Half-molar sodium lactate infusion improves cardiac performance in acute heart failure: a pilot randomised controlled clinical trial

Marek Nalos,Anthony Mclean,Xavier Leverve,Ian Seppelt,Leonie Weisbrodt,Iris Ting,Ray Parkin,Stephen Huang

doi:10.1186/cc13793

Abstract

IntroductionAcute heart failure (AHF) is characterized by inadequate cardiac output (CO), congestive symptoms, poor peripheral perfusion and end-organ dysfunction. Treatment often includes a combination of diuretics, oxygen, positive pressure ventilation, inotropes and vasodilators or vasopressors. Lactate is a marker of illness severity but is also an important metabolic substrate for the myocardium at rest and during stress. We tested the effects of half-molar sodium lactate infusion on cardiac performance in AHF.MethodsWe conducted a prospective, randomised, controlled, open-label, pilot clinical trial in 40 patients fulfilling two of the following three criteria for AHF: (1) left ventricular ejection fraction <40%, (2) acute pulmonary oedema or respiratory failure of predominantly cardiac origin requiring mechanical ventilation and (3) currently receiving vasopressor and/or inotropic support. Patients in the intervention group received a 3 ml/kg bolus of half-molar sodium lactate over the course of 15 minutes followed by 1 ml/kg/h continuous infusion for 24 hours. The control group received only a 3 ml/kg bolus of Hartmann’s solution without continuous infusion. The primary outcome was CO assessed by transthoracic echocardiography 24 hours after randomisation. Secondary outcomes included a measure of right ventricular systolic function (tricuspid annular plane systolic excursion (TAPSE)), acid-base balance, electrolyte and organ function parameters, along with length of stay and mortality.ResultsThe infusion of half-molar sodium lactate increased (mean ± SD) CO from 4.05 ± 1.37 L/min to 5.49 ± 1.9 L/min (P < 0.01) and TAPSE from 14.7 ± 5.5 mm to 18.3 ± 7 mm (P = 0.02). Plasma sodium and pH increased (136 ± 4 to 146 ± 6 and 7.40 ± 0.06 to 7.53 ± 0.03, respectively; both P < 0.01), but potassium, chloride and phosphate levels decreased. There were no significant differences in the need for vasoactive therapy, respiratory support, renal or liver function tests, duration of ICU and hospital stay or 28- and 90-day mortality.ConclusionsInfusion of half-molar sodium lactate improved cardiac performance and led to metabolic alkalosis in AHF patients without any detrimental effects on organ function.Trial registrationClinicaltrials.gov NCT01981655. Registered 13 August 2013.

Highlights

Acute heart failure (AHF) is characterized by inadequate cardiac output (CO), congestive symptoms, poor peripheral perfusion and end-organ dysfunction
After baseline parameters were recorded and transthoracic echocardiography (TTE) was performed, patients were given an intravenous bolus of 3 ml/kg actual body weight (ABW) of the assigned fluid according to randomisation over the course of 15 minutes
Both groups received standard therapy for AHF according to best practice, which included a combination of inotropes, vasopressors, vasodilators, diuretics, intraaortic balloon counterpulsation and mechanical ventilation as required

Summary

Introduction

Acute heart failure (AHF) is characterized by inadequate cardiac output (CO), congestive symptoms, poor peripheral perfusion and end-organ dysfunction. Lactate is a marker of illness severity but is an important metabolic substrate for the myocardium at rest and during stress. Blood lactate is regarded as a marker of illness severity, and increased plasma lactate levels are common in AHF and acute coronary syndromes [9,10,11]. Overall lactate metabolism in severe cardiogenic shock has been found not to be significantly altered, and halfmolar sodium lactate infusion increased cardiac output (CO) while a negative fluid balance was maintained in patients after coronary artery bypass grafting [17,18]

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Conclusion