Lack of utility of arteriojugular venous differences of lactate as a reliable indicator of increased brain anaerobic metabolism in traumatic brain injury

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Object

Ischemic lesions are highly prevalent in patients with traumatic brain injuries (TBIs) and are the single most important cause of secondary brain damage. The prevention and early treatment of these lesions is the primary aim in the modern treatment of these patients. One of the most widely used monitoring techniques at the bedside is quantification of brain extracellular level of lactate by using arteriojugular venous differences of lactate (AVDL). The purpose of this study was to determine the sensitivity, specificity, and predictive value of AVDL as an indicator of increases in brain lactate production in patients with TBIs.

Methods

Arteriojugular venous differences of lactate were calculated every 6 hours using samples obtained though a catheter placed in the jugular bulb in 45 patients with diffuse head injuries (57.8%) or evacuated brain lesions (42.2%). Cerebral lactate concentration obtained with a 20-kD microdialysis catheter implanted in undamaged tissue was used as the de facto gold standard.

Six hundred seventy-three AVDL determinations and cerebral microdialysis samples were obtained simultaneously; 543 microdialysis samples (81%) showed lactate values greater than 2 mmol/L, but only 21 AVDL determinations (3.1%) showed an increase in brain lactate. No correlation was found between AVDL and cerebral lactate concentration (ρ = 0.014, p = 0.719). Arteriojugular venous differences of lactate had a sensitivity and specificity of 3.3 and 97.7%, respectively, with a false-negative rate of 96.7% and a false-positive rate of 2.3%.

Conclusions

Arteriojugular venous differences of lactate do not reliably reflect increased cerebral lactate production and consequently are not reliable in ruling out brain ischemia in patients with TBIs. The clinical use of this monitoring method in neurocritical care should be reconsidered.

Abbreviations used in this paper: AVDL = arteriojugular venous differences of lactate; AVDO2 = AVD of O2; BBB = blood–brain barrier; CBF = cerebral blood flow; CI = confidence interval; CT = computed tomography; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ICU = intensive care unit; LOI = lactate-O2 index; SaO2 = arterial O2 saturation; SjO2 = jugular O2 saturation; TBI = traumatic brain injury.

Article Information

Address reprint requests to: Juan Sahuquillo, M.D., Ph.D., Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035 Barcelona, Spain. email: sahuquillo@neurotrauma.net.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Computed tomography scans obtained in a patient with an evacuated left frontal contusion. An intraparenchymatous ICP sensor was inserted into the left hemisphere; brain tissue PO2 and microdialysis catheters were inserted in the right hemisphere. The arrows show the location of the microdialysis catheter, into which a small quantity of air was injected before removal.

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    Box-and-whisker plot showing the distribution of normal values of AVDL (values obtained from Gibbs et al.).

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    Scatterplot demonstrating a nonsignificant correlation between AVDL values and brain lactate values obtained by cerebral microdialysis.

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    Scatterplot showing a nonsignficant correlation between LOI values and brain lactate values obtained by cerebral microdialysis.

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