The importance of blood lactate clearance as a predictor of early mortality following the modified Norwood procedure

Murtuza, Bari; Wall, Douglas; Reinhardt, Zdenka; Stickley, John; Stümper, Oliver; Jones, Timothy J.; Barron, David J.; Brawn, William J.

doi:10.1016/j.ejcts.2011.01.081

Cited by 25 publications

(25 citation statements)

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“…Hyperlactataemia has been shown to be associated with increased mortality and morbidity in a critical care setting [26,27], in patients with liver failure [28], sepsis [29] and following trauma [30]. Similar relationships have been shown in the post-operative setting following pancreatic resection [31] and other major abdominal surgery [32], cardiac surgery [33] and after hepatic transplantation [34]. …”

Section: Introductionmentioning

confidence: 87%

Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection

et al. 2013

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BackgroundThe aim of this study was to determine if the post-operative serum arterial lactate concentration is associated with mortality, length of hospital stay or complications following hepatic resection.MethodsSerum lactate concentration was recorded at the end of liver resection in a consecutive series of 488 patients over a seven-year period. Liver function, coagulation and electrolyte tests were performed post-operatively. Renal dysfunction was defined as a creatinine rise of >1.5x the pre-operative value.ResultsThe median lactate was 2.8 mmol/L (0.6 to 16 mmol/L) and was elevated (≥2 mmol/L) in 72% of patients. The lactate concentration was associated with peak post-operative bilirubin, prothrombin time, renal dysfunction, length of hospital stay and 90-day mortality (P < 0.001). The 90-day mortality in patients with a post-operative lactate ≥6 mmol/L was 28% compared to 0.7% in those with lactate ≤2 mmol/L. Pre-operative diabetes, number of segments resected, the surgeon’s assessment of liver parenchyma, blood loss and transfusion were independently associated with lactate concentration.ConclusionsInitial post-operative lactate concentration is a useful predictor of outcome following hepatic resection. Patients with normal post-operative lactate are unlikely to suffer significant hepatic or renal dysfunction and may not require intensive monitoring or critical care.

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Section: Introductionmentioning

confidence: 87%

Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection

et al. 2013

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“…MAP is used by all the principal scales that evaluate ICU admittance parameters except for MPM II; bicarbonate is included in APACHE II and SAP II; INR is only included in MPM II. The POCAS scale is the only one that includes blood lactate levels, although the association of elevated lactate values at ICU admission with hospital/operative mortality has already been highlighted in other studies [17,30,31]. …”

Section: Discussionmentioning

confidence: 99%

Development of the Post Cardiac Surgery (POCAS) prognostic score

et al. 2013

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IntroductionThe risk of mortality in cardiac surgery is generally evaluated using preoperative risk-scale models. However, intraoperative factors may change the risk factors of patients, and the organism functionality parameters determined upon ICU admittance could therefore be more relevant in deciding operative mortality. The goals of this study were to find associations between the general parameters of organism functionality upon ICU admission and the operative mortality following cardiac operations, to develop a Post Cardiac Surgery (POCAS) Scale to define operative risk categories and to validate an operative mortality risk score.MethodsWe conducted a prospective study, including 920 patients who had undergone cardiac surgery with cardiopulmonary bypass. Several parameters recorded on their ICU admission were explored, looking for a univariate and multivariate association with in-hospital mortality (90 days). In-hospital mortality was 9%. Four independent factors were included in the POCAS mortality risk model: mean arterial pressure, bicarbonate, lactate and the International Normalized Ratio (INR). The POCAS scale was compared with four other risk scores in the validation series.ResultsIn-hospital mortality (90 days) was 9%. Four independent factors were included in the POCAS mortality risk model: mean arterial pressure, bicarbonate ratio, lactate ratio and the INR. The POCAS scale was compared with four other risk scores in the validation series. Discriminatory power (accuracy) was defined with a receiver-operating characteristics (ROC) analysis. The best accuracy in predicting in-hospital mortality (90 days) was achieved by POCAS. The areas under the ROC curves of the different systems analyzed were 0.890 (POCAS), followed by 0.847 (Simplified Acute Physiology Score (SAP II)), 0.825 (Sepsis-related Organ Failure Assessment (SOFA)), 0.768 (Acute Physiology and Chronic Health Evaluation (APACHE II)), 0.754 (logistic EuroSCORE), 0.714 (standard EuroSCORE) and 0.699 (Age, Creatinine, Ejection Fraction (ACEF) score).ConclusionsOur new system to predict the operative mortality risk of patients undergoing cardiac surgery is better than others used for this purpose (SAP II, SOFA, APACHE II, logistic EuroSCORE, standard EuroSCORE, and ACEF score). Moreover, it is an easy-to-use tool since it only requires four risk factors for its calculation.

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“…The analysis of lactate trends in our series shows that majority of patients had been able to successfully clear blood lactate levels to <2 mmol/L in 12 h. One patient who died in early postoperative period had persistently elevated lactate levels in the first 24 h. Our data are supported by a retrospective study of 221 patients where inability to clear lactate levels to less than 6.76 mmol/L in the first 24 h was found to be a significant predictor of mortality. [16]…”

Section: Discussionmentioning

confidence: 99%

Stage one Norwood procedure in an emerging economy:Initial experience in a single center

et al. 2013

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Objective:The evolution of surgical skills and advances in pediatric cardiac intensive care has resulted in Norwood procedure being increasingly performed in emerging economies. We reviewed the feasibility and logistics of performing stage one Norwood operation in a limited-resource environment based on a retrospective analysis of patients who underwent this procedure in our institution.Methods:Retrospective review of medical records of seven neonates who underwent Norwood procedure at our institute from October 2010 to August 2012.Results:The median age at surgery was 9 days (range 5-16 days). All cases were done under deep hypothermic cardiopulmonary bypass and selective antegrade cerebral perfusion. The median cardiopulmonary bypass (CPB) time was 240 min (range 193-439 min) and aortic cross-clamp time was 130 min (range 99-159 min). A modified Blalock-Taussig (BT) shunt was used to provide pulmonary blood flow in all cases. There were two deaths, one in the early postoperative period. The median duration of mechanical ventilation was 117 h (range 71-243 h) and the median intensive care unit (ICU) stay was 12 days (range 5-16 days). Median hospital stay was 30.5 days (range 10-36 days). Blood stream sepsis was reported in four patients. Two patients had preoperative sepsis. One patient required laparotomy for intestinal obstruction.Conclusions:Stage one Norwood is feasible in a limited-resource environment if supported by a dedicated postoperative intensive care and protocolized nursing management. Preoperative optimization and prevention of infections are major challenges in addition to preventing early circulatory collapse.

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The importance of blood lactate clearance as a predictor of early mortality following the modified Norwood procedure

Abstract: We have identified minimum blood lactate level within the first 24h after the Sano-Norwood procedure as a highly discriminatory predictor of perioperative mortality. These patients might benefit from elective institution of early mechanical circulatory support.

Cited by 25 publications

References 22 publications

Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection

Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection

Development of the Post Cardiac Surgery (POCAS) prognostic score

Stage one Norwood procedure in an emerging economy:Initial experience in a single center

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