Management of Elevated Lactate with Unwashed Blood on VA ECMO

Understanding the Clinical Context

The use of unwashed blood products during VA ECMO support can contribute to elevated lactate through multiple mechanisms, including hemolysis and inadequate tissue perfusion, as recommended by the European Society of Intensive Care Medicine 1, 2
Inadequate ECMO flow causing tissue hypoperfusion remains the most critical reversible cause of true hyperlactatemia, according to the American Thoracic Society 2
Circuit-related complications, including cannula malposition, suctioning, or chatter, can reduce effective blood flow and cause hemolysis, as stated by the Extracorporeal Life Support Organization 2

Check plasma-free hemoglobin levels immediately to quantify the degree of hemolysis, as recommended by the International Society for Apheresis 2
Inspect the ECMO circuit for signs of mechanical hemolysis, including dark discoloration of tubing, excessive negative pressures, or cannula vibration, according to the American Society for Artificial Internal Organs 2
Monitor for cannula suctioning and chatter, which indicate venous collapse and can cause both flow reduction and hemolysis, as stated by the European Society of Cardiology 2

Maintain continuous monitoring of MAP, ECMO flow, and echocardiography as recommended for all VA ECMO patients by the American College of Cardiology 1, 2
Target MAP ≥ 65-70 mmHg to ensure adequate tissue perfusion, according to the American Heart Association 1, 3
Assess pulse pressure, as values < 20 mmHg in the first 24 hours are associated with acute brain injury and poor outcomes, as stated by the Neurocritical Care Society 4, 3
Evaluate for differential hypoxia using continuous cerebral oximetry, particularly with peripheral VA ECMO, as recommended by the Society of Critical Care Medicine 4, 3

Increase ECMO flow if inadequate (typically 60-80 mL/kg/min for adults) to improve tissue perfusion, according to the Extracorporeal Life Support Organization 2
Correct hypovolemia carefully, as it can induce venous collapse and worsen hemolysis, but avoid volume overload, which independently predicts poor outcomes, as stated by the European Society of Intensive Care Medicine 2
Reposition cannulas if malpositioned based on echocardiographic assessment, as recommended by the American Society of Echocardiography 2

Discontinue unwashed blood products and switch to washed or leukoreduced products, as recommended by the American Association of Blood Banks 2
Reduce circuit-related hemolysis by optimizing flow rates and eliminating mechanical causes, according to the International Society for Apheresis 2
Monitor for acquired von Willebrand syndrome (AVWS), which develops in nearly all ECMO patients and contributes to bleeding complications, as stated by the International Society on Thrombosis and Haemostasis 5, 6

Avoid arterial hypoxemia (PaO₂ < 70 mmHg) especially in the first 24-48 hours, as this is associated with acute brain injury, according to the American Thoracic Society 7, 3
Maintain adequate hemoglobin to optimize oxygen-carrying capacity despite hemolysis, as recommended by the American Society of Hematology 2
Monitor central venous oxygen saturation (SvO₂) continuously as part of hemodynamic assessment, according to the Society of Critical Care Medicine 1, 2

Absolute lactate levels outperform lactate clearance for prognostication and should be prioritized, as stated by the Society of Critical Care Medicine 1, 2

Implement standardized neuromonitoring, including continuous cerebral oximetry and serial neurological examinations, as recommended by the Neurocritical Care Society 4, 8, 3

Do not assume all elevated lactate is from hemolysis - inadequate tissue perfusion must be ruled out first, according to the European Society of Intensive Care Medicine 2
Do not use continuous thermodilution or pulse contour cardiac output monitoring as these are unreliable in ECMO patients, as stated by the American Society for Artificial Internal Organs 2
Avoid excessive vasopressor doses (norepinephrine > 0.5 µg/kg/min) which may indicate the need for VA ECMO rather than VV ECMO, according to the American College of Cardiology 1, 2

Target ECMO flow after cannulation is 3–4 L/min, and the arteriovenous O₂ difference should be kept at 3–5 cc O₂ per 100 mL of blood, which serves as a reliable metric for setting flow goals 9.

Continuous accurate flow measurement is essential because adequate ECMO flow is the most critical reversible cause of tissue hypoperfusion; it helps maintain cerebral and end‑organ perfusion while minimizing left‑ventricular afterload 9.

Flow monitoring must be combined with other hemodynamic parameters—mean arterial pressure ≥65–70 mmHg, mixed venous saturation >66%, and arterial blood gases obtained from a right radial arterial line—to assess the adequacy of VA‑ECMO support 9, 10.