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Keller SP, Whitman GJR, Grant MC. Temporary Mechanical Circulatory Support after Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00387-2. [PMID: 38955616 DOI: 10.1053/j.jvca.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024]
Abstract
Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.
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Affiliation(s)
- Steven P Keller
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael C Grant
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Divisions of Cardiac Anesthesia and Surgical Critical, The Johns Hopkins University School of Medicine, Baltimore, MD.
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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.
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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
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Dan K, Takahashi K, Lefor AK. Measuring and maintaining organ perfusion in a patient with Takayasu's arteritis undergoing cardiac surgery. Anaesth Rep 2023; 11:e12236. [PMID: 37408768 PMCID: PMC10318576 DOI: 10.1002/anr3.12236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/07/2023] Open
Abstract
Takayasu's arteritis is a rare vasculitis affecting the aorta and its branches. Disease progression can result in arterial stenosis and subsequent organ dysfunction. Estimating organ perfusion by measuring the peripheral blood pressure can be challenging because it may be altered by arterial stenosis. We report the case of a 61-year-old woman with Takayasu's arteritis with aortic and mitral regurgitation who presented for aortic valve replacement and mitral valvuloplasty. Peripheral arterial pressure was considered a less reliable surrogate for organ perfusion because the patient had diminished blood flow in both the lower and upper extremities. In addition to the bilateral radial arterial pressure, the blood pressure in the ascending aorta was monitored to estimate the patient's organ perfusion pressure during cardiopulmonary bypass. The initial target blood pressure was determined based on the pre-operative baseline and modified by measurement of the aortic pressure. Cerebral oximetry using near-infrared spectroscopy and mixed venous saturation was monitored to estimate oxygen supply-demand balance, which helped evaluate cerebral perfusion and determine the transfusion threshold. The entire procedure was uneventful, and no organ dysfunction was observed postoperatively.
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Affiliation(s)
- K. Dan
- Department of AnaesthesiaTokyo Bay Urayasu Ichikawa Medical CenterChibaJapan
| | - K. Takahashi
- Department of AnaesthesiaJichi Medical University Saitama Medical CenterSaitamaJapan
| | - A. K. Lefor
- Department of SurgeryJichi Medical UniversityTochigiJapan
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Refaeli E, Zarour S, Lior Y, Herut M, Rabkin V, Aharonov M, Ben-Tov T, Cohen B, Matot I. Prevalence of preoperative metabolic disturbances in elderly patients with hip fracture and their association with mortality - A retrospective cohort study. J Clin Anesth 2023; 88:111137. [PMID: 37182398 DOI: 10.1016/j.jclinane.2023.111137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/16/2023]
Abstract
STUDY OBJECTIVES To assess the prevalence of preoperative acidosis and lactatemia in elderly patients having hip fracture surgery and their association with post-operative mortality. DESIGN Retrospective cohort study. SETTING Single tertiary medical center. PATIENTS Patients ≥65 years having first traumatic hip fracture surgery between 2018 and 2021. MEASUREMENTS 90-day postoperative mortality. MAIN RESULTS In total, 1267 patients were included in the primary analysis (mean (SD) age 83(8) years; 802 (69%) females; median [Interquartile Range (IQR)] American Society of Anesthesiologists (ASA) physical score 3 [2,3]). Of these, 1227 were available for the multivariable analyses. Median [IQR] time from hospitalization to surgery was 28 [20, 42] hours. All-cause 90-day mortality rate was 9% (N = 114). The incidence of preoperative acidosis (pH < 7.35) and lactatemia (>1.2 mmol/L) was significantly higher among non-survivors. Mortality was highest in patients with both acidosis and lactatemia (19.1% compared to 4.4% among patients with neither). In a multivariable model, pH <7.35 and lactate >1.2 mmol/L remained independent predictors of 90-day mortality, with adjusted odds ratio (aOR) (95%CI) of 1.99 (1.31 to 3.04) and 2.32 (1.44 to 3.74), respectively, p = 0.001 for both. Time from hospitalization to surgery was not associated with mortality after adjustment for metabolic indices, aOR 1.00 (0.99, 1.00). CONCLUSIONS Preoperative acidosis and lactatemia are common among patients ≥65 years having hip fracture surgery and are associated with 90-day all-cause mortality. Time from hospital admission to surgery is not an independent risk factor, once adjusted for metabolic indices. Future studies should evaluate whether the increased risk associated with preoperative metabolic disturbances is modifiable.
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Affiliation(s)
- E Refaeli
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - S Zarour
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Y Lior
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - M Herut
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - V Rabkin
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - M Aharonov
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - T Ben-Tov
- Division of Orthopedic surgery, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - B Cohen
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel; Outcomes Research Consortium, Cleveland, OH, United States of America
| | - I Matot
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel.
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Zhou Y, Yang C, Jin Z, Zhang B. Intraoperative use of cell saver devices decreases the rate of hyperlactatemia in patients undergoing cardiac surgery. Heliyon 2023; 9:e15999. [PMID: 37215823 PMCID: PMC10196517 DOI: 10.1016/j.heliyon.2023.e15999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023] Open
Abstract
Objective This study was aimed to elucidate the effect of the intraoperative cell saver (CS) on hyperlactatemia of patients who underwent cardiac surgery. Design A sub-analysis of the CS was performed, which is a historial control trial of patients undergoing cardiac surgery. Setting This was a retrospective single-center and not blinded study. Participants We examined the occurrence of hyperlactatemia retrospectively in patients of CS group (n = 78) who were included in prospective trial and received valvular surgery, where CS was used during the procedure. Patients subjected to valvular surgery before February 2021 were adopted in control group (n = 79). Interventions Arterial blood was sampled (1) before cardiopulmonary bypass, (2) during bypass (3) immediately after bypass, (4) on ICU admission and (5) every 4 h up to 24 h postoperatively. Measurements and main results A lower incidence of hyperlactatemia (32.1% vs. 57.0%; P = 0.001) was observed in patients from the CS group. Furthermore, the blood lactate concentration was higher in control group than in CS group during CPB, post CPB, on ICU admission and lasted until 20 h after the operation. Multivariable analysis revealed that intraoperative use of CS was expected to be a protective factor against hyperlactatemia in this study (OR = 0.31, 95% CI 0.15-0.63, P = 0.001). Conclusion Intraoperative use of a CS device was associated with a lower incidence of hyperlactatemia. Whether such device use is valuable to limiting hyperlactatemia in cardiac patients after surgery requires further evaluation in larger prospective studies.
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Affiliation(s)
| | | | | | - Bing Zhang
- Corresponding author. Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, West Changle Road 127, Xi'an, 710000, China.
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Steck DT, Jelacic S, Mostofi N, Wu D, Wells L, Fong CT, Cain KC, Sheu RD, Togashi K. The Association Between Hypophosphatemia and Lactic Acidosis After Cardiac Surgery With Cardiopulmonary Bypass: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:374-381. [PMID: 36528501 DOI: 10.1053/j.jvca.2022.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The clinical significance of hypophosphatemia in cardiac surgery has not been investigated extensively. The aim of this study was to evaluate the association of postoperative hypophosphatemia and lactic acidosis in cardiac surgery patients at the time of intensive care unit (ICU) admission. DESIGN A retrospective cohort study. SETTING At a single academic center. PARTICIPANTS Patients who underwent nontransplant cardiac surgery with cardiopulmonary bypass between August 2009 and December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Serum phosphate and lactate levels were measured upon ICU admission in patients undergoing nontransplant cardiac surgery with cardiopulmonary bypass. There were 681 patients in the low-phosphate (<2.5 mg/dL) group and 2,579 patients in the normal phosphate group (2.5-4.5 mg/dL). A higher proportion of patients in the low phosphate group (26%; 179 of 681; 95% CI: 23-30) had severe lactic acidosis compared to patients in the normal phosphate group (16%; 417 of 2,579; 95% CI: 15-18). In an unadjusted logistic regression model, patients in the low phosphate group had 1.9-times the odds of having severe lactic acidosis (serum lactate ≥4.0 mmol/L) when compared to patients in the normal phosphate group (95% CI: 1.5-2.3), and still 1.4-times the odds (95% CI: 1.1-1.7) after adjusting for several possible confounders. CONCLUSIONS Hypophosphatemia is associated with lactic acidosis in the immediate postoperative period in cardiac surgery patients. Future studies will need to investigate it as a potential treatment target for lactic acidosis.
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Affiliation(s)
- Dominik T Steck
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.
| | - Srdjan Jelacic
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Nicki Mostofi
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - David Wu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Lauren Wells
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Christine T Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Kevin C Cain
- Office of Nursing Research and Department of Biostatistics, University of Washington, Seattle, WA
| | - Richard D Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Kei Togashi
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Orange, CA
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Linde H, Bartusevicius V, Norberg Å, Klevebro F, Grip J. Frequency of blood lactate elevation following esophagectomy and its association to postoperative complications. Acta Anaesthesiol Scand 2023; 67:277-283. [PMID: 36537042 DOI: 10.1111/aas.14181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Esophagectomy is a major surgical intervention and a cornerstone in the treatment of esophageal cancer. There is clinical experience that blood lactate concentration often is elevated in the period following esophagectomy, but the incidence and clinical consequences are sparsely studied. METHODS We extracted data from all patients undergoing esophagectomy at Karolinska University Hospital 2016-2018, n = 153. Most were performed with minimally invasive technique, n = 130. Blood lactate values directly after surgery, highest value during the first night, and morning level on postoperative day one were recorded. Primary outcome was hospital length of stay and secondary outcome was a composite of postoperative infection, additional surgery, or intensive care during the hospital stay. Development of anastomotic leak was analyzed separately. RESULTS Postoperative hyperlactatemia was common as 93% of patients had peak lactate concentration >1.6 mmol/L and 27% >3.5 mmol/L in the first night following operation. Median hospital length of stay was 14 days. Blood lactate showed a weak correlation to hospital stay and intensive care the morning following surgery, but not at arrival to postoperative ward. There were no statistical differences between those with and without anastomotic leak at any of the time points. Elevated lactate in the first 12-16 h postoperatively was related to surgical factors (open technique, surgery time, and perioperative bleeding) but not to patient related factors (ASA-class, Charlson comorbidity index, sex, age) or cumulative fluid balance. CONCLUSION In conclusion, elevated blood lactate in the immediate time following esophagectomy showed a weak association to intensive care and length of stay but not anastomotic leak.
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Affiliation(s)
- Henrik Linde
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Vilhelmas Bartusevicius
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Jonathan Grip
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
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Development of a predictive model for unplanned intensive care unit admission after pancreatic resection within an enhanced recovery pathway. Surg Endosc 2022; 37:2932-2942. [PMID: 36509947 DOI: 10.1007/s00464-022-09787-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is unclear whether routine postoperative admission to the intensive care unit (ICU) can improve outcomes for patients undergoing elective pancreatic surgery. Aim of the study was to determine preoperative and intraoperative predictors of unplanned ICU access in patients undergoing pancreatectomy treated within an established enhanced recovery pathway (ERP) and compare outcomes between direct and late ICU admission. METHODS A retrospective observational study was conducted on adult patients who underwent pancreatic resection (2015-2019) within an ERP. Patients with preoperatively planned ICU admission were excluded from the study. Multiple multivariate logistic regression models were constructed to verify the association of preoperative and intraoperative variables with study outcomes. RESULTS The study included 1486 consecutive patients (cancer diagnosis 60%, pancreaticoduodenectomy 60%; laparoscopic approach 20%; vascular resection 9%). Sixty-six (4.4%) patients had an unplanned ICU admission. Direct admission occurred in 22 (33%) patients and late ICU admission in 44 (67%) patients. Mortality was significantly lower in direct admission group (n = 3, 14%) compared to late admission (n = 25, 57%; p > 0.001). A comprehensive model including preoperative and intraoperative variables identified ASA score ≥ 3 (OR 5.59, p value < 0.001), history of hypertension (OR 2.29, p = 0.029), chronic obstructive pulmonary disease (OR 3.05, p = 0.026), proximal pancreatic resection (OR 2.79, p value 0.046), multivisceral resection (OR 8.86, p value < 0.001), high intraoperative blood loss (OR 1.01 per ml, p < 0.001), and increased serum lactate at the end of surgery (OR 1.25, p = 0.017) as independent factors associated with ICU admission. Area under the ROC curve was 0.891. CONCLUSION Patient comorbidities, surgical complexity, and lactic acidosis at the end of surgery were associated with unplanned postoperative ICU admission. Late ICU admission had very high mortality rates compared to direct admission. Our findings suggest that patients with a combination of preoperative and intraoperative risk factors could benefit from upfront postoperative ICU admission to potentially improve postoperative outcomes.
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Rantanen M, Yousif R, Kallioinen M, Hynninen VV, Peltoniemi M, Söderholm O, Saarikoski T, Anttila V, Aittokallio J. Retrospective observational analysis of a coronary artery bypass grafting surgery patient cohort: Off-pump versus on-pump. Ann Med Surg (Lond) 2022; 84:104812. [DOI: 10.1016/j.amsu.2022.104812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/27/2022] [Accepted: 10/30/2022] [Indexed: 11/11/2022] Open
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Li X, Tan T, Wu H, Zhang C, Luo D, Zhu W, Li B, Zhuang J. Characteristics of sublingual microcirculatory changes during the early postoperative period following cardiopulmonary bypass-assisted cardiac surgery-a prospective cohort study. J Thorac Dis 2022; 14:3992-4002. [PMID: 36389306 PMCID: PMC9641360 DOI: 10.21037/jtd-22-1159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/28/2022] [Indexed: 02/27/2024]
Abstract
BACKGROUND Persistent microcirculatory dysfunction associated with increased morbidity and mortality. Interventions in the early resuscitation can be tailored to the changes of microcirculation and patient's need. However, there is usually an uncoupling of macrocirculatory and microcirculatory hemodynamics during resuscitation. Current research on the patterns of microcirculatory changes and recovery after cardiopulmonary bypass (CPB)-assisted cardiac surgery is limited. This study aimed to analyze changes in the microcirculatory parameters after CPB and their correlation with macrocirculation and to explore the characteristics of microcirculatory changes following CPB-assisted cardiac surgery. METHODS Between December 2018 and January 2019, 24 adult patients with indwelling pulmonary artery catheters after elective cardiac surgery using CPB were enrolled in this study. Both microcirculatory and macrocirculatory parameters were collected at 0, 6, 16, and 24 hours after admission to the intensive care unit (ICU). Video images of sublingual microcirculation were analyzed to obtain the microcirculatory parameters, including total vascular density (TVD), perfused small vessel density (PSVD), the proportion of perfused small vessels (PPV), microvascular flow index (MFI), and flow heterogeneity index (HI). The characteristics of microcirculatory parameter change following cardiac surgery and the correlation between microcirculatory parameters and macroscopic hemodynamic indicators, oxygen metabolic indicators, and carbon dioxide partial pressure difference (PCO2gap) were analyzed. RESULTS There were significant differences in the changes of TVD (P=0.012) and PSVD (P=0.005) during the first 24 hours postoperatively in patients who underwent CPB-assisted cardiac surgery. The microcirculatory density parameters (TVD: r=-0.5059, P=0.0456; PVD: r=-0.5499, P=0.0273) were correlated with oxygen delivery index (DO2I) at 24 hours after surgery. The microcirculatory flow parameters (PPV: r=0.4370, P=0.0327; MFI: r=0.6496, P=0.0006; and HI: r=-0.5350, P=0.0071) had a strong correlation with PCO2gap at 0 hour after surgery. CONCLUSIONS TVD and PSVD might be two most sensitive indicators affected by CPB-assisted cardiac surgery. There was no consistency between microcirculation and macrocirculation until 24 hours following cardiac surgery, meaning the improvement of systemic hemodynamic indicators does not guarantee correspondently improvement in microcirculation. Early controlled oxygen supply after CPB-assisted cardiac surgery may be conducive to the resuscitation of patients to a certain extent.
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Affiliation(s)
- Xiaofeng Li
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Hongxiang Wu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Chongjian Zhang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Dandong Luo
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Weizhong Zhu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Boyu Li
- Department of Center for Private Medical Service & Healthcare, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
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Vasoactive inotropic score as a predictor of long-term mortality in patients after off-pump coronary artery bypass grafting. Sci Rep 2022; 12:12863. [PMID: 35896595 PMCID: PMC9329300 DOI: 10.1038/s41598-022-16900-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 07/18/2022] [Indexed: 11/08/2022] Open
Abstract
Increased vasoactive-inotropic score (VIS) is a reliable predictor of mortality and morbidity after cardiac surgery. Here, we retrospectively evaluated the association between VIS and adverse outcomes in adult patients after off-pump coronary artery bypass grafting (OPCAB). We included 2149 patients who underwent OPCAB. The maximal VIS was calculated for the initial 48 postoperative hours using standard formulae. The primary outcome was 1-year death. The composite adverse outcome was death, resuscitation or mechanical support, myocardial infarction, revascularization, new-onset atrial fibrillation, infection requiring antibacterial therapy, acute kidney injury, and stroke. Path-analysis was conducted using lactate and prognostic nutritional index (PNI). VIS was associated with 1-year death (odds ratio [OR] 1.07 [1.04–1.10], p < 0.001) and 1-year composite outcome (OR 1.02 [1.0–1.03], p = 0.008). In path-analysis, high VIS showed a direct effect on the increased risk of 1-year death and composite outcome. In the pathway using lactate as a mediating variable, VIS showed an indirect effect on the composite outcome but no significant effect on death. Low PNI directly affected the increased risk of 1-year death and composite outcome, and had an indirect effect on both outcomes, even when VIS was used as a mediating variable. In patients undergoing OPCAB, high VIS independently predicted morbidity and 1-year death. Patients with increased lactate levels following high VIS had an increased risk of postoperative complications, although not necessarily resulting in death. However, patients with poor preoperative nutritional status had an increased risk of unfavourable outcomes, including death, implying the importance of preoperative nutritional support.
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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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Wang D, Wang S, Wu J, Le S, Xie F, Li X, Wang H, Huang X, Du X, Zhang A. Nomogram Models to Predict Postoperative Hyperlactatemia in Patients Undergoing Elective Cardiac Surgery. Front Med (Lausanne) 2021; 8:763931. [PMID: 34926506 PMCID: PMC8674505 DOI: 10.3389/fmed.2021.763931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives: Postoperative hyperlactatemia (POHL) is common in patients undergoing cardiac surgery and is associated with poor outcomes. The purpose of this study was to develop and validate two predictive models for POHL in patients undergoing elective cardiac surgery (ECS). Methods: We conducted a multicenter retrospective study enrolling 13,454 adult patients who underwent ECS. All patients involved in the analysis were randomly assigned to a training set and a validation set. Univariate and multivariate analyses were performed to identify risk factors for POHL in the training cohort. Based on these independent predictors, the nomograms were constructed to predict the probability of POHL and were validated in the validation cohort. Results: A total of 1,430 patients (10.6%) developed POHL after ECS. Age, preoperative left ventricular ejection fraction, renal insufficiency, cardiac surgery history, intraoperative red blood cell transfusion, and cardiopulmonary bypass time were independent predictors and were used to construct a full nomogram. The second nomogram was constructed comprising only the preoperative factors. Both models showed good predictive ability, calibration, and clinical utility. According to the predicted probabilities, four risk groups were defined as very low risk (<0.05), low risk (0.05–0.1), medium risk (0.1–0.3), and high risk groups (>0.3), corresponding to scores of ≤ 180 points, 181–202 points, 203–239 points, and >239 points on the full nomogram, respectively. Conclusions: We developed and validated two nomogram models to predict POHL in patients undergoing ECS. The nomograms may have clinical utility in risk estimation, risk stratification, and targeted interventions.
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Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Su Wang
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wu
- Key Laboratory for Molecular Diagnosis of Hubei Province, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Xie
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ximei Li
- Department of Nursing, Huaihe Hospital of Henan University, Kaifeng, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Anchen Zhang
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Niederwieser T, Braunwarth E, Dasari BVM, Pufal K, Szatmary P, Hackl H, Haselmann C, Connolly CE, Cardini B, Öfner D, Roberts K, Malik H, Stättner S, Primavesi F. Early postoperative arterial lactate concentrations to stratify risk of post-hepatectomy liver failure. Br J Surg 2021; 108:1360-1370. [PMID: 34694377 DOI: 10.1093/bjs/znab338] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 09/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) represents the major determinant for death after liver resection. Early recognition is essential. Perioperative lactate dynamics for risk assessment of PHLF and associated morbidity were evaluated. METHODS This was a multicentre observational study of patients undergoing hepatectomy with validation in international high-volume units. Receiver operating characteristics analysis and cut-off calculation for the predictive value of lactate for clinically relevant International Study Group of Liver Surgery grade B/C PHLF (clinically relevant PHLF (CR-PHLF)) were performed. Lactate and other perioperative factors were assessed in a multivariable CR-PHLF regression model. RESULTS The exploratory cohort comprised 509 patients. CR-PHLF, death, overall morbidity and severe morbidity occurred in 7.7, 3.3, 40.9 and 29.3 per cent of patients respectively. The areas under the curve (AUCs) regarding CR-PHLF were 0.829 (95 per cent c.i. 0.770 to 0.888) for maximum lactate within 24 h (Lactate_Max) and 0.870 (95 per cent c.i. 0.818 to 0.922) for postoperative day 1 levels (Lactate_POD1). The respective AUCs in the validation cohort (482 patients) were 0.812 and 0.751 and optimal Lactate_Max cut-offs were identical in both cohorts. Exploration cohort patients with Lactate_Max 50 mg/dl or greater more often developed CR-PHLF (50.0 per cent) than those with Lactate_Max between 20 and 49.9 mg/dl (7.4 per cent) or less than 20 mg/dl (0.5 per cent; P < 0.001). This also applied to death (18.4, 2.7 and 1.4 per cent), severe morbidity (71.1, 35.7 and 14.1 per cent) and associated complications such as acute kidney injury (26.3, 3.1 and 2.3 per cent) and haemorrhage (15.8, 3.1 and 1.4 per cent). These results were confirmed in the validation group. Combining Lactate_Max with Lactate_POD1 further increased AUC (ΔAUC = 0.053) utilizing lactate dynamics for risk assessment. Lactate_Max, major resections, age, cirrhosis and chronic kidney disease were independent risk factors for CR-PHLF. A freely available calculator facilitates clinical risk stratification (www.liver-calculator.com). CONCLUSION Early postoperative lactate values are powerful, readily available markers for CR-PHLF and associated complications after hepatectomy with potential for guiding postoperative care.Presented in part as an oral video abstract at the 2020 online Congress of the European Society for Surgical Research and the 2021 Congress of the Austrian Surgical Society.
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Affiliation(s)
- Thomas Niederwieser
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Kamil Pufal
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Peter Szatmary
- Department of Hepato-Biliary Surgery, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Hubert Hackl
- Institute of Bioinformatics, Biocentre, Medical University of Innsbruck, Innsbruck, Austria
| | - Clemens Haselmann
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Catherine E Connolly
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Keith Roberts
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Hassan Malik
- Department of Hepato-Biliary Surgery, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of General, Visceral and Vascular Surgery, Salzkammergut Klinikum, Vöcklabruck, Austria
| | - Florian Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of Hepato-Biliary Surgery, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Department of General, Visceral and Vascular Surgery, Salzkammergut Klinikum, Vöcklabruck, Austria
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15
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Fessler J, Vallée A, Guirimand A, Sage E, Glorion M, Roux A, Brugière O, Parquin F, Zuber B, Cerf C, Vasse M, Pascreau T, Fischler M, Ichai C, Guen ML. Blood Lactate During Double-Lung Transplantation: A Predictor of Grade-3 Primary Graft Dysfunction. J Cardiothorac Vasc Anesth 2021; 36:794-804. [PMID: 34879926 DOI: 10.1053/j.jvca.2021.10.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Many prognostic factors of grade-3 primary graft dysfunction at postoperative day 3 (PGD3-T72) have been reported, but intraoperative blood lactate level has not been studied. The present retrospective study was done to test the hypothesis that intraoperative blood lactate level (BLL) could be a predictor of PGD3-T72 after double-lung transplantation. DESIGN Retrospective monocentric cohort study. SETTING Foch University Hospital, Suresnes, France. PARTICIPANTS Patients having received a double-lung transplantation between 2012 and 2019. Patients transplanted twice during the study period, having undergone a multiorgan transplantation, or cardiopulmonary bypass, and those under preoperative extracorporeal membrane oxygenation, were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis was performed on a cohort of 449 patients. Seventy-two (16%) patients had a PGD3-T72. Blood lactate level increased throughout surgery to reach a median value of 2.2 (1.6-3.2) mmol/L in the No-PGD3-T72 group and 3.4 (2.3-5.0) mmol/L in the PGD3-T72 group after second lung implantation. The best predictive model for PGD3-T72 was obtained adding a lactate threshold of 2.6 mmol/L at the end of surgery to the clinical model, and the area under the curve was 0.867, with a sensitivity = 76.9% and specificity = 85.4%. Repeated-measures mixed model of BLL during surgery remained significant after adjustment for covariates (F ratio= 4.22, p < 0.001 for interaction). CONCLUSIONS Blood lactate level increases during surgery and reaches a maximum after the second lung implantation. A value below the threshold of 2.6 mmol/L at the end of surgery has a high negative predictive value for the occurrence of a grade-3 primary graft dysfunction at postoperative day 3.
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Affiliation(s)
- Julien Fessler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France.
| | - Alexandre Vallée
- Department of Clinical Research and Innovation, Hôpital Foch, Suresnes, France
| | - Avit Guirimand
- Department of Anesthesiology, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Edouard Sage
- Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France; Department of Thoracic Surgery, Hôpital Foch, Suresnes, France
| | - Matthieu Glorion
- Department of Thoracic Surgery, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Antoine Roux
- Department of Pneumology, Hôpital Foch, Suresnes, France,; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Olivier Brugière
- Department of Pneumology, Hôpital Foch, Suresnes, France,; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - François Parquin
- Department of Thoracic Surgery, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Benjamin Zuber
- Department of Intensive Care Medicine, Hôpital Foch, Suresnes, France
| | - Charles Cerf
- Department of Intensive Care Medicine, Hôpital Foch, Suresnes, France
| | - Marc Vasse
- Department of Clinical Biology, Hôpital Foch, Suresnes, France; INSERM UMRS-1176, Université Paris-Sud, Orsay
| | - Tiffany Pascreau
- Department of Clinical Biology, Hôpital Foch, Suresnes, France; INSERM UMRS-1176, Université Paris-Sud, Orsay
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France.
| | - Carole Ichai
- Department of Intensive Care, Hôpital Pasteur, Nice, France; IRCAN INSERM, Nice, France
| | - Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
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16
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Zhou XF, Yu RG, Chen Q, Xue YM, Chen H. Performance of Lactate and CO 2-Derived Parameters in Predicting Major Postoperative Complications After Cardiac Surgery With Cardiopulmonary Bypass: Protocol of a Diagnostic Accuracy Study. Front Cardiovasc Med 2021; 8:724713. [PMID: 34660725 PMCID: PMC8517114 DOI: 10.3389/fcvm.2021.724713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: CO2-derived parameters are increasingly used to identify either low-flow status or anaerobic metabolism in shock resuscitation. However, the performance of CO2-derived parameters in cardiac surgical patients is poorly understood. This study aims to compare the performance of lactate and CO2-derived parameters in predicting major postoperative complications after cardiac surgery with cardiopulmonary bypass. Methods: This is a prospective, single-center, diagnostic accuracy study. All patients who receive elective cardiac surgery involving cardiopulmonary bypass will be screened for study eligibility. Blood samples will be taken for the calculation of CO2-derived parameters, including the venous-arterial difference in CO2 partial pressure (PCO2 gap), venous-arterial difference in CO2 content to arterial-venous O2 content ratio (Cv-aCO2/Ca-vO2), and venous-arterial difference in CO2 partial pressure to arterial-venous O2 content ratio (Pv-aCO2/Ca-vO2) at ICU admission, and 3, 6, and 12 h later. Baseline, perioperative data will be collected daily for 7 days; patients will be followed up for 28 days to collect outcome data. The primary endpoint is the occurrence of major postoperative complications. Receiver-operating characteristics (ROC) curve analysis will be carried out to assess the predictive performance of lactate and CO2-derived parameters. The performance of the ROC curves will be compared. Discussion: The performance of lactate and CO2-derived parameters in predicting major postoperative complications will be investigated in the non-sepsis population, which has not been extensively investigated. Our study will compare the two surrogates of respiratory quotient directly, which is an important strength. Trial Registration: ChiCTR, ChiCTR2000029365. Registered January 26th, 2020, http://www.chictr.org.cn/showproj.aspx?proj=48744.
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Affiliation(s)
- Xiao-Fen Zhou
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Rong-Guo Yu
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Qian Chen
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yi-Min Xue
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Han Chen
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
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17
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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.
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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.
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18
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Mock-Ohnesorge J, Mock A, Hackert T, Fröhling S, Schenz J, Poschet G, Jäger D, Büchler MW, Uhle F, Weigand MA. Perioperative changes in the plasma metabolome of patients receiving general anesthesia for pancreatic cancer surgery. Oncotarget 2021; 12:996-1010. [PMID: 34012512 PMCID: PMC8121611 DOI: 10.18632/oncotarget.27956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/19/2021] [Indexed: 02/07/2023] Open
Abstract
Background: Modern anesthesia strives to offer personalized concepts to meet the patient’s individual needs in sight of clinical outcome. Still, little is known about the impact of anesthesia on the plasma metabolome, although many metabolites have been shown to modulate the function of various immune cells, making it particularly interesting in the context of oncological surgery. In this study longitudinal dynamics in the plasma metabolome during general anesthesia in patients undergoing pancreatic surgery were analyzed. Materials and Methods: Prospective, observational study with 10 patients diagnosed with pancreatic (pre-) malignancy and subjected to elective resection surgery under general anesthesia. Plasma metabolites (n = 630) were quantified at eight consecutive perioperative timepoints using mass spectrometry-based targeted metabolomics. Results: 39 metabolites significantly changed during the perioperative period. Tryptophan concentrations decreased by 45% with the maximum decrease after anesthesia induction (p = 6.24E-07), while taurine synthesis increased (p = 1.46E-04). Triacylglycerides and lysophosphatidylcholines were significantly reduced with increased liberation of free monounsaturated fatty acids (p = 0.03). Carnitine levels decreased significantly (p = 9.30E-04). Conclusions: The major finding of this study was perioperative tryptophan depletion and increased taurine synthesis. Both are essential for immune cell function and are therefore of significant interest for perioperative management. Further studies are needed to identify influencing anesthetic factors.
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Affiliation(s)
| | - Andreas Mock
- Department of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,Department of Translational Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Fröhling
- Department of Translational Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Judith Schenz
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gernot Poschet
- Centre for Organismal Studies (COS), University of Heidelberg, Heidelberg, Germany
| | - Dirk Jäger
- Department of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Markus W Büchler
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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19
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Effect of Continuous Epinephrine Infusion on Survival in Critically Ill Patients: A Meta-Analysis of Randomized Trials. Crit Care Med 2020; 48:398-405. [PMID: 31789701 DOI: 10.1097/ccm.0000000000004127] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Epinephrine is frequently used as an inotropic and vasopressor agent in critically ill patients requiring hemodynamic support. Data from observational trials suggested that epinephrine use is associated with a worse outcome as compared with other adrenergic and nonadrenergic vasoactive drugs. We performed a systematic review and meta-analysis of randomized controlled trials to investigate the effect of epinephrine administration on outcome of critically ill patients. DATA SOURCES PubMed, EMBASE, and Cochrane central register were searched by two independent investigators up to March 2019. STUDY SELECTION Inclusion criteria were: administration of epinephrine as IV continuous infusion, patients admitted to an ICU or undergoing major surgery, and randomized controlled trials. Studies on epinephrine administration as bolus (e.g., during cardiopulmonary resuscitation), were excluded. The primary outcome was mortality at the longest follow-up available. DATA EXTRACTION Two independent investigators examined and extracted data from eligible trials. DATA SYNTHESIS A total of 5,249 studies were assessed, with a total of 12 studies (1,227 patients) finally included in the meta-analysis. The majority of the trials were performed in the setting of septic shock, and the most frequent comparator was a combination of norepinephrine plus dobutamine. We found no difference in all-cause mortality at the longest follow-up available (197/579 [34.0%] in the epinephrine group vs 219/648 [33.8%] in the control group; risk ratio = 0.95; 95% CI, 0.82-1.10; p = 0.49; I = 0%). No differences in the need for renal replacement therapy, occurrence rate of myocardial ischemia, occurrence rate of arrhythmias, and length of ICU stay were observed. CONCLUSIONS Current randomized evidence showed that continuous IV administration of epinephrine as inotropic/vasopressor agent is not associated with a worse outcome in critically ill patients.
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20
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Govender P, Tosh W, Burt C, Falter F. Evaluation of Increase in Intraoperative Lactate Level as a Predictor of Outcome in Adults After Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:877-884. [DOI: 10.1053/j.jvca.2019.10.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/13/2019] [Accepted: 10/22/2019] [Indexed: 02/08/2023]
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21
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Kramer A, Urban N, Döll S, Hartwig T, Yahiaoui-Doktor M, Burkhardt R, Petros S, Gries A, Bernhard M. Early Lactate Dynamics in Critically Ill Non-Traumatic Patients in a Resuscitation Room of a German Emergency Department (OBSERvE-Lactate-Study). J Emerg Med 2018; 56:135-144. [PMID: 30538084 DOI: 10.1016/j.jemermed.2018.10.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/20/2018] [Accepted: 10/25/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Management of critically ill non-trauma patients in the resuscitation room of an emergency department (ED) is very challenging, and it is difficult to identify patients with a higher risk of death. Previous studies have shown that lactate indices can predict survival for selected diseases and syndromes. OBJECTIVE As reported for other patient populations, we set out to determine whether admission lactate or lactate dynamics (LD) within 24 h can predict 30-day mortality in unselected critically ill non-traumatic patients. METHODS In this retrospective study over a 1-year period, admission lactate, time weighted average lactate (LacTW) and LD of all critically ill adult patients admitted from ED to intensive care unit were analyzed. A linear regression model was implemented to estimate lactate data 1 h after admission. RESULTS The admission lactate, LacTW, and LD within 24 h were analyzed from 392 critically ill patients. The overall 30-day mortality rate was around 29%. Admission lactate (4.1 ± 4.0 mmol/L vs. 6.6 ± 6.1 mmol/L; p < 0.01) and LacTW (1.8 ± 1.7 mmol/L vs. 4.1 ± 4.8 mmol/L; p < 0.01) were different between survivors and non-survivors. LD between survivors and non-survivors did not differ at 1 h, 6 h, 12 h, or 24 h. After excluding patients with out-of-hospital or in-hospital cardiac arrest during resuscitation room management, admission lactate and LD between survivors and non-survivors did not differ at 1 h, 12 h, and 24 h. LD at 6 h (44% ± 42% vs. 33% ± 58%; p = 0.042) and LacTW (1.7 ± 1.6 mmol/L vs. 2.6 ± 3.0 mmol/L; p < 0.01) did differ. CONCLUSIONS In critically ill ED patients initially requiring treatment in a resuscitation room setting, LD at 6 h and LacTW may predict their survival beyond 30 days. These findings need to be confirmed in a prospective study design.
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Affiliation(s)
- Andre Kramer
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Norman Urban
- Institute for Informatics, Martin-Luther-University of Halle-Wittenberg, Halle, Germany
| | - Stephanie Döll
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Thomas Hartwig
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Maryam Yahiaoui-Doktor
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Ralph Burkhardt
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - André Gries
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany; Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Working Group Trauma and Resuscitation Room Management, Task Force Emergency Medicine, German Society of Anaesthesiology and Intensive Care Medicine, Nümberg, Germany
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Abou-Arab O, Braik R, Huette P, Bouhemad B, Lorne E, Guinot PG. The ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content are not associated with overall anaerobic metabolism in postoperative cardiac surgery patients. PLoS One 2018; 13:e0205950. [PMID: 30365515 PMCID: PMC6203355 DOI: 10.1371/journal.pone.0205950] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 10/04/2018] [Indexed: 12/03/2022] Open
Abstract
Background The aim of the present study was to evaluate the ability of the ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content to predict an increase in oxygen consumption (VO2) upon fluid challenge (FC). Methods and results 110 patients admitted to cardiothoracic ICU and in whom the physician had decided to perform an FC (with 500 ml of Ringer's lactate solution) were included. The arterial pressure, cardiac index (Ci), and arterial and venous blood gas levels were measured before and after FC. VO2 and CO2-O2 derived variables were calculated. VO2 responders were defined as patients showing more than a 15% increase in VO2. Of the 92 FC responders, 43 (46%) were VO2 responders. At baseline, pCO2 gap, C(a-v)O2 were lower in VO2 responders than in VO2 non-responders, and central venous oxygen saturation (ScvO2) was higher in VO2 responders. FC was associated with an increase in MAP, SV, and CI in both groups. With regard to ScvO2, FC was associated with an increase in VO2 non-responders and a decrease in VO2 responders. FC was associated with a decrease in pvCO2 and pCO2 gap in VO2 non-responders only. The pCO2 gap/C(a-v)O2 ratio and C(a-v)CO2 content /C(a-v)O2 content ratio did not change with FC. The CO2 gap content/C(a-v)O2 content ratio and the C(a-v)CO2 content /C(a-v)O2 content ratio did not predict fluid-induced VO2 changes (area under the curve (AUC) [95% confidence interval (CI)] = 0.52 [0.39‒0.64] and 0.53 [0.4–0.65], respectively; p = 0.757 and 0.71, respectively). ScvO2 predicted an increase of more than 15% in the VO2 (AUC [95%CI] = 0.67 [0.55‒0.78]; p<0.0001). Conclusions Our results showed that the ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content were not predictive of VO2 changes following fluid challenge in postoperative cardiac surgery patients.
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Affiliation(s)
- Osama Abou-Arab
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-point Fernand Leger, Amiens, France
| | - Rayan Braik
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-point Fernand Leger, Amiens, France
| | - Pierre Huette
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-point Fernand Leger, Amiens, France
| | - Belaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon University Hospital, 2 Bd Maréchal de Lattre de Tassigny, Dijon, France
| | - Emmanuel Lorne
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-point Fernand Leger, Amiens, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon University Hospital, 2 Bd Maréchal de Lattre de Tassigny, Dijon, France
- * E-mail:
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