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

A Diagnostic Model to Predict SARS-CoV-2 Positivity in Emergency Department Using Routine Admission Hematological Parameters

Early detection of SARS-CoV-2 in the emergency department (ED) is a crucial necessity, especially in settings of overcrowding: establishing a pre-diagnostic test probability of infection would help to triage patients and reduce diagnostic errors, and it could be useful in resource-limited countries. Here, we established and validated a clinical predictor of infection based on routine admission hematological parameters. The diagnostic model was developed by comparing 85 consecutive patients with symptomatic COVID-19 confirmed by RT-PCR with 85 symptomatic, SARS-CoV-2-negative controls. Abnormal hematological parameters significantly (p &lt; 0.05) associated with SARS-CoV-2 infection were used to derive a “cumulative score” between 0 and 16. The model was validated in an independent cohort of 170 SARS-CoV-2-positive patients. Several routine hematology parameters were significantly (p &lt; 0.05) associated with SARS-CoV-2 infection. A “cumulative score” score ≥7 discriminated COVID-19-postive patients from controls with a sensitivity of 94% and specificity of 100% (p &lt; 0.001). The high sensitivity of the predictive model was confirmed in the prospective validation set, and the cumulative score (i) predicted SARS-CoV-2 positivity even when the first oro-nasopharyngeal swab RT-PCR result was reported as a false negative in both cohorts and (ii) resulted to be independent from disease severity. The cumulative score based on routine blood parameters can be used to predict an early and accurate diagnosis of SARS-CoV-2 infection in symptomatic patients, thereby facilitating triage and optimizing early management and isolation from the COVID-19 free population, particularly useful in overcrowding situations and in resource-poor settings

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

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

A real life evaluation of non invasive ventilation in acute cardiogenic pulmonary edema: a multicenter, perspective, observational study for the ACPE SIMEU study group

Abstract Background During the past three decades conflicting evidences have been published on the use of non-invasive ventilation (NIV) in patients with acute cardiogenic pulmonary edema (ACPE). The aim of this study is to describe the management of acute respiratory failure (ARF) due to ACPE in twelve Italian emergency departments (EDs). We evaluated prevalence, characteristics and outcomes of ACPE patients treated with oxygen therapy, continuous positive airway pressure (CPAP) or Bi-level positive airway pressure (BiPAP) on admission to the EDs. Methods In this multicenter, prospective, observational study, consecutive adult patients with ACPE were enrolled in 12 EDs in Italy from May 2009 to December 2013. Three study groups were identified according to the initial respiratory treatment: patients receiving oxygen therapy, those treated with CPAP and those treated with BiPAP. Treatment failure was evaluated as study outcome. Results We enrolled 1293 patients with acute cardiogenic pulmonary edema. 273 (21%) began with oxygen, 788 (61%) with CPAP and 232 (18%) with BiPAP. One out of four patient who began with oxygen was subsequently switched to NIV and initial treatment with oxygen therapy had an odds ratio for treatment failure of 3.65 (95% CI: 2.55–5.23, p < 0.001). Conclusions: NIV seems to be the first choice for treatment of ARF due to ACPE, showing high clinical effectiveness and representing a rescue option for patients not improving with conventional oxygen therapy