1
|
Yamaguti T, Auler Junior JOC, Dallan LAO, Galas FRBG, Cunha LCC, Piccioni MDA. Markers of Tissue Perfusion as Predictors of Adverse Outcomes in Patients with Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Surgery. Arq Bras Cardiol 2024; 121:e20230247. [PMID: 38597532 DOI: 10.36660/abc.20230247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 11/14/2023] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Cardiac surgery patients may be exposed to tissue hypoperfusion and anaerobic metabolism. OBJECTIVE To verify whether the biomarkers of tissue hypoperfusion have predictive value for prolonged intensive care unit (ICU) stay in patients with left ventricular dysfunction who underwent coronary artery bypass surgery. METHODS After approval by the institution's Ethics Committee and the signing of informed consent, 87 patients with left ventricular dysfunction (ejection fraction < 50%) undergoing coronary artery bypass surgery were enrolled. Hemodynamic and metabolic biomarkers were collected at five time points: after anesthesia, at the end of the surgery, at ICU admission, and at six and twelve hours after. An analysis of variance for repeated measures followed by a Bonferroni post hoc test was used for repeated, continuous variables (hemodynamic and metabolic variables) to determine differences between the two groups over the course of the study period. The level of statistical significance adopted was 5%. RESULTS Thirty-eight patients (43.7%) who presented adverse outcomes were older, higher Euro score (p<0.001), and elevated ΔpCO2 as analyzed 12 hours after ICU admission (p<0.01), while increased arterial lactate concentration at 6 hours postoperatively was found to be a negative predictive factor (p<0.01). CONCLUSIONS Euro SCORE, six-hour postoperative arterial lactate, 12-hour postoperative ΔPCO2, and eRQ are independent predictors of adverse outcomes in patients with left ventricular dysfunction after cardiac surgery.
Collapse
Affiliation(s)
- Thiana Yamaguti
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - José Otavio Costa Auler Junior
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Luís Alberto Oliveira Dallan
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Ligia Cristina Câmara Cunha
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | |
Collapse
|
2
|
Fang YH, Zhang YJ, Zhen YN, Liu XP, Sun G, Han YX. Hyperlactatemia in patients undergoing pulmonary endarterectomy with deep hypothermic circulatory arrest: Risk factors and its effects on the outcome. Perfusion 2023:2676591231208984. [PMID: 38124315 DOI: 10.1177/02676591231208984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
INTRODUCTION To determine the risk factors of hyperlactatemia in pulmonary endarterectomy (PEA) surgery and assess whether elevated blood lactate levels are associated with adverse outcomes. METHODS In this retrospective observational study, a total of 111 consecutive patients who underwent PEA for chronic thromboembolic pulmonary hypertension at the XXX Hospital between December 2016 and January 2022 were included. We retrospectively evaluated arterial blood samples analyzed intraoperatively. The pre- and intraoperative risk factors for hyperlactatemia and the postoperative outcomes were recorded. RESULTS Lactate levels gradually increased during surgery. The optimal cut-off lactate level for major postoperative complications, calculated using receiver operating characteristic analysis, was 7.0 mmol/L. Deep hypothermic circulatory arrest (DHCA) duration, nadir hematocrit, and preoperative pulmonary vascular resistance were risk factors for lactate levels >7 mmol/L. Moreover, the intraoperative peak lactate level during PEA under DHCA was found to be a statistically significant predictor of major complications being associated with longer mechanical ventilation time (r = 0.294; p = .003) and intensive care unit length of stay (r = 0.327; p = .001). CONCLUSIONS Deep hypothermic circulatory arrest duration, nadir hematocrit, and preoperative pulmonary vascular resistance were associated with hyperlactatemia. Increased lactate levels were independent predictors of longer mechanical ventilation time, intensive care unit length of stay, and major complications.
Collapse
Affiliation(s)
- Ying-Hui Fang
- Department of Anesthesia, China-Japan Friendship Hospital, Beijing, China
| | - Ya-Jun Zhang
- Department of Anesthesia, China-Japan Friendship Hospital, Beijing, China
| | - Ya-Nan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiao-Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Guang Sun
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yong-Xin Han
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
3
|
Wang S, Wang D, Huang X, Wang H, Le S, Zhang J, Du X. Risk factors and in-hospital mortality of postoperative hyperlactatemia in patients after acute type A aortic dissection surgery. BMC Cardiovasc Disord 2021; 21:431. [PMID: 34511074 PMCID: PMC8436469 DOI: 10.1186/s12872-021-02244-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Hyperlactatemia may be caused by increased production due to tissue hypoxia or non-hypoxia. The aim of this study was first to identify risk factors for postoperative hyperlactatemia (POHL) after Stanford type A acute aortic dissection surgery (AADS) and construct a predictive model, and second to evaluate the impact of POHL on prognosis. Methods This retrospective study involved patients undergoing AADS from January 2016 to December 2019 in Wuhan Union Hospital. Multivariate logistic regression analysis was performed to identify independent risk factors for POHL. A nomogram predicting POHL was established based on these factors and was validated in the original dataset. The receiver operating characteristic curve was drawn to assess the ability of postoperative lactate levels to predict the in-hospital mortality. Results A total of 188 patients developed POHL after AADS (38.6%). Male gender, surgery history, red blood cell transfusion and cardiopulmonary bypass time were identified as independent predictors. The C-index of the prediction model for POHL was 0.72, indicating reasonable discrimination. The model was well calibrated by visual inspection and goodness-of-fit test (Hosmer–Lemeshow χ2 = 10.25, P = 0.25). Decision and clinical impact curves of the model showed good clinical utility. The overall in-hospital mortality rate was 10.1%. Postoperative lactate levels showed a moderate predictive power for postoperative in-hospital mortality (C-index: 0.72). Conclusion We developed and validated a prediction model for POHL in patients undergoing AADS, which may have clinical utility in personal risk evaluation and preventive interventions. The POHL could be a good predictor for in-hospital mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02244-7.
Collapse
Affiliation(s)
- Su Wang
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jinnong Zhang
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| |
Collapse
|
4
|
Ezaka M, Tsukamoto J, Matsuo K, Kin N, Yamaoka K. Hyperlactatemia of dialysis-dependent patients after cardiac surgery impacts on in-hospital mortality: a two-center retrospective study. JA Clin Rep 2020; 6:47. [PMID: 32529341 PMCID: PMC7290016 DOI: 10.1186/s40981-020-00348-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
Background Lactate is a well-known marker to estimate prognosis after cardiac surgery and critically ill patients. The liver and kidney have a major role in lactate metabolism; however, there was less characterized about the change of lactate and threshold to predict in-hospital mortality in dialysis-dependent patients undertaking cardiac surgery. We conducted this retrospective observational study to characterize when and how lactate values after cardiac surgery affected in-hospital mortality. Methods This two-center retrospective study included dialysis-dependent patients who underwent cardiac surgery with a cardiopulmonary bypass from January 2014 to December 2018. Lactate values were collected at three points: at ICU admission (T1), the maximum level of lactate within 24 h postoperatively (T2), and 24 h after ICU admission (T3). We determined hyperlactatemia as more than 2 mmol/L following previous studies. Results We enrolled 122 dialysis-dependent patients. The mean age was 73 ± 8 years and hyperlactatemia was observed in 100 patients (81.9%). In-hospital mortality was 11.4%. Univariate analysis and area under curve in ROC suggested that T2 lactate was the most significantly associated with in-hospital mortality (AUC = 0.845). Multivariate logistic analysis showed a significant association between in-hospital mortality when patients showed early peak lactate levels of > 4.5 mmol/L after ICU admission (adjusted OR 8.35; 95% CI: 1.44–57.13). Conclusions In dialysis-dependent patients after cardiac surgery, the early-onset of a maximum arterial lactate concentration of > 4.5 mmol/L was significantly associated with in-hospital mortality.
Collapse
Affiliation(s)
- Mariko Ezaka
- Department of Anesthesiology, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan. .,Teikyo University Graduate School of Public Health, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Junko Tsukamoto
- Department of Anesthesiology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Koichi Matsuo
- Department of Intensive Care Unit, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan
| | - Nobuhide Kin
- Department of Anesthesiology, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan
| | - Kazue Yamaoka
- Teikyo University Graduate School of Public Health, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8605, Japan
| |
Collapse
|
5
|
Zante B, Reichenspurner H, Kubik M, Kluge S, Schefold JC, Pfortmueller CA. Base excess is superior to lactate-levels in prediction of ICU mortality after cardiac surgery. PLoS One 2018; 13:e0205309. [PMID: 30289956 PMCID: PMC6173442 DOI: 10.1371/journal.pone.0205309] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/21/2018] [Indexed: 11/20/2022] Open
Abstract
Introduction Cardiac surgery with the use of cardiopulmonary bypass is known to induce distinct metabolic changes. Respective changes in acid-base status including increased systemic lactate levels were previously related to clinical outcomes, but data remain controversial. Therefore, we aim to investigate the relevance of lactate and base excess (BE) levels on ICU-mortality in patients admitted to the ICU after cardiac surgery. Materials and methods Perioperative data of patients treated in a tertiary care academic center admitted to the ICU after on-pump surgery were analyzed in a retrospective fashion. Receiver operation characteristic (ROC) curves were constructed for admission lactate-levels and BE with calculation of optimal cut-off values to predict ICU mortality. Univariate followed by multivariate regression models were constructed to identify potential outcome-relevant indices. Results Data from 1,058 patients were included in the analysis. Area under the curves for prediction of ICU mortality were 0.79 for lactate levels at ICU admission (sensitivity 61.9%/ specificity 87.5%; optimal cut-off level 3.9mmol/l), and 0.7 for BE (sensitivity 52.4%/ specificity 93.8%, optimal cut-off level -6.7), respectively. Multivariate regression identified BE < -6.7 as the single metabolic predictor of ICU-mortality (HR 4.78, 95%-CI 1.4–16.33, p = 0.01). Explorative subgroup analyses revealed that the combination of lactate ≤3.9mmol/l and BE ≤ -6.7 has stronger impact on mortality than a combination of lactate of >3.9mmol/l and BE > -6.7 (HR 2.56, 95%-CI 0.18–37.17). Conclusions At ICU-admission, severely reduced BE appears superior to hyperlactatemia with regard to prediction of ICU-mortality in patients after cardiac surgery.
Collapse
Affiliation(s)
- Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
- * E-mail:
| | | | - Mathias Kubik
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
- Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joerg C. Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carmen A. Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
6
|
Evans AS, Levin MA, Lin HM, Lee K, Weiner MM, Anyanwu A, Adams DH, Mittnacht AJ. Prognostic Value of Hyperlactatemia and Lactate Clearance After Mitral Valve Surgery. J Cardiothorac Vasc Anesth 2018; 32:636-643. [DOI: 10.1053/j.jvca.2017.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Indexed: 01/13/2023]
|
7
|
Yusuff HO, Zochios V. Lactic Acidosis and Mitral Valve Surgery: Defining the Relationship. J Cardiothorac Vasc Anesth 2017; 32:644-645. [PMID: 29310939 DOI: 10.1053/j.jvca.2017.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Hakeem O Yusuff
- University Hospitals of Leicester NHS Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, United Kingdom
| | - Vasileios Zochios
- University Hospitals Birmingham NHS Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom; Perioperative Critical Care and Trauma Trials Group, Institute of Inflammation and Ageing Centre of Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom.
| |
Collapse
|
8
|
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: 20] [Impact Index Per Article: 2.9] [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.
Collapse
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
| |
Collapse
|
9
|
Haanschoten MC, Kreeftenberg HG, Arthur Bouwman R, van Straten AH, Buhre WF, Soliman Hamad MA. Use of Postoperative Peak Arterial Lactate Level to Predict Outcome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:45-53. [DOI: 10.1053/j.jvca.2016.04.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 12/28/2022]
|
10
|
Andersen LW, Holmberg MJ, Doherty M, Khabbaz K, Lerner A, Berg KM, Donnino MW. Postoperative Lactate Levels and Hospital Length of Stay After Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1454-60. [DOI: 10.1053/j.jvca.2015.06.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Indexed: 11/11/2022]
|
11
|
Lopez-Delgado JC, Esteve F, Javierre C, Torrado H, Rodriguez-Castro D, Carrio ML, Farrero E, Skaltsa K, Mañez R, Ventura JL. Evaluation of Serial Arterial Lactate Levels as a Predictor of Hospital and Long-Term Mortality in Patients After Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1441-53. [PMID: 26321121 DOI: 10.1053/j.jvca.2015.04.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although hyperlactatemia is common after cardiac surgery, its value as a prognostic marker is unclear. The aim of the present study was to determine whether postoperative serial arterial lactate (AL) measurements after cardiac surgery could predict outcome. DESIGN Prospective, observational study. SETTING Surgical intensive care unit in a tertiary-level university hospital. PARTICIPANTS Participants included 2,935 consecutive patients. INTERVENTIONS AL was measured on admission to the intensive care unit and 6, 12, and 24 hours after surgery, and evaluated together with clinical data and outcomes including in-hospital and long-term mortality. MEASUREMENTS AND MAIN RESULTS In-hospital and long-term mortality (mean follow-up 6.3±1.7 years) were 5.9% and 8.7%, respectively. Compared with survivors, nonsurvivors showed higher mean AL values in all measurements (p<0.001). Hyperlactatemia (AL>3.0 mmol/L) was a predictor for in-hospital mortality (odds ratio = 1.468; 95% confidence interval = 1.239-1.739; p<0.001) and long-term mortality (hazard ratio = 1.511; 95% confidence interval = 1.251-1.825; p<0.001). Recent myocardial infarction and longer cardiopulmonary bypass time were predictors of hyperlactatemia. The pattern of AL dynamics was similar in both groups, but nonsurvivors showed higher AL values, as confirmed by repeated measures analysis of variance (p<0.001). The area under the curve also showed higher levels of AL in nonsurvivors (80.9±68.2 v 49.71±25.8 mmol/L/h; p = 0.038). Patients with hyperlactatemia were divided according to their timing of peak AL, with higher mortality and worse survival in patients in whom AL peaked at 24 hours compared with other groups (79.1% v 86.7%-89.2%; p = 0.03). CONCLUSIONS The dynamics of the postoperative AL curve in patients undergoing cardiac surgery suggests a similar mechanism of hyperlactatemia in survivors and nonsurvivors, albeit with a higher production or lower clearance of AL in nonsurvivors. The presence of a peak of hyperlactatemia at 24 hours is associated with higher in-hospital and long-term mortality.
Collapse
Affiliation(s)
- Juan C Lopez-Delgado
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain.
| | - Francisco Esteve
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain
| | - Casimiro Javierre
- Physiological Sciences II Department, University of Barcelona, IDIBELL, Barcelona, Spain
| | - Herminia Torrado
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain
| | - David Rodriguez-Castro
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain
| | - Maria L Carrio
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain
| | - Elisabet Farrero
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain
| | | | - Rafael Mañez
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain
| | - Josep L Ventura
- Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain
| |
Collapse
|
12
|
Dedichen HH, Hisdal J, Aadahl P, Nordhaug D, Olsen PO, Kirkeby-Garstad I. Elevated arterial lactate concentrations early after coronary artery bypass grafting are associated with increased anaerobic metabolism in skeletal muscle. J Cardiothorac Vasc Anesth 2014; 29:367-73. [PMID: 25529437 DOI: 10.1053/j.jvca.2014.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the effect of coronary artery bypass grafting with cardiopulmonary bypass on muscle perfusion, oxygen extraction, and lactate release during postoperative rest and exercise. DESIGN Prospective observational study. SETTING University hospital. PARTICIPANTS Patients undergoing planned coronary artery bypass grafting. INTERVENTION Knee-extensor exercise before and after coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS Femoral artery blood flow was measured with ultrasound. Femoral vein blood and arterial blood were sampled at rest and during light exercise and were analyzed for hemoglobin, lactate, oxygen saturation, and oxygen partial pressure. Fourteen patients were tested before and after surgery. The arterial lactate concentrations were increased after surgery, both at rest and during light exercise. Resting arterial lactate increased from 0.65 (0.5-0.8) to 1.0 (0.9-1.3) mmol/L (p=0.01) (median and interquartile range). Furthermore, lactate was released from the leg even during postoperative rest, and the release of lactate was increased during postoperative exercise. There were no significant differences between the preoperative and postoperative femoral artery blood flow. Femoral vein oxygen partial pressure was reduced significantly after surgery, indicating reduced muscle cell oxygen partial pressure. CONCLUSIONS The patients had elevated anaerobic metabolism in skeletal muscle after surgery to compensate for anemia. Lactate was released from the leg into the general circulation during postoperative rest and exercise. The postoperatively reduced hemoglobin concentration of 11.4 mg/dL (10.6-12.3) resulted in increased anaerobic metabolism and release of lactate from skeletal muscle. The authors concluded that coronary artery bypass grafting patients are susceptible to anaerobic metabolism even with maintained peripheral blood flow.
Collapse
Affiliation(s)
- Hans Henrik Dedichen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; K. G. Jebsen Center for Exercise in Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Jonny Hisdal
- Section for Vascular Investigations, Oslo Vascular Centre, Oslo University Hospital Aker, Oslo, Norway
| | - Petter Aadahl
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dag Nordhaug
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Cardiothoracic Surgery, St. Olav's Hospital, Trondheim, Norway
| | - Per Olav Olsen
- Department of Cardiothoracic Anesthesiology and Intensive Care, St. Olav's Hospital, Trondheim, Norway
| | - Idar Kirkeby-Garstad
- Department of Cardiothoracic Anesthesiology and Intensive Care, St. Olav's Hospital, Trondheim, Norway
| |
Collapse
|
13
|
Laverde Sabogal CE, Correa Rivera AF, Joya Higuera AY. Lactato y déficit de bases en trauma: valor pronóstico. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rca.2013.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
14
|
Laverde Sabogal CE, Correa Rivera AF, Joya Higuera AY. Lactate and base deficit in trauma: Prognostic value. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2013.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
15
|
Lactate and base deficit in trauma: Prognostic value☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1097/01819236-201442010-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
16
|
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.
Collapse
Affiliation(s)
- E O'Connor
- Adult Intensive Care Services, Prince Charles Hospital, Chermside, Queensland, Australia.
| | | |
Collapse
|
17
|
Cerebral hemodynamics and oxygenation during brain tumor resection: A comparative study between different types of infusates. EGYPTIAN JOURNAL OF ANAESTHESIA 2011. [DOI: 10.1016/j.egja.2011.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
18
|
Cevenini G, Barbini P. A bootstrap approach for assessing the uncertainty of outcome probabilities when using a scoring system. BMC Med Inform Decis Mak 2010; 10:45. [PMID: 20796275 PMCID: PMC2940863 DOI: 10.1186/1472-6947-10-45] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 08/26/2010] [Indexed: 12/03/2022] Open
Abstract
Background Scoring systems are a very attractive family of clinical predictive models, because the patient score can be calculated without using any data processing system. Their weakness lies in the difficulty of associating a reliable prognostic probability with each score. In this study a bootstrap approach for estimating confidence intervals of outcome probabilities is described and applied to design and optimize the performance of a scoring system for morbidity in intensive care units after heart surgery. Methods The bias-corrected and accelerated bootstrap method was used to estimate the 95% confidence intervals of outcome probabilities associated with a scoring system. These confidence intervals were calculated for each score and each step of the scoring-system design by means of one thousand bootstrapped samples. 1090 consecutive adult patients who underwent coronary artery bypass graft were assigned at random to two groups of equal size, so as to define random training and testing sets with equal percentage morbidities. A collection of 78 preoperative, intraoperative and postoperative variables were considered as likely morbidity predictors. Results Several competing scoring systems were compared on the basis of discrimination, generalization and uncertainty associated with the prognostic probabilities. The results showed that confidence intervals corresponding to different scores often overlapped, making it convenient to unite and thus reduce the score classes. After uniting two adjacent classes, a model with six score groups not only gave a satisfactory trade-off between discrimination and generalization, but also enabled patients to be allocated to classes, most of which were characterized by well separated confidence intervals of prognostic probabilities. Conclusions Scoring systems are often designed solely on the basis of discrimination and generalization characteristics, to the detriment of prediction of a trustworthy outcome probability. The present example demonstrates that using a bootstrap method for the estimation of outcome-probability confidence intervals provides useful additional information about score-class statistics, guiding physicians towards the most convenient model for predicting morbidity outcomes in their clinical context.
Collapse
Affiliation(s)
- Gabriele Cevenini
- Department of Surgery and Bioengineering, University of Siena, Siena, Italy
| | | |
Collapse
|
19
|
Parolari A, Alamanni F, Juliano G, Polvani G, Roberto M, Veglia F, Fumero A, Carlucci C, Rona P, Brambillasca C, Sisillo E, Biglioli P. Oxygen metabolism during and after cardiac surgery: role of CPB. Ann Thorac Surg 2003; 76:737-43; discussion 743. [PMID: 12963188 DOI: 10.1016/s0003-4975(03)00683-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) has been reported to increase oxygen metabolism and to influence the relation between oxygen consumption (VO(2)) and delivery (DO(2)) in the early hours after cardiac surgery. To investigate the role of CPB, we studied oxygen metabolism in coronary artery bypass procedures performed on-pump (CABG) and off-pump (OPCAB). METHODS Twenty-five patients were randomized to undergo CABG (n = 14) or OPCAB (n = 11). All patients received the same anesthetic management. Oxygen metabolism variables were assessed before induction of anesthesia and up to 18-hours after surgery. RESULTS At baseline, before induction of anesthesia, there were no differences between CABG and OPCAB in oxygen consumption (VO(2)), delivery (DO(2)), or extraction (ExO(2)). After surgery VO(2) and ExO(2) increased in both groups, while DO(2) decreased. No significant differences between CABG and OPCAB were detected in postoperative VO(2), DO(2), and ExO(2) levels. The relation between VO(2) and DO(2) was very similar in CABG and OPCAB patients throughout the study, and no significant differences were detected in slopes and intercepts of the regression lines between CABG and OPCAB at all time points. There was, however, a significant effect of time on the relation between VO(2) and DO(2): this relation was stronger in the postoperative period, and the slope of this relation increased over time as well. CONCLUSIONS A hypermetabolic state and progressive and significant increases in the strength of the relationship between VO(2) and DO(2) and in the slope of this relationship occur after both CABG and OPCAB. Cardiopulmonary bypass is not responsible for these changes in oxygen metabolism.
Collapse
|
20
|
Dixon B, Santamaria JD, Campbell DJ. Plasminogen activator inhibitor activity is associated with raised lactate levels after cardiac surgery with cardiopulmonary bypass. Crit Care Med 2003; 31:1053-9. [PMID: 12682472 DOI: 10.1097/01.ccm.0000055390.97331.db] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the pathophysiology underlying raised lactate levels after cardiac surgery with cardiopulmonary bypass (CPB). DESIGN Prospective observational study. SETTING Medical and surgical intensive care unit of a tertiary hospital. PATIENTS A total of 40 patients undergoing first-time coronary artery bypass grafting with CPB. INTERVENTIONS The prothrombotic response to cardiac surgery with CPB was assessed by measuring plasma levels of prothrombin fragment 1 + 2 and plasminogen activator inhibitor (PAI) activity. The hemodynamic responses to cardiac surgery with CPB were also measured using standard techniques. MEASUREMENTS AND MAIN RESULTS After cardiac surgery, prothrombin fragment 1 + 2 levels increased 6-fold and PAI activity increase 2- to 3-fold (p <.0001). Lactate levels were not associated with prothrombin fragment 1 + 2 and PAI activity levels after CPB. Lactate levels were associated with baseline PAI activity (p =.006), a history of hypertension (p =.02), raised baseline lactate levels (p =.02), an early increase in body temperature after CPB (p =.05), a late increase in oxygen consumption after CPB (p =.03), and a raised white cell count after CPB (p =.06). Lactate levels were inversely associated with the maximum activated clotting time level reached during CPB (p =.02). Multivariate linear regression demonstrated lactate levels were independently associated with baseline PAI activity. CONCLUSION We found cardiac surgery with CPB was associated with a marked prothrombotic response. Lactate levels were associated with elevated baseline PAI activity and evidence of an amplified inflammatory response to cardiac surgery with CPB. Our findings implicate aspects of the inflammatory response, including microvascular thrombosis, in the development of raised lactate levels after cardiac surgery with CPB.
Collapse
Affiliation(s)
- Barry Dixon
- Intensive Care Centre, St. Vincent's Hospital, St. Vincent's Institute of Medical Research, Fitzroy, Australia
| | | | | |
Collapse
|