronary angiography or standard-of-care, no differences in post-resuscitation myocardial dysfunction parameters between the two groups were found. This finding was consistent also in patients randomized to immediate coronary angiography where PCI was performed compared to those where PCI was not performed.
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Affiliation(s)
- Ludvig Elfwén
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Sweden
| | - Rickard Lagedal
- Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University, Sweden
| | - Sten Rubertsson
- Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University, Sweden
| | - Stefan James
- Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Sweden
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Sweden
| | - Jens Olsson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna, Sweden
| | - Ulf Jensen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Sweden
| | - Mattias Ringh
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna, Sweden
| | - Leif Svensson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna, Sweden
| | - Per Nordberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna, Sweden
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Rosenberg RD, Guo CC, Chatterjee S, Schreyer KE, Bashir R, O'Murchu B, Aggarwal V, DeAngelis M, Edmundowicz D, O'Neill BP. The prognostic value of initial serum lactate for survival in postcardiac arrest patients undergoing cardiac catheterization. Catheter Cardiovasc Interv 2020; 97:228-234. [DOI: 10.1002/ccd.28836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Russell D. Rosenberg
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Chen‐Yu C. Guo
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Saurav Chatterjee
- Department of Cardiology, Saint Francis Hospital, Teaching Affiliate University of Connecticut School of Medicine Hartford USA
| | - Kraftin E. Schreyer
- Department of Emergency Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Riyaz Bashir
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Brian O'Murchu
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Vikas Aggarwal
- Division Cardiology, Department of Medicine University of Michigan School of Medicine Ann Arbor USA
| | - Michael DeAngelis
- Department of Emergency Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Daniel Edmundowicz
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Brian P. O'Neill
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
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Abstract
BACKGROUND Previous studies have shown associations between high admission serum lactate, lower lactate clearance, and increased short-term mortality after out-hospital cardiac arrest (OHCA). We studied whether lactate levels predict long- term outcome after OHCA. METHODS We included 458 OHCA patients with lactate measurements during intensive care unit (ICU) stay from the prospective FINNRESUSCI study. We evaluated thresholds for time-weighted (TW) mean lactate values for the first 24, 48, and 72 h. We analyzed lactate clearance and used multivariate regression to assess the prognostic value of the different measurement time points. RESULTS The admission lactate (median [IQR] 3.06 [2.68-3.44] mmol/L vs 4.76 [4.29-5.23] mmol/L) and the last measured lactate (0.98 [0.90-1.06] mmol/L vs 2.40 [2.03-2.78] mmol/L) were higher in non-survivors than in survivors, as were the lowest (0.73 [0.67-0.79] mmol/L vs 1.83 [1.52-2.14] mmol/L) and the highest (3.44 [3.05-3.83] mmol/L vs 5.25 [4.76-5.74] mmol/L) lactate values (all P < 0.001). Time-weighted mean lactate values for the first 24, 48, 72, and for the entire ICU stay were lower in patients with good outcome (P < 0.001). In multivariate backward regression models, time-weighted mean lactate for the entire ICU stay (OR 1.41 per mmol/L, CI 95% 1.08-1.86, P = 0.013) and the last measured lactate in the ICU (OR 2.16 per mmol/L, CI 95% 1.47-3.18, P < 0.001) were independent predictors of poor 1-year outcome. CONCLUSIONS In the present study time-weighted mean lactate values for the entire ICU stay, and the last measured lactate value in the ICU, but not admission lactate or lactate clearance were independent predictors of poor 1-year outcome.
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Corral Torres E, Hernández-Tejedor A, Suárez Bustamante R, de Elías Hernández R, Casado Flórez I, San Juan Linares A. Prognostic value of venous blood analysis at the start of CPR in non-traumatic out-of-hospital cardiac arrest: association with ROSC and the neurological outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:60. [PMID: 32087761 PMCID: PMC7036225 DOI: 10.1186/s13054-020-2762-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The knowledge of new prognostic factors in out-of-hospital cardiac arrest (OHCA) that can be evaluated since the beginning of cardiopulmonary resuscitation (CPR) manoeuvres could be helpful in the decision-making process of prehospital care. We aim to identify metabolic variables at the start of advanced CPR at the scene that may be associated with two main outcomes of CPR (recovery of spontaneous circulation (ROSC) and neurological outcome). METHODS Prospective observational study of all non-traumatic OHCA in patients older than 17 years assisted by emergency medical services (EMS), with doctor and nurse on board, between January 2012 and December 2017. Venous blood gases were sampled upon initially obtaining venous access to determine the initial values of pH, pCO2, HCO3-, base excess (BE), Na+, K+, Ca2+ and lactate. ROSC upon arrival at the hospital and neurological status 30 days later (Cerebral Performance Categories (CPC) scale) were recorded. RESULTS We included 1552 patients with OHCA with blood test data in a 6-year period. ROSC was achieved in 906 cases (58.4%), and good neurological recovery at 30 days (CPC I-II) occurred in 383 cases (24.68%). In multivariate analysis, we found a significant relationship between non-recovery of spontaneous circulation (no-ROSC) and low pH levels (adjusted odds ratio (OR) 0.03 (0.002-0.59), p = 0.020), high pCO2 levels (adjusted OR 1.03 [1.01-1.05], p = 0.008) and high potassium levels (adjusted OR 2.28 [1.43-3.61], p = 0.008). Poor neurological outcomes were associated with low pH levels (adjusted OR 0.06 [0.02-0.18], p < 0.001), high pCO2 (adjusted OR 1.05 [1.03-1.08], p < 0.001), low HCO3- (adjusted OR 0.97 [0.94-0.999], p = 0.044), low BE (adjusted OR 0.96 [0.93-0.98], p < 0.001) and high potassium levels (adjusted OR 1.37 [1.16-1.60], p < 0.001). CONCLUSION There is a significant relationship between severe alterations of venous blood-gas variables and potassium at the start of CPR of non-traumatic OHCA and low-ROSC rate and neurological prognosis.
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Connolly C, Stättner S, Niederwieser T, Primavesi F. Systematic review on peri-operative lactate measurements to predict outcomes in patients undergoing liver resection. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:359-370. [PMID: 32065510 PMCID: PMC7496457 DOI: 10.1002/jhbp.727] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/04/2020] [Accepted: 02/09/2020] [Indexed: 12/26/2022]
Abstract
Lactate measurements have proven utility as a triage tool, therapeutic guide, and prognostic indicator, with broad use in Acute Care and transplantation. Its value in guiding therapy and predicting outcomes following liver resection is less well‐defined. This systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines assessed the relationship between peri‐operative lactate levels and morbidity and mortality after liver resection. Seven relevant studies comprising 2573 patients in total were identified. Six studies assessed intra‐operative or early postoperative lactate levels, one publication examined pre‐operative levels. All studies demonstrated a significant association between peri‐operative lactate levels and adverse outcomes. The influence of pre‐operative diabetes and cirrhosis on postoperative lactate levels was shown in one study each, no study assessed the association of lactate with post‐hepatectomy liver failure according to defined criteria. The heterogeneity of study measurements and end‐points precluded a meta‐analysis from being performed. Early postoperative lactate >3‐3.7 mmol/L is associated with mortality but validation of clear cut‐off levels for outcome prediction is pending. Literature suggests lactate is a useful predictive marker for outcomes post liver surgery, especially when measured in the early postoperative phase. Further research is required to standardize the use of lactate measurements in a meaningful therapeutic manner.
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Affiliation(s)
- Catherine Connolly
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Niederwieser
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Prognostic Abilities of Serial Neuron-Specific Enolase and Lactate and their Combination in Cardiac Arrest Survivors During Targeted Temperature Management. J Clin Med 2020; 9:jcm9010159. [PMID: 31936049 PMCID: PMC7019578 DOI: 10.3390/jcm9010159] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/27/2019] [Accepted: 01/05/2020] [Indexed: 12/26/2022] Open
Abstract
This study aimed to determine the prognostic ability of serial neuron-specific enolase (NSE) and lactate in cardiac arrest survivors treated with targeted temperature management (TTM) and to investigate whether a combination of NSE and lactate could increase prognostic information. This observational, retrospective, cohort study was conducted between January 2013 and December 2018; data were extracted from an out-of-hospital cardiac arrest registry. We collected serial serum NSE and lactate levels during TTM. The primary endpoint was poor neurological outcome at 28 days from cardiac arrest. Of all 160 included patients, 98 (61.3%) had poor neurological outcomes. Areas under the curves (AUCs) for NSE were 0.797, 0.871, and 0.843 at 24, 48, and 72 h, respectively (all p < 0.05). AUCs for lactate were 0.669, 0.578, 0.634, and 0.620 at 0, 24, 48, and 72 h, respectively (all p < 0.05). Although the combination of initial lactate and NSE at 48 h yielded the highest discovered AUC (0.877) it was not statistically different from that for the 48 h NSE alone (p = 0.692). During the TTM, NSE at 48 h from cardiac arrest was the most robust prognostic marker in comatose cardiac arrest survivors. However, a combination of the 48 h NSE with lactate did not increase the prognostic information.
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TURAN SÖNMEZ F. Base Excess and Lactic Acid Levels as Success Criteria in Cardiopulmonary Resuscitation. KONURALP TIP DERGISI 2019. [DOI: 10.18521/ktd.620811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cocchi MN, Salciccioli J, Yankama T, Chase M, Patel PV, Liu X, Mader TJ, Donnino MW. Predicting Outcome After Out-of-Hospital Cardiac Arrest: Lactate, Need for Vasopressors, and Cytochrome c. J Intensive Care Med 2019; 35:1483-1489. [PMID: 31466497 DOI: 10.1177/0885066619873315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Outcome prediction after out-of-hospital cardiac arrest (OHCA) is difficult. We hypothesized that lactate and need for vasopressors would predict outcome, and that addition of a mitochondrial biomarker would enhance performance of the tool. METHODS Prospective observational study of OHCA patients presenting to an academic medical center September 2008 to April 2016. We conducted univariate and multivariate logistic regressions. RESULTS Patients were divided based on 2 variables: vasopressor status and initial lactate (<5 mmol/L, 5-10, ≥10). Three hundred fifty-two patients were evaluated; 249 had a lactate within 3 hours and were included. Patients on vasopressors had higher mortality (74% vs 40%; P < .001). A stepwise increase in mortality is associated with increasing lactate (45% lactate <5, 66% 5-10, and 83% ≥10; P < 001). Multivariable models with lactate group and vasopressors as predictors demonstrated excellent discrimination (area under the receiver operating curve [AUC]: 0.73 [95% confidence interval, CI: 0.66-0.79]; adjusted for additional covariates: AUC: 0.81 [95% CI: 0.75-0.86]). Thirty-six patients had cytochrome c levels available; among these 36, when comparing models with and without cytochrome c, there was no difference (AUC: 0.88 [95% CI: 0.76-1.00] vs AUC: 0.85 [95% CI: 0.73-0.98], respectively; P = .30). CONCLUSION In this prospective validation, the combination of lactate and vasopressors in the immediate postarrest period is predictive of mortality. Cytochrome c offered minimal additional predictive power.
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Affiliation(s)
- Michael N Cocchi
- Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Critical Care, Department of Anesthesia Critical Care, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Tuyen Yankama
- Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Maureen Chase
- Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Parth V Patel
- Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Xiaowen Liu
- Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Timothy J Mader
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Michael W Donnino
- Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Pulmonary Critical Care, Department of Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying Lactate in the Emergency Department. Ann Emerg Med 2019; 75:287-298. [PMID: 31474479 DOI: 10.1016/j.annemergmed.2019.06.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 01/13/2023]
Abstract
The role of lactic acid and its conjugate base, lactate, has evolved during the past decade in the care of patients in the emergency department (ED). A recent national sepsis quality measure has led to increased use of serum lactate in the ED, but many causes for hyperlactatemia exist outside of sepsis. We provide a review of the biology of lactate production and metabolism, the many causes of hyperlactatemia, and evidence on its use as a marker in prognosis and resuscitation. Additionally, we review the evolving role of lactate in sepsis care. We provide recommendations to aid lactate interpretation in the ED and highlight areas for future research.
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Affiliation(s)
- Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, CA.
| | - Jessica Brice
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Matthew Correia
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Dennis Liu
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Michael Self
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Christopher Tainter
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, University of California at San Diego, San Diego, CA
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Villar J, Short JH, Lighthall G. Lactate Predicts Both Short- and Long-Term Mortality in Patients With and Without Sepsis. Infect Dis (Lond) 2019; 12:1178633719862776. [PMID: 31431799 PMCID: PMC6686323 DOI: 10.1177/1178633719862776] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/16/2019] [Indexed: 01/27/2023] Open
Abstract
Objective To measure the relationship between lactate and mortality in hospital inpatients. Main outcomes of interest were 3-day, 30-day, and 1-year all-cause mortality. Design Retrospective cohort study, October 2011 to September 2013. Setting University-affiliated US Veterans Affairs Hospital. Patients All inpatients with lactate level measured during the study period. Measurements Analysis of peak lactate level (mmol/L) during the most recent admission for patients who died, and peak lactate level during an admission for surviving patients. Covariates including sepsis, ICU admission, code blue and rapid response calls, medical vs surgical ward, liver disease, kidney disease, and hospice status were recorded. Results In total, 3325 inpatients were included; 564 patients had sepsis. Median lactate 1.7 mmol/L (interquartile range [IQR] 1.2-2.6). The 3-day, 30-day, and 1-year mortality were 2.5%, 10%, and 24%, respectively. A lactate level cutoff of ⩾4 mmol/L had best test characteristics (sensitivity 52.4%, specificity 91.4%) to predict increased 3-day mortality. Unadjusted risk ratio of death in 3 days for lactate ⩾4 was 10.3 (95% confidence interval [CI] 6.8-15.7). Patients with sepsis had a consistently higher risk of death compared with patients without sepsis for any given level of lactate. Adjusted odds ratio (OR) of 3-day mortality for lactate ⩾4 was 7.6 (95% CI 4.6-12.5); 30-day mortality was 2.6 (95% CI 1.9-3.6); and 1-year mortality was 1.8 (95% CI 1.4-2.6). Lactates in the normal range (<1.7) were also independently associated with 30-day and 1-year mortality. Conclusions Lactate predicts risk of death in all patients, although patients with sepsis have a higher mortality for any given lactate level. We report the novel finding that serum lactate, including normal values, is associated with long-term mortality.
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Affiliation(s)
- Julian Villar
- Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jack H Short
- Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Geoffrey Lighthall
- Department of Anesthesia, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
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The Glucagon-Like Peptide-1 Analog Exenatide Increases Blood Glucose Clearance, Lactate Clearance, and Heart Rate in Comatose Patients After Out-of-Hospital Cardiac Arrest. Crit Care Med 2019; 46:e118-e125. [PMID: 29189347 DOI: 10.1097/ccm.0000000000002814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To investigate the effects of the glucagon-like peptide-1 analog exenatide on blood glucose, lactate clearance, and hemodynamic variables in comatose, resuscitated out-of-hospital cardiac arrest patients. DESIGN Predefined post hoc analyzes from a double-blind, randomized clinical trial. SETTING The ICU of a tertiary heart center. PATIENTS Consecutive sample of adult, comatose patients undergoing targeted temperature management after out-of-hospital cardiac arrest from a presumed cardiac cause, irrespective of the initial cardiac rhythm. INTERVENTIONS Patients were randomized 1:1 to receive 6 hours and 15 minutes of infusion of either 17.4 μg of the glucagon-like peptide-1 analog exenatide (Byetta; Lilly) or placebo within 4 hours from sustained return of spontaneous circulation. The effects of exenatide were examined on the following prespecified covariates within the first 6 hours from study drug initiation: lactate level, blood glucose level, heart rate, mean arterial pressure, and combined dosage of norepinephrine and dopamine. MEASUREMENTS AND MAIN RESULTS The population consisted of 106 patients receiving either exenatide or placebo. During the first 6 hours from study drug initiation, the levels of blood glucose and lactate decreased 17% (95% CI, 8.9-25%; p = 0.0004) and 21% (95% CI, 6.0-33%; p = 0.02) faster in patients receiving exenatide versus placebo, respectively. Exenatide increased heart rate by approximately 10 beats per minute compared to placebo (p < 0.0001). There was no effect of exenatide on other hemodynamic variables. CONCLUSIONS In comatose out-of-hospital cardiac arrest patients, infusion with exenatide lowered blood glucose and resulted in increased clearance of lactate as well as increased heart rate. The clinical importance of these physiologic effects remains to be investigated.
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Vassallo MC, Tartamella F, Bhakta P. Can we trust power analysis on post hoc studies? A paradigm from out of hospital cardiac arrest. Acta Anaesthesiol Scand 2019; 63:829-830. [PMID: 30675717 DOI: 10.1111/aas.13332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 10/05/2018] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Pradipta Bhakta
- Department of Anaesthesia and Intensive Care, University Hospital of Limerick, Dooradoyle, Limerick, Ireland
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Impact of rapid lactate clearance as an indicator of hemodynamic optimization on outcome in out-of-hospital cardiac arrest: A retrospective analysis. PLoS One 2019; 14:e0214547. [PMID: 30934011 PMCID: PMC6443161 DOI: 10.1371/journal.pone.0214547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 03/14/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We analyzed the impact of rapid lactate clearance as an indicator of hemodynamic optimization on the outcome of out-of-hospital cardiac arrest (OHCA) during early post-cardiac arrest care (PCAC). METHODS This retrospective analysis was based on a prospective cohort. We selected adult patients with OHCA who achieved a survival event between May 2006 and December 2017. Serum lactate levels were measured at 0 and 6 h after a survival event. The lactate clearance rate was calculated as (lactate at 0 h-lactate at 6 h)/lactate at 0 h. The threshold lactate clearance value for predicting survival to discharge was determined by receiver operating characteristic (ROC) curve analysis. Rapid lactate clearance was defined as the lactate clearance above the threshold value or normalization of serum lactate level (<2.0 mmol/L) at 6 h after a survival event. The primary outcome was survival to discharge. Multivariate logistic regression was used to predict survival to discharge. RESULTS We enrolled 335 patients. 145 patients (43.3%) survived at discharge. The threshold value of lactate clearance was ≥34% to predict survival to discharge. After adjustment for confounders, the adjusted odds ratios for no hypotension at both 0 and 6 hours and for the presence of rapid lactate clearance for survival to discharge were 8.018 (95% confidence interval [CI] 2.802-22.947) and 2.193 (95% CI 1.263-3.808), respectively. Among patients with early recovery from initial hypotension or with no hypotension events at both 0 and 6 hours, the survival rates were significantly higher in the rapid lactate clearance group than in the non-rapid lactate clearance group. CONCLUSIONS During the early PCAC period, a rapid decrease in serum lactate level was an indicator of good outcome. Hemodynamic optimization including not only prevention and immediate correction of hypotension but also rapid lactate clearance should be considered in OHCA patients.
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Lactate Clearance Predicts Good Neurological Outcomes in Cardiac Arrest Patients Treated with Extracorporeal Cardiopulmonary Resuscitation. J Clin Med 2019; 8:jcm8030374. [PMID: 30889788 PMCID: PMC6462911 DOI: 10.3390/jcm8030374] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background: We evaluated critically ill patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) due to cardiac arrest (CA) with respect to baseline characteristics and laboratory assessments, including lactate and lactate clearance for prognostic relevance. Methods: The primary endpoint was 30-day mortality. The impact on 30-day mortality was assessed by uni- and multivariable Cox regression analyses. Neurological outcome assessed by Glasgow Outcome Scale (GOS) was pooled into two groups: scores of 1–3 (bad GOS score) and scores of 4–5 (good GOS score). Results: A total of 93 patients were included in the study. Serum lactate concentration (hazard ratio (HR) 1.09; 95% confidence interval (CI) 1.04–1.13; p < 0.001), hemoglobin, (Hb; HR 0.87; 95% CI 0.79–0.96; p = 0.004), and catecholamine use were associated with 30-day-mortality. In a multivariable model, only lactate clearance (after 6 h; OR 0.97; 95% CI 0.94–0.997; p = 0.03) was associated with a good GOS score. The optimal cut-off of lactate clearance at 6 h for the prediction of a bad GOS score was at ≤13%. Patients with a lactate clearance at 6 h ≤13% evidenced higher rates of bad GOS scores (97% vs. 73%; p = 0.01). Conclusions: Whereas lactate clearance does not predict mortality, it was the sole predictor of good neurological outcomes and might therefore guide clinicians when to stop ECPR.
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Patel VH, Vendittelli P, Garg R, Szpunar S, LaLonde T, Lee J, Rosman H, Mehta RH, Othman H. Neutrophil-lymphocyte ratio: A prognostic tool in patients with in-hospital cardiac arrest. World J Crit Care Med 2019; 8:9-17. [PMID: 30815378 PMCID: PMC6388309 DOI: 10.5492/wjccm.v8.i2.9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/24/2019] [Accepted: 01/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) portends a poor prognosis and survival to discharge rate. Prognostic markers such as interleukin-6, S-100 protein and high sensitivity C reactive protein have been studied as predictors of adverse outcomes after return of spontaneous circulation (ROSC); however; these variables are not routine laboratory tests and incur additional cost making them difficult to incorporate and less attractive in assessing patient’s prognosis. The neutrophil-lymphocyte ratio (NLR) is a marker of adverse prognosis for many cardiovascular conditions and certain types of cancers and sepsis. We hypothesize that an elevated NLR is associated with poor outcomes including mortality at discharge in patients with IHCA.
AIM To determine the prognostic significance of NLR in patients suffering IHCA who achieve ROSC.
METHODS A retrospective study was performed on all patients who had IHCA with the advanced cardiac life support protocol administered in a large urban community United States hospital over a one-year period. Patients were divided into two groups based on their NLR value (NLR < 4.5 or NLR ≥ 4.5). This cutpoint was derived from receiving operator characteristic curve analysis (area under the curve = 0.66) and provided 73% positive predictive value, 82% sensitivity and 42% specificity for predicting in-hospital death after IHCA. The primary outcome was death or discharge at 30 d, whichever came first.
RESULTS We reviewed 153 patients with a mean age of 66.1 ± 16.3 years; 48% were female. In-hospital mortality occurred in 65%. The median NLR in survivors was 4.9 (range 0.6-46.5) compared with 8.9 (0.28-96) in non-survivors (P = 0.001). A multivariable logistic regression model demonstrated that an NLR above 4.55 [odds ratio (OR) = 5.20, confidence interval (CI): 1.5-18.3, P = 0.01], older age (OR = 1.03, CI: 1.00-1.07, P = 0.05), and elevated serum lactate level (OR = 1.20, CI: 1.03-1.40, P = 0.02) were independent predictors of death.
CONCLUSION An NLR ≥ 4.5 may be a useful marker of increased risk of death in patients with IHCA.
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Affiliation(s)
- Vishal H Patel
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Philip Vendittelli
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Rajat Garg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44915, United States
| | - Susan Szpunar
- Department of Biomedical Investigations and Research, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Thomas LaLonde
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - John Lee
- Department of Critical Care Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Howard Rosman
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
| | - Rajendra H Mehta
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 22705, United States
| | - Hussein Othman
- Department of Cardiovascular Medicine, Ascension-St John Hospital and Medical Center, Detroit, MI 48236, United States
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Prognostic relevance of serum lactate kinetics in critically ill patients. Intensive Care Med 2018; 45:55-61. [PMID: 30478622 DOI: 10.1007/s00134-018-5475-3] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/19/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE Changes of lactate concentration over time were reported to be associated with survival in septic patients. We aimed to evaluate delta-lactate (ΔLac) 24 h after admission (Δ24Lac) to an intensive care unit (ICU) in critically ill patients for short- and long-term prognostic relevance. METHODS In total, 26,285 lactate measurements of 2191 patients admitted to a German ICU were analyzed. Inclusion criterion was a lactate concentration at admission above 2.0 mmol/L. Maximum lactate concentrations of day 1 and day 2 were used to calculate Δ24Lac. Follow-up of patients was performed retrospectively. Association of Δ24Lac and both in-hospital and long-term mortality were investigated. An optimal cut-off was calculated by means of the Youden index. RESULTS Patients with lower Δ24Lac were of similar age, but clinically sicker. As continuous variable, higher Δ24Lac was associated with decreased in-hospital mortality (per 1% Δ24Lac; HR 0.987 95%CI 0.985-0.990; p < 0.001) and an optimal Δ24Lac cut-off was calculated at 19%. Δ24Lac ≤ 19% was associated with both increased in-hospital (15% vs 43%; OR 4.11; 95%CI 3.23-5.21; p < 0.001) and long-term mortality (HR 1.54 95%CI 1.28-1.87; p < 0.001), even after correction for APACHE II, need for catecholamines and intubation. We matched 256 patients with Δ24Lac ≤ 19% to case-controls > 19% corrected for APACHE II scores, baseline lactate level and sex: Δ24Lac ≤ 19% remained associated with lower in-hospital and long-term survival. CONCLUSIONS Lower Δ24Lac was robustly associated with adverse outcome in critically ill patients, even after correction for confounders. Δ24Lac might constitute an independent, easily available and important parameter for risk stratification in the critically ill.
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Markers of cardiogenic shock predict persistent acute kidney injury after out of hospital cardiac arrest. Heart Lung 2018; 48:126-130. [PMID: 30470603 DOI: 10.1016/j.hrtlng.2018.10.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Ischemia and reperfusion injury (IRI) in cardiac arrest patients after return to spontaneous circulation causes dysfunctions in multiple organs. Kidney injury is generally transient but in some patients persists and contributes both to mortality and increased resource utilisation. Ongoing shock may compound renal injury from IRI, resulting in persistent dysfunction. We tested whether cardiac dysfunction was associated with the development of persistent acute kidney injury (PAKI) in the first 72 h after cardiac arrest. METHODS We performed an observational retrospective study from January 2013 to April 2017. We included consecutive patients treated after out-of-hospital cardiac arrest at a single academic medical center with renal function measured and immediately and for 48 h post arrest. We also recorded each patient's pre arrest baseline creatinine, demographic and clinical characteristics. Our primary outcome of interest was PAKI, defined as acute kidney injury (AKI) on at least 2 measurements 24 h apart. We compared demographics and outcomes between patients with PAKI and those without, and used logistic regression to identify independent predictors of PAKI. RESULTS Of 98 consecutive patients, we excluded 24 for missing data. AKI was present in 75% of subjects on arrival. PAKI developed in 35% of patients. PAKI patients had a longer hospital length of stay (median 21 vs 11 days) and lower hospital survival (47% vs 71%). Serum lactate levels, dosage of adrenaline during resuscitation and days of dobutamine infusion strongly predicted PAKI. CONCLUSIONS Among patient who survive cardiac arrest, acute AKI is common and PAKI occurs in more than one third. PAKI is associated both with survival and with length of stay at the hospital. High doses of adrenaline, high serial serum lactate levels, and dose of dobutamine predict PAKI. Evaluation of the trajectory of renal function over the first few days after resuscitation can provide prognostic information about patient recovery.
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Düring J, Dankiewicz J, Cronberg T, Hassager C, Hovdenes J, Kjaergaard J, Kuiper M, Nielsen N, Pellis T, Stammet P, Vulto J, Wanscher M, Wise M, Åneman A, Friberg H. Lactate, lactate clearance and outcome after cardiac arrest: A post-hoc analysis of the TTM-Trial. Acta Anaesthesiol Scand 2018; 62:1436-1442. [PMID: 29926901 DOI: 10.1111/aas.13172] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 05/01/2018] [Accepted: 05/02/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Admission lactate and lactate clearance are implemented for risk stratification in sepsis and trauma. In out-of-hospital cardiac arrest, results regarding outcome and lactate are conflicting. METHODS This is a post-hoc analysis of the Target Temperature Management trial in which 950 unconscious patents after out-of-hospital cardiac arrest were randomized to a temperature intervention of 33°C or 36°C. Serial lactate samples during the first 36 hours were collected. Admission lactate, 12-hour lactate, and the clearance of lactate within 12 hours after admission were analyzed and the association with 30-day mortality assessed. RESULTS Samples from 877 patients were analyzed. In univariate logistic regression analysis, the odds ratio for death by day 30 for each mmol/L was 1.12 (1.08-1.16) for admission lactate, P < .01, 1.21 (1.12-1.31) for 12-hour lactate, P < .01, and 1.003 (1.00-1.01) for each percentage point increase in 12-hour lactate clearance, P = .03. Only admission lactate and 12-hour lactate levels remained significant after adjusting for known predictors of outcome. The area under the receiver operating characteristic curve was 0.65 (0.61-0.69), P < .001, 0.61 (0.57-0.65), P < .001, and 0.53 (0.49-0.57), P = .15 for admission lactate, 12-hour lactate, and 12-hour lactate clearance, respectively. CONCLUSIONS Admission lactate and 12-hour lactate values were independently associated with 30-day mortality after out-of-hospital cardiac arrest while 12-hour lactate clearance was not. The clinical value of lactate as the sole predictor of outcome after out-of-hospital cardiac arrest is, however, limited.
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Affiliation(s)
- J. Düring
- Department of Clinical Sciences, Intensive and Perioperative Care Lund University Skane University Hospital Malmö Sweden
| | - J. Dankiewicz
- Department of Clinical Sciences, Cardiology Lund University Skane University Hospital Lund Sweden
| | - T. Cronberg
- Department of Clinical Sciences, Neurology Lund University Skane University Hospital Lund Sweden
| | - C. Hassager
- Department of Cardiology The Heart Centre Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - J. Hovdenes
- Division of Emergencies and Critical Care Department of Anesthesiology Oslo University Hospital Rikshospitalet Oslo Norway
| | - J. Kjaergaard
- Department of Cardiology The Heart Centre Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - M. Kuiper
- Department of Intensive Care Medical Center Leeuwarden Leeuwarden The Netherlands
| | - N. Nielsen
- Department of Clinical Sciences, Department of Anesthesiology and Intensive Care Lund University Helsingborg Hospital Helsingborg Sweden
| | - T. Pellis
- Department of Anaesthesia and Intensive Care Azienda Ospedaliera ‘Card. G. Panico’ Tricase Italy
| | - P. Stammet
- Medical Department National Rescue Services Luxembourg City Luxembourg
| | - J. Vulto
- Department of Emergency Medicine Medical Centre Leeuwarden Leeuwarden The Netherlands
| | - M. Wanscher
- Department of Cardiothoracic Anaesthesia 4142 The Heart Center Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - M. Wise
- Department of Adult Critical Care University Hospital of Wales Cardiff UK
| | - A. Åneman
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Sidney NSW Australia
- South Western Clinical School University of New South Wales Sydney NSW Australia
- The Ingham Institute for Applied Medical Research Sydney NSW Australia
| | - H. Friberg
- Department of Clinical Sciences, Intensive and Perioperative Care Lund University Skane University Hospital Malmö Sweden
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Dadeh AA, Nuanjaroan B. Using initial serum lactate level in the emergency department to predict the sustained return of spontaneous circulation in nontraumatic out-of-hospital cardiac arrest patients. Open Access Emerg Med 2018; 10:105-111. [PMID: 30288130 PMCID: PMC6163001 DOI: 10.2147/oaem.s165154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To examine the initial level of lactate to predict sustained return of spontaneous circulation (ROSC) in nontraumatic out-of-hospital cardiac arrest (OHCA) patients. Materials and methods This was a 30-month retrospective cohort study in an emergency department (ED) of a tertiary care hospital. The inclusion criteria were adult nontraumatic OHCA patients who came to the ED with ongoing chest compression. The primary outcome was initial serum lactate level at the ED to predict sustained ROSC in nontraumatic OHCA. Logistic regression was used to determine any association between sustained ROSC and significant variables. Results There were 207 patients who met the inclusion criteria. Forty one percent of nontraumatic OHCA patients achieved sustained ROSC. The mean ± SD initial serum lactate in the ROSC group was lower than the non-ROSC group (12.0±4.8 vs 12.6±5), but without statistical significance. The significant factors to predict sustained ROSC were no underlying disease (adjusted odds ratio [aOR] 1.71, 95% CI 0.51–5.71, P=0.014), cardiac arrest in a public area (aOR 2.40, 95% CI 1.2–4.79, P=0.013), and witnessed arrest (aOR 2.39, 95% CI 1.26–4.52, P=0.008). The cut-off points of initial serum lactate to predict mortality at 24 and 48 hours after cardiopulmonary resuscitation were 9.1 (P=0.031) and 9.4 (P=0.049) mmol/L, respectively. Eleven survived to hospital discharge, and 54.5% had good neurological outcome without statistical significance (P=0.553). The significant variables and initial lactate levels were used to develop a scoring system which ranged from −4 to 11. The receiver operating characters curve indicated a cut-off point of 3.6 to predict ROSC with an area under the curve of 0.715. Conclusion The initial serum lactate had no association with sustained ROSC and hospital discharge with good neurological outcome but can be used to predict 24- and 48-hour postresuscitation mortality in nontraumatic OHCA patients with initial serum lactate cut-off points of 9.1 and 9.4 mmol/L, respectively.
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Affiliation(s)
- Ar-Aishah Dadeh
- Department of Emergency Medicine, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand,
| | - Banjaparat Nuanjaroan
- Department of Emergency Medicine, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand,
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Jung YH, Lee BK, Jeung KW, Youn CS, Lee DH, Lee SM, Heo T, Min YI. Prognostic value of serum phosphate level in adult patients resuscitated from cardiac arrest. Resuscitation 2018; 128:56-62. [DOI: 10.1016/j.resuscitation.2018.04.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/29/2018] [Accepted: 04/17/2018] [Indexed: 11/28/2022]
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Thiamine as a Renal Protective Agent in Septic Shock. A Secondary Analysis of a Randomized, Double-Blind, Placebo-controlled Trial. Ann Am Thorac Soc 2018; 14:737-741. [PMID: 28207287 DOI: 10.1513/annalsats.201608-656bc] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Acute kidney injury (AKI) is common in patients with sepsis and has been associated with high mortality rates. The provision of thiamine to patients with sepsis may reduce the incidence and severity of sepsis-related AKI and thereby prevent renal failure requiring renal replacement therapy (RRT). OBJECTIVES To test the hypothesis that thiamine supplementation mitigates kidney injury in septic shock. METHODS This was a secondary analysis of a single-center, randomized, double-blind trial comparing thiamine to placebo in patients with septic shock. Renal function, need for RRT, timing of hemodialysis catheter placement, and timing of RRT initiation were abstracted. The baseline creatinine and worst creatinine values between 3 and 24 hours, 24 and 48 hours, and 48 and 72 hours were likewise abstracted. RESULTS There were 70 patients eligible for analysis after excluding 10 patients in whom hemodialysis was initiated before study drug administration. Baseline serum creatinine in the thiamine group was 1.2 mg/dl (interquartile range, 0.8-2.5) as compared with 1.8 mg/dl (interquartile range, 1.3-2.7) in the placebo group (P = 0.3). After initiation of the study drug, more patients in the placebo group than in the thiamine group were started on RRT (eight [21%] vs. one [3%]; P = 0.04). In the repeated measures analysis adjusting for the baseline creatinine level, the worst creatinine levels were higher in the placebo group than in the thiamine group (P = 0.05). CONCLUSIONS In this post hoc analysis of a randomized controlled trial, patients with septic shock randomized to receive thiamine had lower serum creatinine levels and a lower rate of progression to RRT than patients randomized to placebo. These findings should be considered hypothesis generating and can be used as a foundation for further, prospective investigation in this area.
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