Diagnostic laparoscopy to investigate unexplained lactic acidosis in critically ill patients - A descriptive single centre cohort study.

Mohammed Ahmed Sajid,Zulfiqar Hanif,Khurram Shahzad Khan

doi:10.1016/j.amsu.2018.11.008

Mohammed Ahmed Sajid, Zulfiqar Hanif + Show 1 more

Open Access

https://doi.org/10.1016/j.amsu.2018.11.008

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Abstract

IntroductionUnexplained lactic acidosis (LA) in a critically ill patient often prompts investigations to rule out any reversible intra-abdominal cause. Equivocal results can lead to an emergency laparotomy (EL) with subsequent high morbidity and mortality rates. Our objective was to determine the clinical impact of urgent diagnostic laparoscopy (UDL) in such patients.MethodsThis was a descriptive single-centre cohort study. UDL on 28 consecutive critically ill patients with unexplained LA who were referred to a single surgeon over 16 years period were analysed. UDL was proformed either at bedside or in theatre without prior computerised tomography (CT) scan. Patient's demographics, ASA grade, referral route and intraoperative findings were analysed.ResultsEighteen patients underwent bedside UDL in the critical care setting and further 10 had UDL in theatre. Fourteen patients had normal UDL, out of these 10 had LA secondary to low cardiac output states. Fourteen patients had positive UDL findings. Seven patients had features of mesenteric ischaemia, two had gangrenous gallbladder, two had hepatic ischaemia, one patient had acute pancreatitis, one had gangrenous uterus and one had gastric volvulus. Five of the 14 patients with positive UDL were converted to laparotomy for definitive management. In total, of the 28 patients in the cohort, 23 patients avoided EL.ConclusionUDL is useful and feasible investigation for unexplained LA in the critically ill patients and it can avoid unnecessary EL in many patients. We would recommend the use of UDL as a safe and feasible investigation in such patients.

Highlights

Unexplained lactic acidosis (LA) in a critically ill patient often prompts investigations to rule out any reversible intra-abdominal cause
We propose bedside urgent diagnostic laparoscopy (UDL) as a useful diagnostic tool for the investigation of intra-abdominal cause of LA in critically ill patients where medical causes of LA have been excluded like cardiorespiratory, renal, alcohol or drug related
The inclusion cretia was unexplained LA in critically ill patients where extra-abdominal causes were excluded with reasonable confidence and patients were not stable enough to be transferred to radiology department for computerised tomography (CT) scan

Summary

Introduction

Unexplained lactic acidosis (LA) in a critically ill patient often prompts investigations to rule out any reversible intra-abdominal cause. Lactic acidosis (LA) defined as a serum lactate of ≥4 mmol/L is a common finding in critically ill patients [1]. It is an indicator of higher morbidity and mortality especially in patients who are relatively unstable as being hightlighted in Surviving Sepsis Campaign Bundle: 2018 update [2]. Accumulation of lactate results in lactic acidaemia, and this is commonly seen in critically ill patients due to reduced hepatic and renal clearance [3,4]. Causes such as hypovolaemia and septic shock (e.g. intra-abdominal pathology) cause impaired oxygen delivery to tissues [5]. The end result is a critically ill patient with potentially reversible LA

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