Two-Hour Lactate Clearance Predicts Negative Outcome in Patients with Cardiorespiratory Insufficiency

Objective. To evaluate 2-hour lactate clearance as a prognostic marker in acute cardiorespiratory insufficiency. Design. Prospective observational study. Setting. Emergency Department (ED) and 16-bed medical High Dependency Unit (HDU). Methods and Main Results. 95 consecutive admissions from the ED for acute cardiorespiratory insufficiency were prospectively enrolled. Arterial lactate concentration was assessed at ED arrival and 1, 2, 6, and 24 hours later. The predictive value of 2-hour lactate clearance was evaluated for negative outcomes defined as hospital mortality or need for endotracheal intubation versus positive outcomes defined as discharge or transfer to a general medical ward. Logistic regression and ROC curves found 2-hour lactate clearance >15% was a strong predictor of negative outcome (P < .0001) with a sensitivity of 86% (95%CI = 67%–95%) and a specificity of 91% (95%CI = 82%–96%), Positive predictive value was 80% (95%CI = 61%–92%), and negative predictive value was 92% (95%CI = 84%–98%). Conclusions. Systematic monitoring of lactate clearance at 2 hours can be used in to identify patients at high risk of negative outcome and perhaps to tailor more aggressive therapy. Equally important is that a 2-hour lactate clearance >15% is highly predictive of positive outcome and may reassure clinicians that the therapeutic approach is appropriate

Time-weighted lactate as a predictor of adverse outcome in acute heart failure

The role of dynamic changes in lactate concentrations on prognosis in acute heart failure has been poorly investigated. The aim of this study was to explore the predictive value of 24 h time-weighted lactate (LACTW ) in patients with acute heart failure

Lactate Arterial-Central Venous Gradient among COVID-19 Patients in ICU: A Potential Tool in the Clinical Practice

Objective: In physiological conditions, arterial blood lactate concentration is equal to or lower than central venous blood lactate concentration. A reversal in this rate (i.e., higher lactate concentration in central venous blood), which could reflect a derangement in the mitochondrial metabolism of lung cells induced by inflammation, has been previously reported in patients with ARDS but has been never explored in COVID-19 patients. The aim of this study was to explore if the COVID-19-induced lung cell damage was mirrored by an arterial lactatemia higher than the central venous one; then if the administration of anti-inflammatory therapy (i.e., canakinumab 300mg subcutaneous) could normalize such abnormal lactate a-cv difference.Methods: A prospective cohort study was conducted, started on March 25, 2020, for a duration of 10 days, enrolling 21 patients affected by severe COVID-19 pneumonia undergoing mechanical ventilation consecutively admitted to the ICU of the Rimini Hospital, Italy. Arterial and central venous blood samples were contemporarily collected to calculate the difference between arterial and central venous lactate (Delta a-cv lactate) concentrations within 24h from tracheal intubation (T 0) and 24 hours after canakinumab administration (T 1).Results: At T 0, 19 of 21 (90.5%) patients showed a pathologic Delta a-cv lactate (median 0.15mmol/L; IQR 0.07-0.25). In the 13 patients undergoing canakinumab administration, at T 1, Delta a-cv lactate decreased in 92.3% of cases, the decrease being statistically significant (T 0: median 0.24, IQR 0.09-0.31mmol/L; T 1: median -0.01, IQR -0.08-0.04mmol/L; p=0.002).Conclusion: A reversed Delta a-cv lactate might be interpreted as one of the effects of COVID-19-related cytokine storm, which could reflect a derangement in the mitochondrial metabolism of lung cells induced by severe inflammation or other uncoupling mediators. In addition, Delta a-cv lactate decrease might also reflect the anti-inflammatory activity of canakinumab. Our preliminary findings need to be confirmed by larger outcome studies

End-tidal arterial CO2 partial pressure gradient in patients with severe hypercapnia undergoing noninvasive ventilation

BACKGROUND: Patients with severe hypercapnia represent a particularly serious condition in an emergency department (ED), requiring immediate attention. Noninvasive ventilation (NIV) is an integral part of the treatment for acute respiratory failure. The present study aimed to validate the measurement of end-tidal CO(2) (EtCO(2)) as a noninvasive technique to evaluate the effectiveness of NIV in acute hypercapnic respiratory failure. METHODS: Twenty consecutive patients admitted to the ED with severe dyspnea were enrolled in the study. NIV by means of bilevel positive airway pressure, was applied to the patients simultaneously with standard medical therapy and continued for 12 hours; the arterial blood gases and side-stream nasal/oral EtCO(2) were measured at subsequent times: T0 (admission to the ED), T1h (after 1 hour), T6h (after 6 hours), and T12h (after 12 hours) during NIV treatment. RESULTS: The arterial CO(2) partial pressure (PaCO(2))–EtCO(2) gradient decreased progressively, reaching at T6h and T12h values lower than baseline (P < 0.001), while arterial pH increased during the observation period (P < 0.001). A positive correlation was found between EtCO(2) and PaCO(2) values (r = 0.89, P < 0.001) at the end of the observation period. CONCLUSION: In our hypercapnic patients, the effectiveness of the NIV was evidenced by the progressive reduction of the PaCO(2)–EtCO(2) gradient. The measurement of the CO(2) gradient could be a reliable method in monitoring the effectiveness of NIV in acute hypercapnic respiratory failure in the ED

Lactate clearance in cardiorespiratory emergency

Early goal directed therapy has been found to improve prognosis in septic patients, if the therapeutic goal is achieved within the first six hours. The aim of our study is to demonstrate that in patients with acute cardiorespiratory failure, rapid (within 2 hours) lactate clearance can help define patients&rsquo; prognosis. 67 consecutive patients, admitted to our 16-bed Emergency Medicine ward for acute cardiorespiratory failure (age 75,9 &plusmn; 9,8) (APACHE II score 19,0 &plusmn; 4,1), were included in the study. Blood lactate concentration was read at admission and after 2, 6 and 24 hours. We evaluated mortality at seven days and the use of orotracheal intubation (patients with negative outcome) vs. discharge or transfer to a non-emergency ward with subsequent discharge (patients with negative outcome). Lactate concentration at admission was 4,6 &plusmn; 2,5 mmol/l; lactate clearance (%) at 2 hours was 40,4 &plusmn; 32,1 in patients with a positive outcome and &ndash;8,3 &plusmn; 5,0 in patients with a negative outcome (p &lt; 0,05). Lactate clearance at 2 hours &lt; 25% is correlated to a negative outcome with an 84,2% sensitivity and a 79,2% specificity. The positive predictive value was 61,5% and the negative predictive value was 92,2%. Systematic lactate clearance monitoring can be used in cases of acute cardiorespiratory insufficiency to identify patients with a high risk of negative outcome. In our study, low clearance at two hours was associated with an increase in mortality and/or the need for orotracheal intubation. Conversely, a clearance at two hours of &gt; 25% in most cases confirms the therapeutic strategy undertaken. Serial evaluation of blood lactate concentration may therefore be useful in guiding treatment strategies

Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring for surgical hip repair in two patients with severe aortic stenosis

BACKGROUND AND OBJECTIVES: Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area <1.0 cm2 or a mean aortic valve gradient >30 mm Hg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair. CASE REPORT: Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2 mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions. CONCLUSION: Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients

Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea in the emergency department

Background: Dyspnea is one of the most frequent complaints in the Emergency Department. Thoracic ultrasound should help to differentiate cardiogenic from non-cardiogenic causes of dyspnea. We evaluated whether the diagnostic accuracy can be improved by adding a point-of-care-ultrasonography (POC-US) to routine exams and if an early use of this technique produces any advantage. Methods: One hundred sixty-eight patients were enrolled and randomized in two groups: Group 1 received an immediate POC-US in addition to routine laboratory and instrumental tests; group 2 received an ultrasound scan within 1 h from the admission to the Emergency Department. The concordance between initial and final diagnosis and the percentage of wrong diagnosis in the two groups were evaluated. Mortality, days of hospitalization in Emergency Medicine department and transfers to other wards were compared. Sensitivity and specificity of the routine protocol and the one including ultrasonography for the diagnosis of the causes of dyspnea were also analyzed. Results: Eighty-eight patients were randomized in group 1 and 80 in group 2. The concordance rate between initial and final diagnoses was significantly different (0.94 in group 1 vs. 0.22 in group 2, p < 0.005). The percentage of wrong initial diagnosis was 5% in group 1 and 50% in group 2 (p < 0.0001). Conclusions: Adding POC-US to routine exams improves the diagnostic accuracy of dyspnea and reduces errors in the Emergency Department

Inferior vena cava collapsibility to guide fluid removal in slow continuous ultrafiltration: A pilot study

Objective: To investigate whether ultrasound determination of the inferior vena cava diameter (IVCD) and its collapsibility index (IVCCI) could be used to optimize the fluid removal rate while avoiding hypotension during slow continuous ultrafiltration (SCUF). Methods: Twenty-four consecutive patients [13 men and 11 women, mean age 72 ± 5 years; New York Heart Association (NYHA) functional classes III-IV] with acute decompensated heart failure (ADHF) and diuretic resistance were admitted to our 16-bed medical ICU. Blood pressure (BP), heart rate (HR), respiratory rate (RR), blood samples for hematocrit, creatinine, sodium, potassium, and arterial BGA plus lactate were obtained at baseline and than every 2 h from the beginning of SCUF. IVCD, assessed by M-mode subcostal echocardiography during spontaneous breathing, was evaluated before SCUF, at 12 h, and just after the cessation of the procedure. The IVCCI was calculated as follows: [(IVCDmax - IVCDmin)/IVCD max] × 100. Results: Mean UF time was 20.3 ± 4.6 h with a mean volume of 287.6 ± 96.2 ml h-1 and a total ultrafiltrate production of 5,780.8 ± 1,994.6 ml. No significant difference in MAP, HR, RR, and IVCD before and after UF was found. IVCCI increased significantly after UF (P 30%. In all the other patients, a significant increase in IVCCI was obtained without any hemodynamic instability. Conclusion: IVC ultrasound is a rapid, simple, and non-invasive means for bedside monitoring of intravascular volume during SCUF and may guide fluid removal velocity. © 2010 Copyright jointly hold by Springer and ESICM

Diaphragmatic motility assessment in COPD exacerbation, early detection of Non-Invasive Mechanical Ventilation failure: a pilot study

Background Patients with respiratory failure due to Chronic Obstructive Pulmonary Disease (COPD) have decreased diaphragmatic mobility [1]. Non Invasive Mechanical Ventilation (NIMV) is a cornerstone in COPD exacerbation therapy. The availability of early predictors of NIMV failure may be helpful to guide decision-making. Only pH, respiratory rate and PaO2/FiO2 have been considered predictors of response to NIMV [2]. Ultrasonographic (US) assessment of diaphragmatic kinetic is a fast, reliable and reproducible method [3], but its predictive value on NIMV success is not known.Objective:Primary endpoint was to evaluate if the diaphragmatic excursion measurement was able to predict a longer weaning time. Secondary endpoint was to find out a cut-off value of diaphragmatic excursion and a weaning time interval able to predict worst outcome. Methods: Fifty-two (39 males, aged 71±7 years) Caucasian patients with COPD exacerbation treated with NIMV were enrolled. Diaphragm motility was assessed by ultrasonography before starting ventilation at 6 and 24 hours and at the weaning from NIMV. The diaphragmatic excursion (centimeters); the inspiratory and expiratory times (seconds); the inspiration and expiration velocity (cm/sec), the breathing period (seconds), the diaphragm motion time (seconds) and the diaphragm resting time (seconds) were evaluated. Results: Forty-five patients completed the study. The mean time on NIMV was 4.11 ± 1.07 days, with a total time of ventilation of 32.6 ± 86 hours. All the ultrasound diaphragm motility parameters, except for inspiration and expiration velocity, significantly improved at the weaning. Diaphragm excursion at the baseline was significantly correlated with pH (r=0.458; p=0.002), PaO2/FiO2 (r=0.567; p&lt;0.001), and weaning time (r=0.774; p&lt;0.0001). In a multiple linear regression analysis only diaphragm excursion was significantly associated with longer weaning time (coefficient of estimated model -9.247; Standard Error 3.101; p=0.003). ROC curve with weaning time longer than 36 hours was considered as positive state. The AUC value was 0.912 (Standard Error 0.015, p&lt;0.001). The higher sensitivity rate (100%) was achieved with a specificity rate of 86.7% and a cut-off value of 3.165 cm, therefore patients with an excursion lower than 3.165 cm should be weaned after at least 36 hours, while patients with an excursion higher than 3.165 cm could be weaned within 36 hours. Conclusion: US measurements of diaphragmatic performance may have a role in the early evaluation of exacerbation of COPD and in predicting the response to NIMV therapy, it should be included as a routine test in patients presenting to ED with ECOPD

Levosimendan as a treatment for acute renal failure associated with cardiogenic shock after hip fracture

Abstract Inotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75-year-old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery