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Hu J, Liu Y, Huang L, Song M, Zhu G. Association between cardiopulmonary bypass time and mortality among patients with acute respiratory distress syndrome after cardiac surgery. BMC Cardiovasc Disord 2023; 23:622. [PMID: 38114945 PMCID: PMC10729512 DOI: 10.1186/s12872-023-03664-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/08/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) can lead to lung injury and even acute respiratory distress syndrome (ARDS) through triggering systemic inflammatory response. The objective of this study was to investigate the impact of CPB time on clinical outcomes in patients with ARDS after cardiac surgery. METHODS Totally, patients with ARDS after cardiac surgery in Beijing Anzhen Hospital from January 2005 to December 2015 were retrospectively included and were further divided into three groups according to the median time of CPB. The primary endpoints were the ICU mortality and in-hospital mortality, and ICU and hospital stay. Restricted cubic spline (RCS), logistic regression, cox regression model, and receiver operating characteristic (ROC) curve were adopted to explore the relationship between CPB time and clinical endpoints. RESULTS A total of 54,217 patients underwent cardiac surgery during the above period, of whom 210 patients developed ARDS after surgery and were finally included. The ICU mortality and in-hospital mortality were 21.0% and 41.9% in all ARDS patients after cardiac surgery respectively. Patients with long CPB time (CPB time ≥ 173 min) had longer length of ICU stay (P = 0.011), higher ICU (P < 0.001) mortality and in-hospital(P = 0.002) mortality compared with non-CPB patients (CPB = 0). For each ten minutes increment in CPB time, the hazards of a worse outcome increased by 13.3% for ICU mortality and 9.3% for in-hospital mortality after adjusting for potential factors. ROC curves showed CPB time presented more satisfactory power to predict mortality compared with APCHEII score. The optimal cut-off value of CPB time were 160.5 min for ICU mortality and in-hospital mortality. CONCLUSIONS Our findings demonstrated the significant prognostic value of CPB time in patients with ARDS after cardiac surgery. Longer time of CPB was associated with poorer clinical outcomes, and could be served as an indicator to predict short-term mortality in patients with ARDS after cardiac surgery.
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Affiliation(s)
- Jiaxin Hu
- Department of Respiratory and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, No.2 Anzhen Road, Beijing, 100029, PR China
| | - Yan Liu
- Department of Infectious Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
| | - Lixue Huang
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Man Song
- Department of Infectious Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
| | - Guangfa Zhu
- Department of Respiratory and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, No.2 Anzhen Road, Beijing, 100029, PR China.
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Singh A, Nanda C, Mehta Y. Unexpected values of mixed venous blood analysis: Back to basics before sampling. J Anaesthesiol Clin Pharmacol 2023; 39:509-510. [PMID: 38025562 PMCID: PMC10661622 DOI: 10.4103/joacp.joacp_537_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/07/2022] [Accepted: 01/09/2022] [Indexed: 12/01/2023] Open
Affiliation(s)
- Ajmer Singh
- Department of Cardiac Anaesthesia, Institute of Critical Care and Anesthesiology, Medanta-The Medicity, Sector-38, Gurugram, Haryana, India
| | - Chinmaya Nanda
- Department of Cardiac Anaesthesia, Institute of Critical Care and Anesthesiology, Medanta-The Medicity, Sector-38, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Cardiac Anaesthesia, Institute of Critical Care and Anesthesiology, Medanta-The Medicity, Sector-38, Gurugram, Haryana, India
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Zhang T, Lu L, Li M, Zhang D, Yu P, Zhang X, Zhang Z, Lei C. Exosome from BMMSC Attenuates Cardiopulmonary Bypass-Induced Acute Lung Injury Via YAP/β-Catenin Pathway: Downregulation of Pyroptosis. Stem Cells 2022; 40:1122-1133. [PMID: 36063391 DOI: 10.1093/stmcls/sxac063] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/22/2022] [Indexed: 01/04/2023]
Abstract
Acute lung injury (ALI) accompanied with systemic inflammatory response is an important complication after cardiopulmonary bypass (CPB). Pyroptosis, which is induced by the secretion of inflammatory factors, has been implicated in ALI. However, recent studies have suggested that bone marrow mesenchymal stem cell-derived exosomes (BMMSC-Exo) can ameliorate ALI, but the mechanism is poorly understood. Therefore, we aim to examine the effects of BMMSC-Exo in CPB-induced ALI, and its underlying mechanism. CPB rat models (male Sprague-Dawley rats) were administered BMMSC-Exo intravenously before induction of ALI. Lung tissue, bronchoalveolar lavage fluid (BALF), and alveolar macrophage (AM) were collected after the treatments for further analysis, and rat AM NR8383 cells were used for in vitro study. HE staining was performed to detect macrophage infiltration. Western blot was used to detect related proteins expression. And ELISA assay was performed to investigate secretion of inflammatory factors. These results showed that BMMSC-Exo treatment ameliorated macrophage infiltration and oxidative stress, and downregulated expression of pyroptosis-related proteins, including NLRP3, cleaved caspase-1, and GSDMD-N, in the lung tissue and AM, as well as decreased the secretion of IL-18 and IL-1β in BALF. Moreover, BMMSC-Exo activated YAP/β-catenin signaling pathway. Overall, these findings of this study indicated that BMMSC-Exo suppressed CPB-induced pyroptosis in ALI by activating YAP/β-catenin axis, which could be a novel strategy for lung protection during CPB.
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Affiliation(s)
- Taoyuan Zhang
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, People's Republic of China.,Department of Anesthesiology, Rizhao International Heart Hospital, Rizhao, Shandong, People's Republic of China
| | - Linhe Lu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Man Li
- Central Medical Branch of PLA General Hospital, Beijing, People's Republic of China
| | - Ding Zhang
- Department of Anesthesiology, Rizhao International Heart Hospital, Rizhao, Shandong, People's Republic of China
| | - Peng Yu
- Department of Anesthesiology, Rizhao Traditional Chinese Medicine Hospital, Rizhao, Shandong, People's Republic of China
| | - Xinhao Zhang
- Department of Anesthesiology, Rizhao International Heart Hospital, Rizhao, Shandong, People's Republic of China
| | - Zheng Zhang
- Department of Cardiology, PLA Rocket Force Characteristic Medical Center, Beijing, People's Republic of China
| | - Chong Lei
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
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Does severe hyperlactatemia during cardiopulmonary bypass predict a worse outcome? Ann Med Surg (Lond) 2022; 73:103198. [PMID: 35070281 PMCID: PMC8767239 DOI: 10.1016/j.amsu.2021.103198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/14/2021] [Accepted: 12/19/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The aim of the current study was to evaluate the impact of increased blood lactate levels during cardiopulmonary bypass (CPB) on immediate results in patients who underwent open heart surgery. MATERIALS AND METHODS We performed a retrospective single-center study on 1290 patients. Adult cardiac surgical patients who underwent valve surgery, coronary artery bypass graft, combined procedure, adult congenital anomalies and aortic surgery were enrolled. Patients with associated comorbidities such as liver dysfunction, hemodynamic instability before surgery were excluded. Arterial blood lactate concentration was measured immediately after weaning from CPB and evaluated together with clinical data and outcomes including in hospital mortality. Patients were classified into 3 groups according to their peak arterial lactate level: group I [normal lactatemia, lactate ˂ 2 mmol/l (n = 749)], group II [mild hyperlactatemia, lactate 2-5 mmol/l (n = 489)], group III [severe hyperlactatemia, lactate ˃ 5 mmol/l (n = 52)]. RESULTS When comparing outcomes across the 3 groups, severe hyperlactatemia was correlated with worse outcomes including higher in-hospital mortality, low output cardiac syndrome, postoperative renal insufficiency, myocardial infarction, red blood cell transfusion (RBC) transfusion, prolonged mechanical ventilation and longer intensive care unit (ICU) stay hours. CONCLUSION Blood lactate level above 5 mmol/l and more during CPB is associated with higher in-hospital mortality rate and postoperative complications. More attention must be given to correct the common abnormalities conditions inherent of CPB in order to conduct adequate tissue perfusion and reduce the risk of hyperlactatemia.
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Stephens EH, Epting CL, Backer CL, Wald EL. Hyperlactatemia: An Update on Postoperative Lactate. World J Pediatr Congenit Heart Surg 2021; 11:316-324. [PMID: 32294015 DOI: 10.1177/2150135120903977] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
While hyperlactatemia in postoperative cardiac surgery patients was once believed to solely reflect hypoperfusion, either from the accumulated "oxygen debt" during bypass or ongoing inadequate perfusion, our understanding of lactate generation, clearance, and management has evolved. A contemporary understanding of lactate balance is critical to the management of the postoperative patient with hyperlactatemia. In this review, we summarize the current understanding of lactate metabolism in pediatric patients following cardiac surgery and highlight two types of hyperlactatemia: type A, which is secondary to inadequate oxygen delivery and tissue hypoxia, and type B, which in postoperative pediatric cardiac surgery patients largely reflects increased glycolysis driven by the stress response. Both types may coexist; thus, it is imperative that providers first assess the patient for evidence of hypoperfusion. In patients with evidence of adequate perfusion, a type B component is often associated with a concomitant balanced (normal anion gap) metabolic acidosis and hyperglycemia. These patients will benefit from a more nuanced approach to their type B hyperlactatemia, as many will have a benign course and may be managed expectantly.
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Affiliation(s)
- Elizabeth H Stephens
- Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Conrad L Epting
- Divisions of Critical Care and Cardiology, Department of Pediatrics, Northwestern University, Chicago, IL, USA.,Pathology, Northwestern University, Chicago, IL, USA
| | - Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Eric L Wald
- Divisions of Critical Care and Cardiology, Department of Pediatrics, Northwestern University, Chicago, IL, USA
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Kesävuori R, Vento A, Lundbom N, Schramko A, Jokinen JJ, Raivio P. Minimal volume ventilation during robotically assisted mitral valve surgery. Perfusion 2019; 34:705-713. [PMID: 31090485 DOI: 10.1177/0267659119847917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION A minimal volume ventilation method for robotically assisted mitral valve surgery is described in this study. In an attempt to reduce postoperative pulmonary dysfunction, 40 of 174 patients undergoing robotically assisted mitral valve surgery were ventilated with a small tidal volume during cardiopulmonary bypass. METHODS After propensity score matching, 31 patients with minimal volume ventilation were compared with 54 patients with no ventilation. Total ventilation time, PaO2/FiO2 ratio, arterial lactate concentration, and the rate of unilateral pulmonary edema in the matched minimal ventilation and standard treatment groups were evaluated. RESULTS Patients in the minimal ventilation group had shorter ventilation times, 12.0 (interquartile range: 9.9-15.0) versus 14.0 (interquartile range: 12.0-16.3) hours (p = 0.036), and lower postoperative arterial lactate levels, 0.99 (interquartile range: 0.81-1.39) versus 1.28 (interquartile range: 0.99-1.86) mmol/L (p = 0.01), in comparison to patients in the standard treatment group. There was no difference in postoperative PaO2/FiO2 ratio levels or in the rate of unilateral pulmonary edema between the groups. CONCLUSION Minimal ventilation appeared beneficial in terms of total ventilation time and blood lactatemia, while there was no improvement in arterial blood gas measurements or in the rate of unilateral pulmonary edema. The lower postoperative arterial lactate levels may suggest improved lung perfusion among patients in the minimal volume ventilation group. The differences in the ventilation times were in fact small, and further studies are required to confirm the possible advantages of the minimal volume ventilation method in robotically assisted cardiac surgery.
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Affiliation(s)
- Risto Kesävuori
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Department of Radiology, HUS Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland
| | - Antti Vento
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Nina Lundbom
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland
| | - Alexey Schramko
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Janne J Jokinen
- Department of Surgery, Päijät-Häme Central Hospital, Lahti, Finland
| | - Peter Raivio
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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Khirfan G, Ahmed MK, Faulx MD, Dakkak W, Dweik RA, Tonelli AR. Gasometric gradients between blood obtained from the pulmonary artery wedge and pulmonary artery positions in pulmonary arterial hypertension. Respir Res 2019; 20:6. [PMID: 30621691 PMCID: PMC6325872 DOI: 10.1186/s12931-018-0969-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/20/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Little is known on the pulmonary gradients of oxyhemoglobin, carboxyhemoglobin and methemoglobin in pulmonary arterial hypertension (PAH). We sought to determine these gradients in group 1 PAH and assess their association with disease severity and survival. METHODS During right heart catheterization (RHC) we obtained blood from pulmonary artery (PA) and pulmonary artery wedge (PAW) positions and used co-oximetry to test their gasometric differences. RESULTS We included a total of 130 patients, 65 had group 1 PAH, 40 had pulmonary hypertension (PH) from groups 2-5 and 25 had no PH during RHC. In all groups, PAW blood had higher pH, carboxyhemoglobin and lactate as well as lower pCO2 than PA blood. In group 1 PAH (age 58 ± 15 years, 72% females), methemoglobin in the PAW was lower than in the PA blood (0.83% ± 0.43 vs 0.95% ± 0.50, p = 0.03) and was directly associated with the degree of change in pulmonary vascular resistance (R = 0.35, p = 0.02) during inhaled nitric oxide test. Oxyhemoglobin in PA (HR (95%CI): 0.90 (0.82-0.99), p = 0.04) and PAW (HR (95%CI): 0.91 (0.84-0.98), p = 0.003) blood was associated with adjusted survival in PAH. CONCLUSIONS Marked differences were observed in the gasometric determinations between PAW and PA blood. The pulmonary gradient of methemoglobin was lower in PAH patients compared to controls and a higher PAW blood methemoglobin was associated with a more pronounced pulmonary vascular response to inhaled nitric oxide. Pulmonary artery and PAW oxyhemoglobin tracked with disease severity and survival in PAH.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Mostafa K. Ahmed
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
- Department of Chest Diseases, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Michael D. Faulx
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH USA
| | - Wael Dakkak
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL USA
| | - Raed A. Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Adriano R. Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
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8
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Andersen LW. Lactate Elevation During and After Major Cardiac Surgery in Adults: A Review of Etiology, Prognostic Value, and Management. Anesth Analg 2017; 125:743-752. [PMID: 28277327 DOI: 10.1213/ane.0000000000001928] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elevated lactate is a common occurrence after cardiac surgery. This review summarizes the literature on the complex etiology of lactate elevation during and after cardiac surgery, including considerations of oxygen delivery, oxygen utilization, increased metabolism, lactate clearance, medications and fluids, and postoperative complications. Second, the association between lactate and a variety of outcomes are described, and the prognostic role of lactate is critically assessed. Despite the fact that elevated lactate is strongly associated with many important outcomes, including postoperative complications, length of stay, and mortality, little is known about the optimal management of postoperative patients with lactate elevations. This review ends with an assessment of the limited literature on this subject.
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Affiliation(s)
- Lars W Andersen
- From the *Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; †Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; ‡Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; and §Department of Medicine, Regional Hospital Holstebro, Aarhus University, Holstebro, Denmark
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Saugel B, Bendjelid K, Critchley LA, Rex S, Scheeren TWL. Journal of Clinical Monitoring and Computing 2016 end of year summary: cardiovascular and hemodynamic monitoring. J Clin Monit Comput 2017; 31:5-17. [PMID: 28064413 DOI: 10.1007/s10877-017-9976-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 01/02/2017] [Indexed: 12/29/2022]
Abstract
The assessment and optimization of cardiovascular and hemodynamic variables is a mainstay of patient management in the care for critically ill patients in the intensive care unit (ICU) or the operating room (OR). It is, therefore, of outstanding importance to meticulously validate technologies for hemodynamic monitoring and to study their applicability in clinical practice and, finally, their impact on treatment decisions and on patient outcome. In this regard, the Journal of Clinical Monitoring and Computing (JCMC) is an ideal platform for publishing research in the field of cardiovascular and hemodynamic monitoring. In this review, we highlight papers published last year in the JCMC in order to summarize and discuss recent developments in this research area.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Karim Bendjelid
- Department of Anesthesiology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Lester A Critchley
- Department of Anesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Steffen Rex
- Department of Anesthesiology and Department of Cardiovascular Sciences, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Tsang R, Checchia P, Bronicki RA. Hemodynamic Monitoring in the Acute Management of Pediatric Heart Failure. Curr Cardiol Rev 2016; 12:112-6. [PMID: 26585037 PMCID: PMC4861939 DOI: 10.2174/1573403x12666151119165007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/15/2015] [Indexed: 01/08/2023] Open
Abstract
One of the basic tenets of cardiac critical care is to ensure adequate tissue oxygenation. As
with other critical illness such as trauma and acute myocardial infarction studies have demonstrated
that making the right diagnosis at the right time improves outcomes. The same is true for the management
of patients at risk for or in a state of shock. In order to optimize outcomes an accurate and timely
assessment of cardiac function, cardiac output and tissue oxygenation must be made. This review discusses
the limitations of the standard assessment of cardiovascular function, and adjunctive monitoring
modalities that may be used to enhance the accuracy and timely implementation of therapeutic
strategies to improve tissue oxygenation.
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Affiliation(s)
- Rocky Tsang
- Baylor College of Medicine, Department of Pediatrics, Section of Critical Care Medicine, Texas Children's Hospital, 6621 Fannin st. W6006, Houston, Texas, 77030, USA.
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Du W, Long Y, Wang XT, Liu DW. The Use of the Ratio between the Veno-arterial Carbon Dioxide Difference and the Arterial-venous Oxygen Difference to Guide Resuscitation in Cardiac Surgery Patients with Hyperlactatemia and Normal Central Venous Oxygen Saturation. Chin Med J (Engl) 2016; 128:1306-13. [PMID: 25963349 PMCID: PMC4830308 DOI: 10.4103/0366-6999.156770] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: After cardiac surgery, central venous oxygen saturation (ScvO2) and serum lactate concentration are often used to guide resuscitation; however, neither are completely reliable indicators of global tissue hypoxia. This observational study aimed to establish whether the ratio between the veno-arterial carbon dioxide and the arterial-venous oxygen differences (P(v−a)CO2/C(a−v)O2) could predict whether patients would respond to resuscitation by increasing oxygen delivery (DO2). Methods: We selected 72 patients from a cohort of 290 who had undergone cardiac surgery in our institution between January 2012 and August 2014. The selected patients were managed postoperatively on the Intensive Care Unit, had a normal ScvO2, elevated serum lactate concentration, and responded to resuscitation by increasing DO2 by >10%. As a consequence, 48 patients responded with an increase in oxygen consumption (VO2) while VO2 was static or fell in 24. Results: At baseline and before resuscitative intervention in postoperative cardiac surgery patients, a P(v−a)CO2/C(a−v)O2 ratio ≥1.6 mmHg/ml predicted a positive VO2 response to an increase in DO2 of >10% with a sensitivity of 68.8% and a specificity of 87.5%. Conclusions: P(v−a)CO2/C(a−v)O2 ratio appears to be a reliable marker of global anaerobic metabolism and predicts response to DO2 challenge. Thus, patients likely to benefit from resuscitation can be identified promptly, the P(v−a)CO2/C(a−v)O2 ratio may, therefore, be a useful resuscitation target.
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Affiliation(s)
| | | | | | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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12
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Abstract
Hemodynamic monitoring is central to the management of critically ill patients in the cardiac intensive care unit (CICU). The goals of hemodynamic monitoring are to anticipate threats and complications before they arise, to gauge the effectiveness of interventions, and to avoid progression to a decompensated shock state. Although there are numerous modalities of hemodynamic monitoring in the CICU, discordance exists between assessments based on physical exam and standard hemodynamic parameters and those based on measurements of cardiac output. This article will review both the standard and advanced hemodynamic monitoring strategies employed in the CICU.
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Affiliation(s)
- Rocky Tsang
- Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex, USA
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O'Connor E, Fraser JF. The interpretation of perioperative lactate abnormalities in patients undergoing cardiac surgery. Anaesth Intensive Care 2012; 40:598-603. [PMID: 22813486 DOI: 10.1177/0310057x1204000404] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hyperlactataemia and lactic acidosis are commonly encountered during and after cardiac surgery. Perioperative lactate production increases in the myocardium, skeletal muscle, lungs and in the splanchnic circulation during cardiopulmonary bypass. Hyperlactataemia has a bimodal distribution in the perioperative period. An early increase in lactate levels, arising intraoperatively or soon after intensive care unit admission, is a familiar and concerning finding for most clinicians. It is highly suggestive of tissue ischaemia and is associated with a prolonged intensive care unit stay, a prolonged requirement for respiratory and cardiovascular support and increased postoperative mortality. Its presence should prompt a thorough search for potential causes of tissue hypoxia. In contrast, late-onset hyperlactataemia, a less well recognised complication, occurs 4 to 24 hours after completion of surgery and is typically associated with preserved cardiac output and oxygen delivery. Risk factors for late-onset hyperlactataemia include hyperglycaemia, long cardiopulmonary bypass time and elevated endogenous catecholamines. Although patients with this complication may have a longer duration of ventilation and intensive care unit length of stay than those with normolactataemia, an association with increased mortality has not been demonstrated. The discovery of late-onset hyperlactataemia should not delay the postoperative progress of an otherwise stable patient following cardiac surgery.
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Affiliation(s)
- E O'Connor
- Adult Intensive Care Services, Prince Charles Hospital, Chermside, Queensland, Australia.
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14
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Tütün U, Parlar AI, Altinay L, Topcu DI, Babaroglu S, Yay K, Mungan U, Cicekcioglu F, Saydam GS, Katircioglu SF. Does on-pump normothermic beating-heart valve surgery with low tidal volume ventilation protect the lungs? Heart Surg Forum 2012; 14:E297-301. [PMID: 21997651 DOI: 10.1532/hsf98.20111006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postoperative pulmonary dysfunction following cardiopulmonary bypass (CPB) usually develops secondary to the inflammatory process with contact activation, hypothermia, operative trauma, general anesthesia, atelectasis, pain, and pulmonary ischemia/reperfusion due to cross-clamping. The aim of the present study was to evaluate the effects of an on-pump, normothermic, and beating-heart technique and of low-volume ventilation on lung injury. METHODS We compared the results for 20 patients who underwent operations with an on-pump, normothermic, and beating-heart technique of mitral valve surgery with low-volume ventilation (group 1) with the results for 23 patients who underwent their operations with an on-pump, hypothermic cardiac-arrest technique (group 2). In both groups, blood samples were collected from the right superior pulmonary vein, and inflammation and oxidative stress markers (malondialdehyde, lactic acid, platelet-activating factor, and myeloperoxidase) were studied. RESULTS Malondialdehyde, myeloperoxidase, and lactate values were significantly lower in group 1 than in group 2 just before the termination of CPB (P < .05). We observed no differences between the 2 groups with regard to values for platelet-activating factor. CONCLUSIONS Inflammation and oxidative stress markers were lower in the group of patients who underwent beating-heart valve surgery with low-volume ventilation. These results reflect less of an ischemic insult and lower inflammation compared with the results for the patients who underwent conventional operations.
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Affiliation(s)
- Ufuk Tütün
- Department of Cardiovascular Surgery, Türkiye Yüksek htisas E itim ve Ara tırma, Hastanesi, Ankara.
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Abstract
BACKGROUND : The intra- and postoperative monitoring of lactate and acid-base has been advocated in pediatric cardiac critical care as surrogate markers of cardiac output, oxygen delivery, and cellular perfusion. Many clinicians use lactate and base excess routinely as markers of tissue perfusion and to assess the effectiveness of their intervention. This review discusses the strengths and weaknesses of using these measurements in pediatric cardiac critical care. METHODOLOGY : A search of MEDLINE, EMBASE, PubMed, and the Cochrane Database was conducted to find controlled trials of lactate and base excess. Adult and pediatric data were considered. Guidelines published by the Society of Critical Care Medicine, the American Heart Association, the American Academy of Pediatrics, and the International Liaison Committee on Resuscitation were reviewed including further review of references cited. RESULTS AND CONCLUSIONS : Many factors other than tissue hypoxia may contribute to hyperlactemia in critical illness. Although the presence of hyperlactemia on admission appears to be associated with intensive care unit mortality and morbidity in some retrospective analyses, significant overlap between survivors and nonsurvivors means that nonsurvivors cannot be predicted from admission lactate measurement. Persistently elevated postoperative lactate is associated with increased morbidity and mortality in the pediatric cardiac population. To date there is no randomized control trial of goal-directed therapy in adult or pediatric cardiac care that includes normalization of lactate as a target. Overall equivalent time measurements of base excess, anion gap, and pH have a low predictive value for morbidity and mortality in children after cardiac surgery. Lactate is one of a cluster of markers of cellular perfusion and oxygen delivery. Alone, as a single measurement, it has minimal predictive value and is nondiscriminatory for survival.
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[Microcirculatory alterations in critically ill patients: pathophysiology, monitoring and treatments]. ACTA ACUST UNITED AC 2010; 29:135-44. [PMID: 20116198 DOI: 10.1016/j.annfar.2009.10.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Accepted: 10/28/2009] [Indexed: 01/18/2023]
Abstract
Microcirculation represents a complex system devoted to provide optimal tissue substrates and oxygen. Therefore, pathophysiological and technological knowledge developments tailored for capillary circulation analysis should generate major advances for critically ill patients' management. In the future, microcirculatory monitoring in several critical care situations will allow recognition of macro-microcirculatory decoupling, and, hopefully, it will promote the use of treatments aimed at preserving tissue oxygenation and substrate delivery.
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R, Vallet B. Year in review in intensive care medicine, 2004. II. Brain injury, hemodynamic monitoring and treatment, pulmonary embolism, gastrointestinal tract, and renal failure. Intensive Care Med 2005; 31:177-88. [PMID: 15678311 DOI: 10.1007/s00134-004-2552-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Accepted: 12/23/2004] [Indexed: 12/20/2022]
Affiliation(s)
- Peter Andrews
- Intensive Care Medicine Unit, Western General Hospital, Edinburgh, UK
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