Elevated Serum Lactate Levels Research Articles

Multiorgan dysfunction in birth asphyxia

To obtain multi-organ dysfunction frequency, associated factors in neonates with birth asphyxia, and explore its relationship with short-term outcomes. A prospective study included 120 asphyxiated neonates admitted to Hue Central Hospital, Vietnam. Central nervous system (CNS), renal, pulmonary, cardiovascular, liver, and gastrointestinal evaluations were conducted systematically. Of the asphyxiated neonates, 33.3% had severe asphyxia, while 66.7% had moderate asphyxia. Multiorgan dysfunction was observed in 55.8%, with involvement of two or more systems. CNS, pulmonary, liver, renal, cardiovascular, and gastrointestinal dysfunction occurred in 50.0%, 51.7%, 45.0%, 31.7%, 17.5%, and 13.3% of asphyxiated neonates, respectively. The overall mortality rate was 21.6%. Organ dysfunction was significantly associated with increased mortality, particularly respiratory, renal, and CNS dysfunction (odds ratios: 7.43, 6.56, and 5.92, respectively; p<0.001). Mortality risk increased with the number of affected organs/systems, with odds ratios of 41.33 and 5.52 for involvement of five and four organs, respectively (p<0.01). Severe asphyxia, Apgar score≤5 at 5 minutes, and elevated serum lactate levels (≥5 mmol/L) were significantly associated with multiorgan dysfunction (p<0.05). Birth asphyxia in neonates often leads to multiorgan damage, increasing the risk of mortality. Preventive methods, prompt resuscitation, and systematic organ dysfunction screening are crucial to manage affected organs and improve outcomes.

Association between hypomagnesemia and serum lactate levels in patients with sepsis: a retrospective observational study

BackgroundSepsis-3 emphasizes the recognition of sepsis-induced cellular metabolic abnormalities, and utilizes serum lactate level as a biomarker of cellular metabolic abnormalities. Magnesium plays an important role as a cofactor in glucose metabolism, although it is not well known that magnesium deficiency causes elevated serum lactate levels. Additionally, it remains unclear how magnesium status affects the role of serum lactate levels as a marker of metabolic abnormalities in sepsis. Thus, this study aimed to investigate the association between serum magnesium and lactate levels in patients with sepsis and explore this relationship from the perspectives of time course and circulatory abnormalities.MethodsThis retrospective observational study of adult patients with sepsis was performed at the 16-bed intensive care unit of Jichi Medical University Hospital between June 2011 and December 2017. The relationship between serum magnesium and lactate levels for 5 days from intensive care unit admission was investigated along the time course. Multivariate logistic regression analysis was performed to evaluate the association between serum magnesium and lactate levels during intensive care unit admission.ResultsAmong 759 patients included, 105 had hypomagnesemia (magnesium level < 1.6 mg/dL), 558 had normal serum magnesium levels (1.6–2.4 mg/dL), and 96 had hypermagnesemia (magnesium level > 2.4 mg/dL) at intensive care unit admission. From intensive care unit admission to day 5, the hypomagnesemia group had higher serum lactate levels and a higher frequency of lactic acidosis than the normal magnesium level and hypermagnesemia groups (70% vs. 51.6% vs. 50%; P < 0.001). Hypomagnesemia at intensive care unit admission was independently associated with lactic acidosis, i.e., lactic acid level > 2 mmol/L (odds ratio, 2.76; 95% confidence interval, 1.60–4.76; P < 0.001).ConclusionsHypomagnesemia was associated with serum lactate levels in the early and post-resuscitation phases of sepsis. Further studies are needed to elucidate whether the magnesium status is associated with sepsis-induced cellular and metabolic abnormalities.

Study the beneficial effects of oxygen blender during cardiopulmonary bypass in reducing lactate levels in patients undergoing open-heart surgery

Serum lactate levels rise during Cardio-Pulmonary Bypass (CPB) surgery for a variety of reasons, including peripheral circulatory failure, haemodilution, or excessive use of inotropic agents. Additionally, it has been reported that elevated serum lactate levels during the perioperative period are strongly associated with the worst postoperative outcomes, including mortality.To find out the beneficial effects of an oxygen blender during cardiopulmonary bypass in reducing lactate levels in patients undergoing open-heart surgery.This Prospective comparative study was done on 150 patients who underwent open-heart surgeries. Patients were divided into group A-75 patients: with direct oxygen flow without oxygen blender, group B- 75 patients: with oxygen blender. The serum lactate levels during CPB, postoperative levels and outcomes were monitored and both the groups were compared.Average FIO2 of 38 % was enough to maintain PO2 of 168 mm Hg by using the oxygen blender with the flow rates. Group A showed severe hyperoxemia (p-value &amp;#60;0.0001) and hypocarbia, resulting in severe respiratory alkalosis during CPB and severe acidosis in the immediate postoperative period in most of the cases. Group B showed a significant reduction in the serum lactate value at CPB one hour with 3.1 mmol/l reductions, 3.8 mmol/L reductions at 2 hours and 4.4 mmol/L reductions at ICU arrival (p-value &amp;#60;0.0001).Serum lactate values reduced significantly in the patients with oxygen blender. Study proved that application of an oxygen blender during CPB improved the postoperative results following open-heart surgeries. The researchers conclude that using an oxygen mask was beneficial.

Elevated venous lactate level as an early predictive marker of organ failure in acute pancreatitis: a retrospective study.

The aim of this study was to elucidate the relationship between venous lactate levels and the severity of acute pancreatitis (AP). Retrospective data analysis was conducted on patients diagnosed with acute pancreatitis. The comparative assessment encompassed baseline characteristics, laboratory data, illness severity, local consequences, and organ failure instances. This comparison was performed between patients exhibiting normal serum lactic acid levels (HL) and those displaying elevated HL levels. The association between serum HL levels and other pertinent clinical markers was investigated using linear regression. Logistic regression analysis was employed to evaluate the utility of elevated serum lactate levels in identifying high-risk groups. Significantly elevated serum HL levels were observed in patients with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) in contrast to those with mild acute pancreatitis (MAP) (p<0.01). Multivariate logistic analysis demonstrated that higher lactate levels independently predicted organ failure (95% CI 0.738-0.902, p<0.05). Receiver operating characteristic (ROC) curve analysis indicated that the lactate (LAC) cut-off value of 2.45 mmol/L yielded sensitivity and specificity values of 76.5% and 79.1%, respectively, for predicting AP-associated organ failure. The corresponding area under the curve (AUC) was 0.820. In AP patients, elevated serum HL levels signify disease severity and hold predictive potential for assessing the risk of organ failure.

Case 321: Leigh Syndrome.

A 9-month-old preterm male infant born at 33 weeks gestation presented with a 2-month history of developmental decline. The parents reported that over the past several months, they noted regression of milestones, where the infant stopped smiling, crying, expressing himself, or making eye contact. The parents also reported that the infant had multiple seizures during which he would wake up stiff and stare into space for 10-20 seconds while his lips would become blue. The parents were referred to a neurologist, where physical examination was notable for hypotonia. Electroencephalography (EEG) revealed frequent bilateral parietal epileptiform discharges. The patient was subsequently started on lacosamide. The patient's medical history was notable for abnormally low citrulline levels at birth, with negative results of urea cycle disorder testing at the time, along with left inguinal hernia repair performed 3 months ago. More recent laboratory analysis had shown persistently elevated serum lactate and alanine levels. There was no history of travel, recent infection, or vaccine administration. MRI of the brain with spectroscopy was performed for further evaluation.

Clinical significance of serum lactate and lactate dehydrogenase levels for disease severity and clinical outcomes in patients with colorectal cancer admitted to the intensive care unit

ObjectiveSerum lactate (LA) and lactate dehydrogenase (LDH) levels have a major impact on the clinical treatment of malignant tumors and critically ill patients. Nevertheless, the assessment of disease severity in oncology patients admitted to the intensive care unit (ICU) remains incomplete when considering the serum LA and LDH levels. This study aimed to investigate the significance of serum LDH and LA levels in assessing disease severity and predicting clinical outcomes in patients with colorectal cancer (CRC) admitted to the ICU. MethodsThis retrospective study included patients with CRC who were admitted to the ICU between January 2017 and December 2022. The patients were divided into three groups based on the tumor treatment methods they had received within 3 months before ICU admission: post-chemotherapy group, post-surgery group, and palliative treatment group. The association between serum LA and LDH levels and disease severity and clinical outcomes was analyzed. ResultsOf 137 patients with CRC admitted to the ICU were finally studied. Patients in the post-chemotherapy group exhibited higher serum LA and LDH levels compared to those in the other two groups. Additionally, they had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, longer ICU length of stay, and a higher 30-day mortality. We found a significant positive correlation between serum LA levels and APACHE II scores as well as ICU length of stay and 30-day mortality. In contrast, we only observed a significant positive correlation between serum LDH levels and disease severity in the post-chemotherapy group, whereas no significant correlation between LDH levels and 30-day mortality in any of the three groups. ConclusionOur study concludes that elevated serum LA levels, rather than LDH levels, are more effective in assessing disease severity and could be used as predictors for clinical outcomes in patients with CRC admitted to the ICU.

Correlation between Persistent Serum Lactate Elevation and Brain Magnetic Resonance Imaging Abnormalities in Children with Status Epilepticus

Purpose: This study was conducted to evaluate the correlation between persistent serum lactate elevation and brain magnetic resonance imaging (MRI) in children with status epilepticus (SE). Methods: In this prospective analytical study, serum lactate levels were measured 24 hours after episodes of SE, and brain MRI was performed within 7 to 14 days after SE termination. MRI abnormalities were classified as acute encephalopathy (AE) grade I to III. The Kruskal-Wallis test was utilized for statistical analysis. Results: The study included 42 participants with SE, of whom 85.70% were boys, with a mean age of 4.94 years. Viral encephalitis was the most common diagnosis, accounting for 47.60% of cases. Elevated serum lactate levels were detected in 71.40% of patients, and approximately 47.60% exhibited abnormal MRI findings consistent with AE grade I. The median serum lactate levels for AE grades I, II, and III were 1.50, 3.10, and 0.78 mmol/L, respectively. Two patients died, and 66.70% experienced neurologic sequelae. A significant correlation (&lt;i&gt;P&lt;/i&gt;=0.021) was observed between persistent serum lactate elevation and abnormal brain MRI findings. Conclusion: In children with SE, AE grade I was the most common neuroimaging pattern observed, and persistently elevated serum lactate level was correlated with abnormal brain MRI findings.

Case 321.

A 9-month-old preterm male infant born at 33 weeks gestation presented with a 2-month history of developmental decline. The parents reported that over the past several months, they noted regression of milestones, where the infant stopped smiling, crying, expressing himself, or making eye contact. The parents also reported that the infant had multiple seizures during which he would wake up stiff and stare into space for 10-20 seconds while his lips would become blue. The parents were referred to a neurologist, where physical examination was notable for hypotonia. Electroencephalography (EEG) revealed frequent bilateral parietal epileptiform discharges. The patient was subsequently started on lacosamide. The patient's medical history was notable for abnormally low citrulline levels at birth, with negative results of urea cycle disorder testing at the time, along with left inguinal hernia repair performed 3 months ago. More recent laboratory analysis had shown persistently elevated serum lactate and alanine levels. There was no history of travel, recent infection, or vaccine administration. MRI of the brain with spectroscopy was performed for further evaluation (Figs 1-6).

Study of predictors of low cardiac output syndrome after cardiac valve surgery

Objective: Low cardiac output syndrome (LCOS) is defined as a decrease in cardiac index (CI) &lt;2.0L/min/m2 and systolic blood pressure &lt;90mmHg, accompanied by signs of a tissue hypoperfusion (cool peripheries, clammy skin, altered mental status, reduced urine output, elevated serum lactate levels) and the need for medication or mechanical circulatory support to improve hemodynamics [4,7]. LCOS is one of the serious complications after open cardiac surgery with a rate of 2-14% depending on the patient and the risk of death increases 12-25 times [3]. Besides modern equipment, early detection and timely treatment reduce mortality as well as increase myocardial recovery. LCOS prognostic factors play an important role. The aim of this study is to identify the prognostic signs of LCOS after valvular surgery.&#x0D; Subjects and methods: A cross-sectional descriptive study on patients undergoing valvular heart surgery at the Cardiovascular Anesthesiology Department - Cardiovascular Center - Hue Central Hospital from February 2022 to July 2022. LCOS is the dependent variable and the independent variable was divided into three groups before surgery, during surgery and after surgery. The data were processed by software R4.2.2. Using univariate logistic regression to identify independent prognostic factors. &#x0D; Results: A study on 60 patients after heart valve surgery showed that: LCOS after heart valve surgery has a rate of 28.3% with an average time of 5.88 hours after surgery. Through univariate logistic regression analysis, the results found independent prognostic factors including: EF &lt;=40% at preoperative time points (OR=12.9, 95%CI 1.73 – 26.5), EF 0h (OR) =2.3, 95%CI 2.4-8.9), EF 4h (OR=2.9, 95%CI 1.9-6.7), EF 24h (OR=1.9, 95%CI 1.5-9.5), lactate at 0h postoperative time (OR=1.81, 95%CI 1.25-2.8), 4h (OR=1.41, 95%CI 1.13-1.85), 8h (OR=1.38, 95%CI 1.14-1.73), 12h (OR=1.35, 95%CI 1.11-1.72), creatinine at 24 h after surgery (OR=1.02, 95%CI 1.01-1.04), time to extracorporeal circulation (OR=1.02, 95%CI 1.02-1.04), time to clamp aorta (OR=1.2, 95%CI 1.1-1.2).[1]&#x0D; Conclusion: Low cardiac output syndrome is one of the serious complications after heart valve surgery, early detection and timely treatment reduce the risk of death for patients. The study showed that many factors before, during and after surgery are independent prognostic factors for LCOS after surgery.

Experience of surgical treatments for abdominal inferior vena cava injuries in a regional trauma center in Korea

Purpose: Inferior vena cava (IVC) injuries are a rare type of traumatic abdominal injuries that are challenging to treat and have a very high mortality rate. This study described our experience with the surgical treatment of traumatic IVC injuries, and we investigated the demographics, clinical profiles, and surgical outcomes of cases at a regional trauma center.Methods: Among the 16 patients who were treated for a traumatic IVC injury between January 2014 and March 2022, 14 underwent surgery. The surgical outcomes included overall mortality and 24-hour mortality, and we investigated the factors associated with these surgical outcomes. The 14 patients were divided into two groups according to the location of the IVC injury (retrohepatic IVC or higher vs. subhepatic IVC), and differences between the two groups were analyzed. Results: A body mass index (BMI) &gt;23.0 kg/m2 (P=0.046), an elevated serum lactate level (P=0.043), and a shorter operation time (P=0.016) were associated with overall mortality. A higher BMI (P=0.050), high serum lactate level (P=0.004), shorter operation time (P=0.005), and an injury at the retrohepatic IVC or higher level (P=0.031) were associated with 24-hour mortality. Younger age (P=0.028), higher BMI (P=0.005), an acidic pH (P=0.028), high lactatemia (P=0.012), a higher hemoglobin level (P=0.012), and shorter door-to-operating room time (P=0.028) were associated with injury at the retrohepatic IVC or higher level. Patients with subhepatic IVC injuries had a high rate of direct repair (75.0%) and a significantly lower 24-hour mortality rate (37.5%, P=0.031).Conclusions: Subhepatic IVC injuries are easy to access and are usually treated with a direct repair method. Injuries at the retrohepatic IVC or higher level are difficult to treat surgically and require a systematic and multidisciplinary treatment strategy.

A STUDY OF THIAMINE DEFICIENCY IN PATIENTS WITH ACUTE ONSETENCEPHALOPATHY

Introduction:Vitamin B1, also known as thiamine, and its crucial role in energy metabolism and proper functioning of the nervous and cardiovascular systems. Thiamine is an essential vitamin that must be obtained through diet since the body does not produce it naturally. It is stored in the liver but only lasts for about 18 days. Thiamine is absorbed in the duodenum and transported across the blood-brain barrier. The recommended daily intake varies based on age, health condition, and life stages.Thiamine plays a vital role in various biochemical pathways in the brain, including energy production, lipid metabolism, neurotransmitter synthesis, and synaptic transmission. Thiamine deficiency can have diverse clinical effects, affecting the nervous and cardiovascular systems most severely and potentially leading to death if left untreated.Different thiamine deficiency syndromes are identified, including dry beriberi (peripheral neurologic manifestations), wet beriberi (cardiac effects), gastrointestinal beriberi (digestive symptoms), and Wernickes encephalopathy (neuropsychiatric condition). While alcohol abuse-associated malnutrition is a common cause of Wernickes encephalopathy in developed countries, it can also occur due to other factors such as decreased thiamine absorption, increased body requirements, or thiamine loss in certain medical conditions.Thiamine deficiency is considered a potential public health concern, particularly in communities in South Asia and West Africa, where diets heavily reliant on polished rice or cassava may contribute to the risk. Studies have shown varying prevalence rates of thiamine deficiency in different populations, including healthy adults and pregnant/lactating mothers in South-East Asia and India. While specific population-based studies are lacking in the Kashmiri population, preliminary evidence suggests the presence of thiamine deficiency disorders in infants, peripartum females, and adults with diverse presentations. Objectives: Early detection and treatment of Patients with Encephalopathy related to Thiamine deficiency Study Design/ Methodology:The study was hospital-based and prospective in nature, conducted in the Department of General Medicine, SMHS, GMC - Srinagar from May 2021 to September 2022. The study was done on patients aged more than 18 years of age attending emergency department of Government Medical College, Srinagar with acute onset encephalopathy. Observations And Results:In this study, 96 patients with acute onset encephalopathy were recruited based on CAM score criteria. The patients were divided into two groups: a low thiamine group and a normal thiamine group, based on their whole-blood thiamine levels. Among the patients, 15.6% had normal thiamine levels, while 84.4% had low thiamine levels. The mean thiamine level in the normal thiamine group was 5.46±4.44 ug/dL, and in the low thiamine group, it was 1.35±0.42 ug/dL (p=0.0001). Patients with normal thiamine levels were excluded from further analysis, leaving a group of 84.4% of patients with thiamine deficiency.Within the thiamine deficiency group, patients were further divided into responders and non-responders based on their response to a thiamine challenge. The responders group comprised 17 patients, including 11 males, 6 females (including 3 pregnant females), with a mean age of 36.25±9.44. Non-responders had a mean age of 61.8±15. Among responders, 70.58% had recurrent vomiting compared to 37.5% in non-responders. Confusion was the most common initial presentation in both groups, followed by lethargy. Behavioural changes were seen in a higher percentage of responders compared to non-responders. Ataxia was more prevalent in the responders group.Various laboratory parameters were analyzed between responders and non-responders. There was no significant difference in mean pH, sodium, potassium, total protein, serum albumin, and blood sugar levels between the two groups. However, lactate levels and the drop in lactate following thiamine therapy were higher in responders. Responders had lower levels of serum urea and serum creatinine compared to non-responders.MRI brain findings suggestive of Wernickes encephalopathy were observed in 53% of responders. Polished rice consumption was common among all patients, with 85% of responders and 62% of non-responders consuming polished rice as their main staple diet. Traditional salt tea intake was also prevalent in both groups. Conclusions: Thiamine deficiency can manifest in various clinical scenarios, including recurrent vomiting, hypoxia, electrolyte imbalances (such as hyponatremia and hypernatremia), and systemic diseases like uremia, hepatic encephalopathy, and septic shock. Pregnant women, who experience increased demand and may have thiamine loss due to vomiting, are also at risk of developing thiamine deficiency.The diagnosis of thiamine deficiency is primarily clinical and is confirmed by the response of neurological signs to high-dose intravenous thiamine treatment. MRI is considered the most valuable paraclinical study for diagnosis. Elevated serum lactate levels and the response of lactate to high-dose parenteral thiamine can serve as surrogate markers for thiamine-responsive encephalopathy. It is crucial to administer high doses of parenteral thiamine immediately to patients suspected of having encephalopathy due to thiamine deficiency to prevent complications associated with Wernicke-Korsakoff syndrome.

Impact of Serum Lactate as an Early Serum Biomarker for Cardiopulmonary Parameters within the First 24 Hours of Intensive Care Unit Treatment in Patients with Isolated Traumatic Brain Injury.

Cardiopulmonary (CP) complications are well-known phenomena in patients with isolated traumatic brain injury (iTBI) that can lead to tissue hypoperfusion and hypoxia. Serum lactate level is a well-known biomarker, indicating these systemic dysregulations in various diseases, but this has not been investigated in iTBI patients so far. The current study evaluates the association between serum lactate levels upon admission and CP parameters within the first 24 h of intensive care unit (ICU) treatment in iTBI patients. 182 patients with iTBI who were admitted to our neurosurgical ICU between December 2014 and December 2016 were retrospectively evaluated. Serum lactate levels on admission, demographic, medical, and radiological data upon admission, as well as several CP parameters within the first 24 h of ICU treatment, were analyzed, as well as the functional outcome at discharge. The total study population was dichotomized into patients with an elevated serum lactate level (lactate-positive) and patients with a low serum lactate level (lactate-negative) upon admission. 69 patients (37.9%) had an elevated serum lactate level upon admission, which was significantly associated with a lower Glasgow Coma Scale score (p = 0.04), a higher head AIS score (p = 0.03), and a higher Acute Physiology and Chronic Health Evaluation II score (p = 0.01) upon admission, as well as a higher modified Rankin Scale score (p = 0.002) and a lower Glasgow Outcome Scale score (p < 0.0001) at discharge. Furthermore, the lactate-positive group required a significantly higher norepinephrine application rate (NAR; p = 0.04) and a higher fraction of inspired oxygen (FiO2; p = 0.04) to maintain the defined CP parameters within the first 24 h. ICU-admitted iTBI patients with elevated serum lactate levels upon admission required higher CP support within the first 24 h of ICU treatment after iTBI. Serum lactate may be a helpful biomarker for improving ICU treatment in the early stages.

Involvement of Vasopressin in Tissue Hypoperfusion during Cardiogenic Shock Complicating Acute Myocardial Infarction in Rats

Acute heart failure (AHF) due to acute myocardial infarction (AMI) is likely to involve cardiogenic shock (CS), with neuro-hormonal activation. A relationship between AHF, CS and vasopressin response is suspected. This study aimed to investigate the implication of vasopressin on hemodynamic parameters and tissue perfusion at the early phase of CS complicating AMI. Experiments were performed on male Wistar rats submitted or not to left coronary artery ligation (AMI and Sham). Six groups were studied Sham and AMI treated or not with either a vasopressin antagonist SR-49059 (Sham-SR, AMI-SR) or agonist terlipressin (Sham-TLP, AMI-TLP). Animals were sacrificed one day after surgery (D1) and after hemodynamic parameters determination. Vascular responses to vasopressin were evaluated, ex vivo, on aorta. AHF was defined by a left ventricular ejection fraction below 40%. CS was defined by AHF plus tissue hypoperfusion evidenced by elevated serum lactate level or low mesenteric oxygen saturation (SmO2) at D1. Mortality rates were 40% in AMI, 0% in AMI-SR and 33% in AMI-TLP. Immediately after surgery, a sharp decrease in SmO2 was observed in all groups. At D1, SmO2 recovered in Sham and in SR-treated animals while it remained low in AMI and further decreased in TLP-treated groups. The incidence of CS among AHF animals was 72% in AMI or AMI-TLP while it was reduced to 25% in AMI-SR. Plasma copeptin level was increased by AMI. Maximal contractile response to vasopressin was decreased in AMI (32%) as in TLP- and SR- treated groups regardless of ligation. Increased vasopressin secretion occurring in the early phase of AMI may be responsible of mesenteric hypoperfusion resulting in tissue hypoxia. Treatment with a vasopressin antagonist enhanced mesenteric perfusion and improve survival. This could be an interesting therapeutic strategy to prevent progression to cardiogenic shock.

Clinical Spectrum of Biopsy Proven Mitochondrial Myopathy.

Clinical spectrum of mitochondrial myopathy extends beyond chronic progressive external ophthalmoplegia (CPEO). While information on encephalomyopathies is abundant, clinical data on predominant myopathic presentation of mitochondrial disorders are lacking. Clinical, electrophysiological, biochemical, and follow-up data of patients with predominant myopathic presentation and muscle biopsy confirmed primary mitochondrial myopathy was obtained. We excluded known syndromes of mitochondrial cytopathies and encephalomyopathies. Among 16 patients, 7 had CPEO, 4 had CPEO with limb-girdle muscle weakness (LGMW), and 5 had isolated LGMW. Systemic features included seizures with photosensitivity (n = 3), diabetes (n = 1), cardiomyopathy (n = 1), and sensorineural hearing loss (n = 1) and were more common in isolated LGMW. Elevated serum creatine kinase (CK) and lactate levels and electromyography (EMG) myopathic potentials were more frequent with LGMW. During follow-up, LGMW had more severe progression of weakness. We identified three subsets of mitochondrial myopathy with distinct clinical features and evolutionary patterns. Isolated LGMW was seen in 30% of patients and would represent severe end of the spectrum.

Role of serum lactate as prognostic marker of mortality among emergency department patients with multiple conditions: A systematic review.

In the Emergency Department, the physician's purpose is to rapidly and accurately diagnose the severity of a patient's condition so that proper treatment can be administered. Therefore, this study pays close attention to the association and prognostic value of blood lactate on different disease outcomes by systematically reviewing recently published studies. The search strategy was developed based on searches in the year 2022 for potential publications including original articles, case reports, and reviews using the following web databases google scholar, PubMed, and Science Direct. A total of 25 studies were identified and reviewed extensively to evaluate the link between mortality and serum lactate levels. This literature review presents the strong association of elevated serum lactate levels with the in-hospital mortality rate among emergency department patients. These findings suggest that even a moderately raised lactate level in serum can predict the severe outcome in emergency department patients suffering from different conditions. Therefore, early (at the time of administration of hospital) and periodic serum lactate value determination through different techniques and scores is of need and should become part of routine analyses in emergency department to predict and choose therapies that could benefit critically ill patients.

Broad ligament hernia: A rare condition causing small bowel obstruction

Dear Editor, Small bowel obstruction (SBO) is a condition characterized by intraluminal flow blockage caused by several etiologies. Postlaparotomy adhesion, incarcerated hernia, and neoplasm are the top 3 causes of SBO. Internal herniation, though rare, accounts for approximately 1% of SBO. Broad ligament hernia is an even more unusual form of internal herniation, reported in 4%–5% of internal herniation cases. Here, we report a case of broad ligament herniation, leading to strangulated SBO. A 68-year-old multiparity woman without history of abdominal surgery presented to the emergency department with acute onset of lower abdominal pain. The pain was intermittent, colicky, located on the infraumbilical region, lasting for 6 hours before she sought medical attention, and did not respond to analgesics. At triage, vital signs were relatively stable, except blood pressure of 188/81 mm Hg. Physical examination showed tenderness over the left lower quadrant and hypoactive bowel sound. Hemogram, liver function, and renal function were within normal limits, except for a slightly elevated serum lactate level of 13.2 mg/dL. Supine kidney, ureter, and bladder radiograph showed a mildly dilated bowel loop. The initial impression was ileus, and she was kept on bowel rest with intravenous fluid repletion after an enema. After 24 hours of medical treatment, her symptoms persisted with several vomiting bouts. Muscle guarding over the left lower quadrant of abdomen was noted. Contrast-enhanced computed tomography showed disclosing diffuse loop dilatation of the small intestine with the transitional zone in the pelvic region and a moderate amount of ascites. Under the impression of SBO, she underwent emergent exploratory laparotomy. Internal herniation of the small intestine into a 3-cm defect in the left broad ligament was found, resulting in strangulation of the small bowel measured approximately 40 cm in length. The nonviable segment of the small intestine was resected and anastomosed via hand-sewn method. In addition, the defect of the left broad ligament was repaired, and the right-sided broad ligament was examined as well. The patient had an uneventful postoperative recovery and was discharged on postoperative day 9. There are several classification systems regarding broad ligament herniation, which is summarized in Supplementary Data, https://links.lww.com/FJSS/A4. Computed tomography is the imaging modality of choice. Mechanical SBO with double transitional zone, bowel loops herniated beside the uterus with slight deviation of uterus to the contralateral side, enlargement of the distance between the uterus and one of the ovaries, and presence of free fluid in the pelvis would lead to suspicion of broad ligament herniation.[1] A standard therapeutic intervention has not yet been established.[2] Diagnostic laparoscopy could be performed if the preoperative diagnosis is uncertain. Once the broad ligament defect with internal herniation has been found, it can be managed with the laparoscopic approach. However, laparoscopic surgery is contraindicated in the following situations: when the diameter of small bowel is greater than 4 cm, there is evidence of bowel ischemia, history of severe adhesion, or presence of inflammatory bowel disease.[3] In conclusion, broad ligament hernia should be considered one of the differential diagnoses in a multiparity woman without previous surgical history, presenting with SBO. Early diagnosis and timely surgical intervention may reduce the likelihood of morbidity and mortality.

Milrinone for treatment of elevated lactate in the pre-operative newborn with hypoplastic left heart syndrome.

There is a paucity of information reported regarding the use of milrinone in patients with hypoplastic left heart syndrome prior to the Norwood procedure. At our institution, milrinone is initiated in the pre-operative setting when over-circulation and elevated serum lactate levels develop. We aimed to review the responses associated with the administration of milrinone in the pre-operative hypoplastic left heart syndrome patient. Second, we compared patients who received high- versus low-dose milrinone prior to Norwood procedure. Single-centre retrospective study of patients diagnosed with hypoplastic left heart syndrome between January 2000 and December 2019 who underwent Norwood procedure. Patient characteristics and outcomes were compared. During the study period, 375 patients were identified; 79 (21%) received milrinone prior to the Norwood procedure with median lactate 2.55 mmol/l, and SpO2 93%. Patients who received milrinone were older at the time of Norwood procedure (6 vs. 5 days) and were more likely to be intubated and sedated. In a subset analysis stratifying patients to low- versus high-dose milrinone, median lactate decreased from time of initiation (2.39 vs 2.75 to 1.6 vs 1.8 mmol/l) at 12 hours post-initiation, respectively. Repeated measures analysis showed a significant decrease in lactate levels by 4 hours following initiation of milrinone, that persisted over time, with no significant difference in mean arterial pressure. The use of milrinone in the pre-operative over-circulated hypoplastic left heart syndrome patient is well tolerated, is associated with decreased lactate levels, and was not associated with significant hypotension or worsening of excess pulmonary blood flow.

A Young Man With Epigastric Abdominal Pain

A Young Man With Epigastric Abdominal Pain

Relationship Between the Anion Gap and Serum Lactate in Hypovolemic Shock.

Background and objectives: Previous studies evaluating patients in the Intensive Care Unit with established lactic acidosis determined that the anion gap is an insensitive screening tool for elevated blood lactate. No prior study has examined the relationship between anion gap and serum lactate within the first hours of the development of lactic acidosis. Design, setting, participants, & measurements: Data were obtained prospectively from a convenience sample of adult trauma patients at a single level 1 trauma center. Venous samples were drawn prior to initiation of intravenous fluid resuscitation. A linear regression model was constructed to assess the relationship between serum lactate and anion gap, and 95% prediction intervals were computed. Logistic regression models were constructed to determine the sensitivity and specificity for several different anion gap and lactate cutpoints. Results: 128 patients with elevated serum lactate levels (>2.1 mmol/L) and 63 patients with normal serum lactate levels (< 2.1 mmol/L) were included. The sensitivity of an elevated anion gap (> 10) to reveal hyperlactatemia was only 43% whereas specificity was 84%. Sensitivity improved if the upper limit of normal anion gap was lowered and with increasing levels of serum lactate. The coefficient of determination between serum lactate level and AG yielded an R2 of 0.30 (p < 0.001) and the slope of this relationship was 2.185 with a 95% confidence interval of 2.011-2.359. The mean 95% prediction interval was + 8.9. Conclusions: Within the first hour of the development of lactic acidosis due to hypovolemic shock, the anion gap was not a sensitive indicator of an elevated serum lactate level, but it was fairly specific. The anion gap increased to a greater extent than the serum lactate, the 95% mean prediction interval was wide and approximately 70% of the change in anion gap could not be explained by increases in serum lactate, suggesting that other anions contribute to the anion gap in lactic acidosis.

Elevated Serum Lactate in Glioma Patients: Associated Factors.

IntroductionSerum lactate levels in brain cancer patients correlate with tumor malignancy grading, and serum lactate has been suggested as a potential biomarker and prognostic factor. The purpose of this study was to identify potential sources of elevated serum lactate in patients with brain gliomas by examining factors of importance for serum lactate production and clearance.MethodsIn this cross-sectional study, data were collected from 261 glioma patients who underwent surgery from March 2011 to June 2015. We recorded patient gender, age, blood serum measures of lactate, glucose, pH, hemoglobin and base excess, patient health status, medications, and tumor characteristics. Patients with elevated and normal serum lactate levels were compared, and we explored if there were correlations between the variables. The association of serum lactate with the measured variables was investigated by simple and multivariable linear regression models.Results and DiscussionPatients with elevated serum lactate had higher blood glucose, larger tumor volumes, and more tumor edema; more often needed pressor medication during surgery; and more often received corticosteroid treatment. The investigated variables were highly correlated. Multivariable linear regression indicated that gender, tumor volume, Charlson Comorbidity Index, hyperglycemia, and corticosteroid treatment were associated with serum lactate levels. Histopathology was not an independent factor. In conclusion, comorbidities, hyperglycemia, and presurgical corticosteroid treatment exhibited the strongest association with serum lactate in glioma patients.