Postoperative Lactate Research Articles

The prognostic value of peak arterial lactate levels within 72 h of lung transplantation in identifying patient outcome

BackgroundLactic acidosis is often seen in lung transplantation (LTx). Postoperative lactate is frequently associated with poor outcome in postoperative and critically ill patients. Our aim was to evaluate the predictive value of postoperative peak lactate levels within 72 h of LTx for 30-day and late mortality.MethodsWe evaluated patients who underwent LTx from January 2015 to September 2017. All admitted patients were classified according to the peak lactate level (PL) within 72 h of surgery: PL <5 mmol/L (Group 1); PL =5–10 mmol/L (Group 2), and PL >10 mmol/L (Group 3). We performed logistic regression analysis and used Cox regression models to identify the peak lactate level as a predictive factor for 30-day and late mortality, respectively.ResultsOf 255 eligible patients, mean age 55.61±12.16, mean lactate 4.99±2.93 and 80% male, and 40% had hyperlactatemia (PL >5 mmol/L) after LTx. The 30-day mortality rate was 17.9%, 28.9% and 68.8% in the three groups, respectively (P<0.05). Multivariate regression analyses revealed postoperative PL as a notable predictor of 30-day mortality [odds ratio =2.62 (1.42–4.84), P=0.002] as well as for late mortality [hazard ratio =2.70 (1.13–6.42), P=0.025].ConclusionsThe postoperative peak lactate level within 72 h of surgery was an independent predictor for 30-day and late mortality in LTx patients.

Abstract 13400: Patients Less Than or Equal to 2.5kg Have Higher Morbidity and Mortality After Norwood-sano Palliation

Introduction: In patients with single ventricle heart disease, prematurity and low weight at the Norwood operation are risk factors for mortality. Reports assessing peri-operative and long-term outcomes of Norwood palliation in patients ≤ 2.5kg are limited. Methods: All patients who underwent Norwood-Sano procedure between 2005-2020 were identified. Patients ≤ 2.5kg at the time of the Norwood operation (cases) were matched 1:3 with patients ≥ 3.0 kg (comparisons) for year of surgery and cardiac diagnosis. Demographic and peri-operative characteristics, survival to hospital discharge and 2-year neurodevelopmental outcomes were compared. Results: Twenty-seven cases (mean±SD weight 2.2±0.3 kg, mean age 15.6±14.1 days at surgery) and 81 comparisons (mean weight 3.5±0.4 kg, mean age 10.9±7.9 days at surgery) were identified. There was no statistically significant difference in the presence of chromosomal abnormalities (7.4% vs. 12.3%, p=0.485), prenatal diagnosis made (88.9% vs. 75.3%, p=0.141), or duration of cardiopulmonary bypass (140.7±65.6 vs. 121.3±42.3 min, p=0.068) between cases and comparisons, respectively. Cases had a longer time to post-operative lactate &lt; 2 mmol/L (33.1±27.5 vs. 17.9±12.2 hours, p&lt;0.001), longer duration of ventilation (30.5±24.5 vs. 18.6±17.5 days, p=0.005), higher need for dialysis (48.1% vs. 19.8%, p=0.007) and greater need for extracorporeal membrane oxygenation support (29.6% vs. 12.3%, p=0.004). Cases also had significantly higher in-hospital (25.9% vs. 1.2%, p&lt;0.001) and 2-year (59.2% vs. 11.1%, p&lt;0.001) mortality. The 2-year Bayley Scales of Infant and Toddler Development, III, was completed on all living cases (n=11) and most comparisons (n=63; 1 refusal and 8 too young); delay, a score of &lt; 70, showed the following differences between cases vs. comparisons for cognitive (86.9 vs. 91, p=0.363), language (84.9 vs. 88.2, p=0.494) and motor (73.6 vs. 87.3, p=0.013). Conclusions: Patients ≤ 2.5kg at the time of Norwood-Sano have significantly higher post-operative morbidity and mortality up to 2-year follow-up, and worse 2-year neurodevelopmental motor outcomes. Additional studies are warranted to assess the outcome of alternative therapeutic options in this patient population.

Peritonitis-associated hyperlactatemia for evaluating mortality in secondary peritonitis.

In sepsis, lactate measurements correlate with mortality; however, the role of lactate in predicting mortality in patients of secondary peritonitis is not yet fully established. Data were maintained prospectively on 224 patients of secondary peritonitis over a period of 10 years. Arterial lactate measurements were performed twice in each patient - once, initially on admission (ALI ) and the other, 24 h after surgery (AL24 ); from these values, percentage lactate clearance was calculated. These lactate indices and other demographic factors were correlated with mortality. Overall mortality was 16.07% (36 patients) and morbidity was 63.39% (pulmonary complications commonest); preoperative lactate (more than 2.35 mmol/L), 24-h postoperative lactate (more than 2.05 mmol/L), need for vasopressors and mechanical ventilation independently correlated with morbidity and mortality. A simple prognostic scale constructed using cut-off values of ALI , AL24 , need for vasopressor support and mechanical ventilation showed a sensitivity of 97.22% and specificity of 52.13% for predicting mortality. Preoperative and postoperative arterial lactate levels, need for vasopressors and mechanical ventilation, are independent predictors of mortality. Using these parameters, it may be possible to identify high risk patients that can benefit from early, goal directed therapy to reduce the mortality of secondary peritonitis.

Efficacy of Glyceryl trinitrate (GTN) to facilitate the rewarming process during cardiopulmonary bypass

BackgroundDoes Glyceryl trinitrate (GTN) administered during rewarming on cardiopulmonary bypass (CPB) impact: time to completion of rewarming prior to separation from CPB circuit, early post-op patient peripheral – core temperature gradient, time to maintenance of normothermia (core temperature > 36.5 °C) for minimum of 2 h in the initial post-op period, and plasma lactate concentrations initially post-CPB.MethodsSingle centre prospective randomized trial conducted in the Mater Misericordiae University teaching hospital in Dublin Ireland. Trial registration: ISRCTN registry, ISRCTN10480871, registered 16th of August 2017. 82 patients enrolled. Patients randomised to low dose GTN infusion (0.01 mcg/kg/min) or higher dose GTN infusion (0.5 mcg/kg/min) during rewarming on CPB.Measurements and Main resultsThere was no significant difference between the treatment arms for the total time to being rewarmed, U = 759.0, p = 0.84. There were also no differences between the treatment arms for the time to achieve core temperature greater than 36.5 after two hours, U = 714.0, p = 0.52, the time to achieve plateau core skin temperature, U = 688.0, p = 0.37, and the post-intervention protamine lactate, U = 721.0, p = 0.56.ConclusionsHigher dose GTN infusion during rewarming on CPB does not improve peripheral-core temperature gradient post operatively and has no effect on post-operative lactate concentrations.

Intravenous lidocaine to prevent endothelial dysfunction after major abdominal surgery: a randomized controlled pilot trial

BackgroundMajor abdominal surgery is associated with endothelial glycocalyx disruption. The anti-inflammatory effects of lidocaine were recently associated with endothelial barrier protection.MethodsThis was a single-centre, parallel group, randomized, controlled, double blind, pilot trial. Forty adult patients scheduled for major abdominal surgery were included between December 2016 and March 2017 in the setting of a University Hospital in Brussels (Belgium); reasons for non-inclusion were planned liver resection and conditions associated to increased risk of local anesthetics systemic toxicity. Patients were randomized to receive either lidocaine by continuous intravenous administration or an equivalent volume of 0.9% saline.The primary endpoint was the postoperative syndecan-1 concentration (difference between groups). Near-infrared spectroscopy of the thenar eminence in association with the vascular occlusion test, and contemporary analysis of flow-mediated dilation of the brachial artery were the secondary outcomes, along with haemodynamic data. Blood samples and data were collected before surgery (T0), and at 1–3 h (T1) and 24 h (T2) post-surgery.ResultsSyndecan-1 concentration increased significantly post-surgery (P < 0.001), but without any difference between groups. The near-infrared spectroscopy-derived and flow-mediated dilation-derived variables showed minor changes unrelated to group assignment. Compared with the placebo group, the intervention group had a significantly lower peri-operative mean arterial pressure and cardiac index, despite equally conducted goal-directed haemodynamic management. Postoperative lactate concentrations were similar between groups.ConclusionsLidocaine failed to have any effect on endothelial function. Since in comparisons to other types of clinical situations, syndecan-1 was only slightly upregulated, endothelial dysfunction after major abdominal surgery might be overestimated.Trial registration« ISRCTN Registry » identifier: ISRCTN63417725. Date: 15/06/2020. Retrospectively registered.

Renal resistive index as a predictor of postoperative complications in liver resection surgery. Observational study.

Mortality after liver surgery reduced during the last three decades to less than 2%, but post-operative morbidity occurs in 20-50% of cases. Patients are often considered eligible for post-operative intensive-care unit (ICU) admission. Predicting which patients that are at higher risk could lead to a more precise perioperative management. We investigated whether renal resistive index (RRI), alone or along with other items, can predict post-operative complication after hepatic resection. All consecutive patients undergoing hepatectomy for primary or metastatic neoplasm at our Institution between February 2015 and March 2017 were enrolled. They received RRI measurement before entering in operative room and after awakening from general anesthesia. 183 Patients were enrolled. High surgical invasiveness, surgery time > 360min, pre-operative RRI and postoperative serum lactate clearance < - 6%, showed to be associated with postoperative complications. Pre-operative RRI, complex liver resection, long-lasting surgery and poor lactate clearance (cLac) close to awakening from general anesthesia, all together may permit to classify the risk of post-operative adverse outcome after hepatic resection surgery.

Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery

Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores. Prospective, observational study. A single, tertiary university cardiovascular surgical intensive care unit. 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass. Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit. Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm2) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours. In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.

Value of Routine Flexible Sigmoidoscopy and Potential Predictive Factors for Colonic Ischemia after Open Ruptured Abdominal Aortic Aneurysm Repair.

Background and Objectives: colonic ischemia (CI) after ruptured abdominal aortic aneurysm (rAAA) repair is associated with increased morbidity and mortality. CI may be detected by using flexible sigmoidoscopy, but routine use of flexible sigmoidoscopy after rAAA is not clearly proven. The objective of this study was to evaluate the efficacy of routine flexible sigmoidoscopy in detecting CI after rAAA repair, and to identify potential hemodynamic, biochemical, and clinical variables that can predict the development of CI in the patients who underwent rAAA surgery. Materials and Methods: we retrospectively included all rAAA cases treated in Viborg hospital from 1 April 2014 until 31 August 2017, recorded the findings on flexible sigmoidoscopy, and the incidence of CI. We collected specific hemodynamic, biochemical, and clinical variables, measured pre- and perioperatively, and the first three postoperative days. The association between CI and possible predictors was analyzed in a logistic regression model. Results: a total of 80 patients underwent open rAAA repair during the study period. Flexible sigmoidoscopy was performed in 58 of 80 patients (73.5%) who survived at least 24 h after open rAAA surgery. Perioperative variables lowest arterial pH (p = 0.02) and types of operations—aortobifemoral bypass vs. straight graft (p = 0.04) showed statistically significant differences between CI groups. The analysis of the postoperative variables showed statistically significant difference in highest lactate on postoperative day 1 (p = 0.01), and lowest hemoglobin on postoperative day 2 (p = 0.04) comparing CI groups. Logistic regression model revealed that postoperative hemoglobin and lactate turned out to be independent risk factors for the development of CI (respectively OR = 0.44 (95% CI = 0.29–0.67) and OR = 1.91 (95% CI = 1.2–3.05)). Conclusions: flexible sigmoidoscopy can identify patients being at higher risk of mortality after open rAAA repair. The postoperative lactate and hemoglobin were found to be independent risk factors for the development of CI after open rAAA repair. Further larger studies are warranted to demonstrate these findings.

Postoperative Serum Lactate Levels for In-Hospital Mortality Prediction Among Heart Transplant Recipients.

BackgroundHyperlactatemia is a common phenomenon following cardiac surgeries and is associated with prolonged ICU stay and higher morbidity and mortality rates, but such analyses have never focused on patients undergoing heart transplantation (HTX), in whom hyperlactatemia defined with the traditional threshold is observed in nearly every individual. The present study aimed to assess the prognostic value and clinical usefulness of postoperative serum lactate level measurements for in-hospital mortality prediction following HTX.Material/MethodsForty-six consecutive patients who underwent HTX in the Department of Cardiovascular Surgery and Transplantology between 2010 and 2015 were enrolled into a retrospective analysis. Serum lactate level measurements within the first 48 h after HTX were obtained from arterial blood gas analyses, that were routinely conducted every 6 h. Lactate clearance was determined for each patient individually throughout 3 different time frames: the first 24-h (Lac clear 0–24) and second 24-h period (Lac clear 24–48), and the first 48 h after surgery (Lac clear 0–48).ResultsThe ICU admission serum lactate levels differed between the deceased and survivors (7.6 vs. 4.3 mmol/L; p=0.000). Among all tested postoperative lactate level measurements, only the measurement taken upon ICU admission predicted in-hospital mortality (OR 1.94 95% CI [1.09–3.43]; p=0.024). The receiving operating characteristic (ROC) curve for in-hospital mortality was constructed for ICU admission measurement, with the optimal cut-off point estimated at 7.0 mmol/L.ConclusionsSerum lactate level measurement upon ICU admission can be used as a predictive parameter for in-hospital mortality among heart transplant recipients. Values greater than 7.0 mmol/L can predict in-hospital mortality with 90% accuracy.

Negative Outcomes Associated with Reoperative Sternotomy and LVAD Explantation at the Time of Cardiac Transplantation

The number of heart transplants that require a reoperative sternotomy has increased dramatically with the growing utilization of LVADs. A reoperative surgical field complicates the recipient cardiectomy. The objective of this study was to evaluate the effect of reoperative sternotomy and LVAD explantation on the duration of surgery, the physiologic impact to the patient, and transfusion requirements. This study is a single institution, retrospective review of all adult heart transplants between January 2013 and August 2018. Patients were excluded if they underwent a multi-organ transplant. Eligible patients were divided into three groups: non-reoperative, non-LVAD reoperative sternotomy, and LVAD explantation. The physiologic effect on the patient was estimated by the peak postoperative lactate level. During the study period, 174 adult heart transplants were performed. Twenty-two patients met exclusion criteria and the final cohort included 152 patients. The average age was 54 ± 12 years. The non-LVAD reoperative sternotomy group included 32 patients (21.0%) patients and 39 (25.7%) were in the LVAD explantation group. The results are summarized in Table 1. Patient outcomes were negatively affected by reoperative sternotomy in regards to duration of operative times, intra- and post operative blood product requirements, and physiologic stress as indicated by lactate levels. When compared to other patients undergoing a reopeartive sternotomy, those with an LVAD had longer operative times and larger intraoperative blood product requirements. This study illustrates a negative impact of reoperative sternotomy and LVAD explanation on the heart transplant procedure itself and the consequences for the patient. The growing use of LVADs as a bridge to transplant will continue to increase the number of patients undergoing reoperative sternotomies. This study supports the development of less invasive devices for use as a bridge to transplant.

Prognostic Implication of Longitudinal and Peak Lactate Levels after LVAD Implantation

Serial measurements of lactate levels are commonly performed after LVAD implantation, but the prognostic implications have not been well studied. The objective of this study is to evaluate the association of lactic acid levels with in-hospital mortality, after LVAD implantation. We retrospectively identified all patients at our Institution who underwent implantation of a durable LVAD between 1/1/2009 and 12/1/2018 and had lactate levels recorded in the immediate 48-hour postoperative period (n=507). We excluded patients who received biventricular mechanical support (N=19). Baseline characteristics were compared using T-test/Wilcoxon rank-sum test and Chi squared test. Multivariable logistic regression was used to assess peak-lactate levels between those who were discharge alive after index LVAD implant hospitalization (S-group) vs. those who died during the index hospitalization (M-group). A total of 488 patients were included in the analysis. The baseline characteristics of the S-group (N=432) and the M-group (N=56) are compared in the Table. The two groups had similar preimplant lactate levels (1.1 [0.9-1.4] vs. 1.0 [0.9-1.3] mmol/L, p=0.72). However, peak lactate levels were significantly lower in the S-group compared to the M-group (2.8 [2.0-4.2] vs. 4.6 [2.8-6.9] mmol/L, p<0.0001). Furthermore, the time to peak lactate was significantly lower in the S-group compared to the M-group (4.9 [3.1-9.8] vs. 9.2 [4.4-21.8] hours, p<0.0001). After adjusting for age, sex, BMI, race, LVAD type, INTERMACS profile and ischemic cardiomyopathy, peak lactate was significantly associated with mortality during the index admission OR: 1.2 (95% CI: 1.1-1.4), p=0.001. Lactate level in the first 48-hours after LVAD implantation surgery is an independent predictor of mortality. Further research is needed to assess the mechanisms responsible for elevated postoperative lactate levels and whether targeted therapy will improve clinical outcomes. Baseline Characteristics.

Delta neutrophil index for predicting mortality in trauma patients who underwent emergent abdominal surgery: A case controlled study.

Delta neutrophil index (DNI) can be used as a biomarker for infection to predict patient outcomes. We aimed to investigate the relationship between DNI and clinical outcomes in trauma patients who underwent abdominal surgery. We retrospectively analyzed injured patients who underwent emergent abdominal surgery in the regional trauma center of Wonju Severance Christian Hospital between March 2016 and May 2018. Patient characteristics, operation type, preoperative and postoperative laboratory findings, and clinical outcomes were evaluated. Logistic regression analysis was performed for risk factors associated with mortality. Overall, 169 patients (mean age, 53.8 years; 66.3% male) were enrolled in this study, of which 19 (11.2%) died. The median injury severity score (ISS) was 12. The non-survivors had a significantly higher ISS [25(9-50) vs. 10(1-50), p<0.001] and serum lactate level (9.00±4.10 vs. 3.04±2.23, p<0.001) and more frequent shock (63.2% vs 23.3%, p<0.001) and solid organ injury (52.6% vs. 25.3%, p = 0.013) than the survivors. There were significant differences in postoperative DNI between the two groups (p<0.009 immediate post-operation, p = 0.001 on postoperative day 1 [POD1], and p = 0.013 on POD2). Logistic regression analysis showed that the independent factors associated with mortality were postoperative lactate level (odds ratio [OR] 1.926, 95% confidence interval [CI] 1.101-3.089, p = 0.007), postoperative sequential organ failure assessment score (OR 1.593, 95% CI 1.160-2.187, p = 0.004), and DNI on POD1 (OR 1.118, 95% CI 1.028-1.215, p = 0.009). The receiver operating characteristics curve demonstrated that the area under the curve of DNI on POD1 was 0.887 (cut-off level: 7.1%, sensitivity 85.7%, and specificity 84.4%). Postoperative DNI may be a useful biomarker to predict mortality in trauma patients who underwent emergent abdominal surgery.

Systematic review on peri-operative lactate measurements to predict outcomes in patients undergoing liver resection.

Lactate measurements have proven utility as a triage tool, therapeutic guide, and prognostic indicator, with broad use in Acute Care and transplantation. Its value in guiding therapy and predicting outcomes following liver resection is less well‐defined. This systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines assessed the relationship between peri‐operative lactate levels and morbidity and mortality after liver resection. Seven relevant studies comprising 2573 patients in total were identified. Six studies assessed intra‐operative or early postoperative lactate levels, one publication examined pre‐operative levels. All studies demonstrated a significant association between peri‐operative lactate levels and adverse outcomes. The influence of pre‐operative diabetes and cirrhosis on postoperative lactate levels was shown in one study each, no study assessed the association of lactate with post‐hepatectomy liver failure according to defined criteria. The heterogeneity of study measurements and end‐points precluded a meta‐analysis from being performed. Early postoperative lactate >3‐3.7 mmol/L is associated with mortality but validation of clear cut‐off levels for outcome prediction is pending. Literature suggests lactate is a useful predictive marker for outcomes post liver surgery, especially when measured in the early postoperative phase. Further research is required to standardize the use of lactate measurements in a meaningful therapeutic manner.

Retrospective Comparison of Endoscopic Versus Open Procedure for Mitral Valve Disease

Objectives We investigated whether the totally video-assisted thoracoscopic mitral valve surgery provides superior clinical outcomes and less inflammatory injury reaction compared with conventional sternotomy. Methods A total of 504 consecutive patients admitted for mitral valve surgery from May 2014 through May 2019 in a single center were retrospectively analyzed according to two distinct procedure approach: the totally video-assisted thoracoscopic approach (group A, n = 127) and standard median sternotomy (group B, n = 377). The primary end point was the durations of cardiopulmonary bypass, aortic cross-clamping, the ventilation time and intensive care unit of stay; the secondary endpoints included inflammation indexes like high sensitivity C-reactive protein, neutrophil-lymphocyte ratio and metabolic injury parameters cardiac Troponin and lactate. Results There was only one in-hospital death due to diffuse intravascular coagulation in group A, but similar complications such as repair failure, re-thoracotomy and stroke in both groups. The durations of cardiopulmonary bypass and aortic cross-clamping were significantly longer in group A. In contrast, ventilation time and intensive care unit of stay were shortened compared with these in group B. In addition, postoperative equivalent lactate clearance but lower high sensitivity C-reactive protein, neutrophil-lymphocyte ratio and cardiac Troponin level was in group A than those in group B within postoperative 24 hours(P < 0.05). Conclusions The analysis of present study indicated despite relatively longer cardiopulmonary bypass time, the totally thoracoscopic mitral valve procedure seemed to be favorable with regard to the extent of inflammatory reaction, cardiac injury and postoperative recovery compared with conventional median sternotomy.

Selective lower body perfusion during aortic arch surgery in neonates and small children.

Introduction:Aortic arch reconstruction surgery represents a challenge for the medical personnel involved in treatment. Along the years, the perfusion strategies for aortic arch reconstruction have evolved from deep hypothermic cardiac arrest to antegrade cerebral perfusion with moderate hypothermia, and recently to a combined cerebral and lower body perfusion with moderate hypothermia. To achieve a lower body perfusion, several cannulation strategies have been described. In this study, we investigated the feasibility of utilizing an arterial sheath introduced in the femoral artery to achieve an effective lower body perfusion.Methods:We included patients who underwent an aortic arch reconstruction surgery with a lower body perfusion, from January 2017 to June 2019. To achieve a lower body perfusion, a three-way stopcock was connected to the arterial line, where one end was connected to the central cannulation for cerebral perfusion and the other to an arterial sheath that was introduced through the femoral artery. A total of 25 patients were included. Peri- and postoperative lactate and creatinine levels and signs of malperfusion were recorded.Results:During the reperfusion phase, after selective perfusion ended none of the patients showed a significant increase in lactate, creatinine, and liver enzyme levels. After 24 hours, there were no signs of an acute kidney injury, femoral vessel injury, or limb malperfusion.Conclusion:These findings show that a sufficient lower body perfusion through an arterial sheath placed in the femoral artery for aortic arch reconstruction can be achieved. This approach caused no complications related to the arterial sheath during the early postoperative period and is an easy way to maintain perfusion of systemic organs.

Comparison of the operative and postoperative effects of del Nido and blood cardioplegia solutions in cardiopulmonary bypass surgery.

ObjectiveOur goal was to compare the operative and postoperative effects of del Nido cardioplegia (DN group) and blood cardioplegia (BC group) performed in cardiac surgery.MethodsA total of 83 patients were included, separated into DN group and BC group. The operative and postoperative effects of the two groups were compared for the first 24 hours until extubation. The operative and postoperative complete blood count (CBC), biochemical values and clinical parameters were compared.ResultsThe first control activated clotting time (ACT) levels in DN group patients were lower (P=0.003) during the operation. The amount of cardioplegia in DN group were lower than that in BC group (P=0.001). The pump outflow and postoperative lactate level of DN group were lower than those of BC group (P=0.005, P=0.018, respectively), as well as the amounts of NaHCO3 (P=0.006) and KCl (P=0.001) used during the operation. The same occurred with the first monocytes (Mo) and mean corpuscular volume (MCV) levels in the postoperative intensive care unit (P=0.006, P=0.002). However, the first glucose level and the eosinophil (Eo) level were higher in DN group (P=0.011, P=0.047, respectively).ConclusionIn the operative evaluation, the amount of cardioplegia, the first ACT levels, the pump outflow lactate level and the amounts of NaHCO3 and KCl in DN group were lower. In postoperative evaluation, measured level of lactate, Mo and MCV in DN group were all lower; their glucose and Eo levels were higher.

Role of serial lactate measurement to predict 28-day mortality in patients undergoing emergency laparotomy for perforation peritonitis: prospective observational study

BackgroundSerial lactate measurement is found to predict mortality in septic shock. Majority of patients with perforation peritonitis for emergency laparotomy are in sepsis and mortality rate is substantial. However, lactate dynamics has not been studied in this patient population.MethodsAfter institutional ethics clearance and informed written consent, 113 patients with suspected or proven perforation peritonitis presenting for emergency laparotomy were recruited in this prospective observational trial. Baseline Mannheim peritonitis index (MPI), SOFA and APACHE II score were calculated. Lactate values were obtained at baseline, immediate and 24-h postoperative period. Primary outcome was 28-day mortality.ResultsMortality was 15.04% at 28 days. Age, SOFA, qSOFA, APACHE, preoperative lactate, MPI and site of perforation were significantly different between survivors and non-survivors. Arterial lactate values at preoperative (cut off 2.75 mmol/L), immediate postoperative (cut off 2.8 mmol/L) and 24 h-postoperative period (cut off 2.45 mmol/L) independently predicted mortality at day 28. Combination of MPI and 24-h lactate value was best predictor of mortality with AUC 0.99.ConclusionPreoperative, immediate postoperative and 24-h postoperative lactate value independently predict 28-day mortality in perforation peritonitis patients undergoing emergency laparotomy. Combination of MPI and 24-h lactate value is the most accurate predictor of mortality.Trial registrationClinical Trial Registry of India - CTRI/2018/01/011103

Sustained high-dose thiamine supplementation in high-risk cardiac patients undergoingsurgery under cardiopulmonary bypass (apply trial): a pilot study

Introduction Numerous studies showed that relative thiamine depletion in critically ill patients and in patients undergoing cardiac surgery may contribute to cardiac dysfunction and hyperlactatemia leading to adverse outcomes. Thus, in preparation for a larger trial, we performed a pilot, randomized, placebo-controlled feasibility trial of sustained thiamine supplementation in high-risk patients undergoing cardiac surgery under CPB. Methods Forty patients who underwent high-risk cardiac surgery under CPB were randomly assigned to receive either 200 mg of Thiamine or placebo intravenously after anesthesia induction; after CPB; on the evening of the day of surgery; on three postoperative days (twice a day). Primary endpoints were successful compliance with protocol and successful recruitment of patients. Secondary endpoints included: vasoinotropic score and norepinephrine equivalent dose, postoperative peak lactate and creatinine levels, incidence of acute kidney injury, daily SOFA score, rate of postoperative complications, incidence of adverse events, 7-day and 30-day mortality. Results The mean recruitment rate was 6.6 patients per month (1.6 patients per week). Compliance with protocol was excellent as all patients enrolled into the study received all assigned intervention. No patients develop allergic reactions to the study drug. All patients completed the 30-day follow-up. There were no differences in secondary endpoints. Statistical analysis performed with the Stata Statistical Software using Mann-Whitney U test, T test of Student and ANOVA. Discussion The rationale for thiamine administration in patients undergoing cardiac surgery comes from results of several studies that showed a high incidence of thiamine deficiency postoperatively. Our study implies that it is feasible to achieve an acceptable recruitment rate in a typical tertiary institution with full compliance with the protocol and it's not associated with major safety concerns in patients receiving complex cardiac surgery.

Hemoadsorption does not Have Influence on Hemolysis During Cardiopulmonary Bypass.

Cardiopulmonary bypass (CPB) induces hemolysis, which manifests as plasma free hemoglobin. We investigated in a post hoc analysis of a single-center, blinded, controlled study whether the use of a novel hemoadsorption device (CytoSorb, CytoSorbents Europe GmbH, Berlin, Germany) affects hemolysis during CPB. A total of 35 patients undergoing elective CPB surgery with an expected CPB duration of more than 120 min were included in the analysis. The hemoadsorption device was used in 17 patients (intervention group) and not used in 18 patients (control group). The primary outcome was differences of postoperative free hemoglobin and haptoglobin levels. As secondary outcomes, we investigated differences in postoperative lactate dehydrogenase and bilirubin levels. Postoperative free hemoglobin levels were not significantly different between the groups. However, there were statistically significant differences between the treatment and control groups in the median levels of haptoglobin (58.4 vs. 17.9 mg/dL, respectively; P < 0.01) and lactate dehydrogenase (353.0 vs. 432.0 U/L, respectively; P < 0.05) on postoperative day 1. Thus, in this study, we did not find an effect on hemolysis in patients treated with hemoadsorption, though lower haptoglobin level and higher secondary hemolysis markers on postoperative day 1 in patients not treated with the hemoadsorber may be an indication of some moderate effect of the device. Studies with larger samples are needed to clarify the significance of the small differences detected in this study.

Research progress in breast blood supply and breast reduction

To review the research on distribution of the nerve and blood supply of breast, and the development of breast reduction in recent years. The related literatures about the distribution of the nerve and blood supply of breast, the development of breast reduction, and postoperative lactation function in recent years were reviewed extensively. The above aspects were analyzed and summarized in combination with the author's experiences. With the anatomical study of mammary gland, nipple areola complex nerve distribution and blood supply, breast reduction has been developed rapidly, and a variety of surgical methods have been formed. But each has its own advantages and disadvantages, and its indications are different. Through the application and improvement of the auxiliary examination technique, severe complications such as nipple areola complex necrosis reduce obviously after operation. Through the selection of position of the incision and pedicle, the degree of retaining the pedicle glands, the application of auxiliary liposuction technique, and the improvement of suture technique, the scar of incision reduces, the sensation of nipple areola is preserved more, and a more satisfactory breast shape is obtained. Some of the patients who gave birth after breast reduction have lactation function. There are some shortcomings in various surgical methods at present, individualized surgical methods should be adopted according to the characteristics of the patients. Further research is needed on how to preserve more sensation of nipple areola, obtain a good and lasting breast shape, and preserve lactation function of women after operation.