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Andersen LW. Lactate Elevation During and After Major Cardiac Surgery in Adults: A Review of Etiology, Prognostic Value, and Management. Anesth Analg 2017; 125:743-752. [PMID: 28277327 DOI: 10.1213/ane.0000000000001928] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elevated lactate is a common occurrence after cardiac surgery. This review summarizes the literature on the complex etiology of lactate elevation during and after cardiac surgery, including considerations of oxygen delivery, oxygen utilization, increased metabolism, lactate clearance, medications and fluids, and postoperative complications. Second, the association between lactate and a variety of outcomes are described, and the prognostic role of lactate is critically assessed. Despite the fact that elevated lactate is strongly associated with many important outcomes, including postoperative complications, length of stay, and mortality, little is known about the optimal management of postoperative patients with lactate elevations. This review ends with an assessment of the limited literature on this subject.
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Affiliation(s)
- Lars W Andersen
- From the *Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; †Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; ‡Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; and §Department of Medicine, Regional Hospital Holstebro, Aarhus University, Holstebro, Denmark
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Bhardwaj V, Kapoor PM, Irpachi K, Ladha S, Chowdhury UK. Basic arterial blood gas biomarkers as a predictor of mortality in tetralogy of Fallot patients. Ann Card Anaesth 2017; 20:67-71. [PMID: 28074799 PMCID: PMC5290699 DOI: 10.4103/0971-9784.197839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Serum lactate and base deficit have been shown to be a predictor of morbidity and mortality in critically ill patients. Poor preoperative oxygenation appears to be one of the significant factors that affects early mortality in tetralogy of Fallot (TOF). There is little published literature evaluating the utility of serum lactate, base excess (BE), and oxygen partial pressure (PO2) as simple, widely available, prognostic markers in patients undergoing surgical repair of TOF. Materials and Methods: This prospective, observational study was conducted in 150 TOF patients, undergoing elective intracardiac repair. PO2, BE, and lactate levels at three different time intervals were recorded. Arterial blood samples were collected after induction (T1), after cardiopulmonary bypass (T2), and 48 h (T3) after surgery in the Intensive Care Unit (ICU). To observe the changes in PO2, BE, and lactate levels over a period of time, repeated measures analysis was performed with Bonferroni method. The receiver operating characteristics (ROC) analysis was used to find area under curve (AUC) and cutoff values of various biomarkers for predicting mortality in ICU. Results: The patients who could not survive showed significant elevated lactate levels at baseline (T1) and postoperatively (T2) as compared to patients who survived after surgery (P < 0.001). However, in nonsurvivors, the BE value decreased significantly in the postoperative period in comparison to survivors (−2.8 ± 4.27 vs. 5.04 ± 2.06) (P < 0.001). In nonsurvivors, there was a significant fall of PO2 to a mean value of 59.86 ± 15.09 in ICU (T3), whereas those who survived had a PO2 of 125.86 ± 95.09 (P < 0.001). The ROC curve analysis showed that lactate levels (T3) have highest mortality predictive value (AUC: 96.9%) as compared to BE (AUC: 94.5%) and PO2 (AUC: 81.1%). Conclusion: Serum lactate and BE may be used as prognostic markers to predict mortality in patients undergoing TOF repair. The routine analysis of these simple, fast, widely available, and cost-effective biomarkers should be encouraged to predict prognosis of TOF patients.
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Affiliation(s)
| | | | - Kalpana Irpachi
- Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
| | - Suruchi Ladha
- Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
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3
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Naik R, George G, Karuppiah S, Philip MA. Hyperlactatemia in patients undergoing adult cardiac surgery under cardiopulmonary bypass: Causative factors and its effect on surgical outcome. Ann Card Anaesth 2016; 19:668-675. [PMID: 27716698 PMCID: PMC5070327 DOI: 10.4103/0971-9784.191579] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/11/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES OF THE STUDY To identify the factors causing high lactate levels in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) and to assess the association between high blood lactate levels and postoperative morbidity and mortality. METHODS A retrospective observational study including 370 patients who underwent cardiac surgeries under cardiopulmonary bypass. The patients were divided into 2 groups based on serum lactate levels; those with serum lactate levels greater than or equal to 4 mmol/L considered as hyperlactatemia and those with serum lactate levels less than 4 mmol/L. Blood lactate samples were collected intraoperatively and postoperatively in the ICU. Preoperative and intraoperative risk factors for hyperlactatemia were identified using the highest intraoperative value of lactate. The postoperative morbidity and mortality associated with hyperlactatemia was studied using the overall (intraoperative and postoperative values) peak lactate levels. Preoperative clinical data, perioperative events and postoperative morbidity and mortality were recorded. RESULTS Intraoperative peak blood lactate levels of 4.0 mmol/L or more were present in 158 patients (42.7%). Females had higher peak intra operative lactate levels (P = 0.011). There was significant correlation between CPB time (Pearson correlation coefficient r = 0.024; P = 0.003) and aortic cross clamp time (r = 0.02, P = 0.007) with peak intraoperative blood lactate levels. Patients with hyperlactatemia had significantly higher rate of postoperative morbidity like atrial fibrillation (19.9% vs. 5.3%; P = 0.004), prolonged requirement of inotropes (34% vs. 11.8%; P = 0.001), longer stay in the ICU (P = 0.013) and hospital (P = 0.001). CONCLUSIONS Hyperlactatemia had significant association with post-operative morbidity. Detection of hyperlactatemia in the perioperative period should be considered as an indicator of inadequate tissue oxygen delivery and must be aggressively corrected.
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Affiliation(s)
- Rakesh Naik
- Department of Cardiothoracic and Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Gladdy George
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sathappan Karuppiah
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Madhu Andrew Philip
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Abstract
OBJECTIVES In this review, we discuss hemodynamic monitoring modalities, including their application, the interpretation of data, limitations, and impact on outcomes. DATA SOURCE MEDLINE, PubMed. CONCLUSIONS One of the tenets of critical care medicine is to ensure adequate tissue oxygenation. This assessment must be timely and accurate to optimize outcomes. The clinical assessment of cardiac function, cardiac output, and tissue oxygenation based on the physical examination and standard hemodynamic variables, although an indispensable part of this exercise, has significant limitations. The use of adjunctive hemodynamic monitoring modalities provides a much more objective, accurate, and timely assessment of the patient's hemodynamic profile and is invaluable for assessing the patient's clinical status, clinical trajectory, and response to interventions.
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Fisher EM, Kerr ME, Hoffman LA, Steiner RP, Baranek RA. A Comparison of Gastric and Rectal CO₂ in Cardiac Surgery Patients. Biol Res Nurs 2016; 6:268-80. [PMID: 15788736 DOI: 10.1177/1099800404274049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Critical care nurses assess and treat clinical conditions associated with inadequate oxygenation. Changes in regional organ (gut) blood flow are believed to occur in response to a decrease in oxygenation. Although the stomach is a widely accepted monitoring site, there are multiple methodological and measurement issues associated with the gastric environment that limit the accuracy of P CO2 detection. The rectum may provide nurses with an alternative site for monitoring changes in PCO2 without the limitations associated with gastric monitoring. This pilot study used a repeated measures design to examine changes in gastric and rectal PCO2 during elective coronary artery bypass grafting with cardiopulmonary bypass (CPB) and in the immediate 4-hr postoperative period in 26 subjects. The systemic indicators explained little variation in the regional indicators during protocol. A comparison of rectal and gastric PCO2 revealed no statistically significant differences in the direction or magnitude of change over any phase of cardiac surgery (baseline, CPB, post-CPB). A reduction in both rectal and gastric PCO2 occurred during CPB, and both values trended upward during the post-CPB phase. However, poor correlation and agreement was found between the measures of PCO2 at the two sites. Although clinically important, the cause is unclear. Possible explanations include variation in CO2 production between the gastric and rectal site, differences in sensitivity of the two monitoring instruments, or the absence of hemodynamic complications, which limited the extent of change in PCO2. Further investigation using patients with more profound changes in oxygenation are needed to identify response patterns and possible mechanisms.
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Affiliation(s)
- Elaine M Fisher
- The University of Akron, College of Nursing, Akron, OH 44325-3701, USA.
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6
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Ghadimi K, Gutsche JT, Setegne SL, Jackson KR, Augoustides JG, Ochroch EA, Bavaria JE, Cheung AT. Severity and Duration of Metabolic Acidosis After Deep Hypothermic Circulatory Arrest for Thoracic Aortic Surgery. J Cardiothorac Vasc Anesth 2015; 29:1432-40. [DOI: 10.1053/j.jvca.2015.07.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Indexed: 01/05/2023]
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Abstract
In critical care, the monitoring is essential to the daily care of ICU patients, as the optimization of patient's hemodynamic, ventilation, temperature, nutrition, and metabolism is the key to improve patients' survival. Indeed, the decisive endpoint is the supply of oxygen to tissues according to their metabolic needs in order to fuel mitochondrial respiration and, therefore, life. In this sense, both oxygenation and perfusion must be monitored in the implementation of any resuscitation strategy. The emerging concept has been the enhancement of macrocirculation through sequential optimization of heart function and then judging the adequacy of perfusion/oxygenation on specific parameters in a strategy which was aptly coined “goal directed therapy.” On the other hand, the maintenance of normal temperature is critical and should be regularly monitored. Regarding respiratory monitoring of ventilated ICU patients, it includes serial assessment of gas exchange, of respiratory system mechanics, and of patients' readiness for liberation from invasive positive pressure ventilation. Also, the monitoring of nutritional and metabolic care should allow controlling nutrients delivery, adequation between energy needs and delivery, and blood glucose. The present paper will describe the physiological basis, interpretation of, and clinical use of the major endpoints of perfusion/oxygenation adequacy and of temperature, respiratory, nutritional, and metabolic monitorings.
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KIEFER P, EICHELBRÖNNER O, HANNEKUM A, GEORGIEFF M, RADERMACHER P. Persistent gastric mucosal acidosis in a child after cardiac surgery. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.6.5.242.244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVE To review the principles of venous oximetry; the physiology of oxygen transport balance; clinical studies on venous oximetry; and the assignment of a classification of recommendation and level of evidence. DATA SOURCE A MEDLINE-based literature source. CONCLUSION One of the tenets of critical care medicine is to provide a timely and accurate assessment of tissue oxygenation. In conjunction with other monitoring modalities, the routine deployment of central venous catheters readily enables the clinician to complete this task.
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Beltran NE, Sanchez-Miranda G, Godinez MM, Diaz U, Sacristan E. The predictive value of gastric reactance for postoperative morbidity and mortality in cardiac surgery patients. Physiol Meas 2010; 31:1423-36. [PMID: 20834113 DOI: 10.1088/0967-3334/31/11/002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
No useful method to directly monitor the level of end organ tissue injury is currently available clinically. Gastric reactance has been proposed to measure changes in a tissue structure caused by ischemia. The purpose of this study was to assess whether gastric reactance is a reliable, clinically relevant predictor of complications and a potentially useful tool to assess hypoperfusion in cardiovascular surgery patients. The value of gastric reactance measurements, standard hemodynamic and regional perfusion variables, and scores to predict postoperative complications were compared in 55 higher risk cardiovascular surgery patients with cardiopulmonary bypass. Low frequency gastric reactance, X(L), had a significant predictive value of postoperative persistent shock requiring more than 48 h of vasopressors and associated complications, before, during and after surgery (p < 0.05). Results suggest that reactance is an earlier predictor of patients at risk than all other variables tested. Patients with a high reactance (X(L) > 26) before surgery had a significantly higher incidence of complications, higher mortality and more days in the ICU than patients with a low reactance (X(L) < 13). X(L) was found to be a reliable and clinically relevant measurement. These results justify further clinical research to explore how this information may be used to improve patient management.
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Affiliation(s)
- N E Beltran
- Innovamedica S.A.P.I de C.V. Cantil 175-4. Col. Jardines del Pedregal. 01900, Mexico City, Mexico
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11
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Plasmatic levels of inflammatory markers during cardiopulmonary bypass in hypothermia and normothermia. COR ET VASA 2010. [DOI: 10.33678/cor.2010.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Davison DL, Chawla LS, Selassie L, Jones EM, McHone KC, Vota AR, Junker C, Sateri S, Seneff MG. Femoral-based central venous oxygen saturation is not a reliable substitute for subclavian/internal jugular-based central venous oxygen saturation in patients who are critically ill. Chest 2010; 138:76-83. [PMID: 20418366 DOI: 10.1378/chest.09-2680] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Central venous oxygen saturation (Scv(O(2))) has been used as a surrogate marker for mixed venous oxygen saturation (Sv(O(2))). Femoral venous oxygen saturation (Sfv(O(2))) is sometimes used as a substitute for Scv(O(2)). The purpose of this study is to test the hypothesis that these values can be used interchangeably in a population of patients who are critically ill. METHODS We conducted a survey to assess the frequency of femoral line insertion during the initial treatment of patients who are critically ill. Scv(O(2)) vs Sfv(O(2)) STUDY: Patients with femoral and nonfemoral central venous catheters (CVCs) were included in this prospective study. Two sets of paired blood samples were drawn simultaneously from the femoral and nonfemoral CVCs. Blood samples were analyzed for oxygen saturation and lactate. RESULTS One hundred and fifty physicians responded to the survey. More than one-third of the physicians insert a femoral line at least 10% of the time during the initial treatment of patients who were critically ill. Scv(O(2)) vs Sfv(O(2)) STUDY: Thirty-nine patients were enrolled. The mean Scv(O(2)) and Sfv(O(2)) were 73.1% +/- 11.6% and 69.1% +/- 12.9%, respectively (P = .002), with a mean bias of 4.0% +/- 11.2% (95% limits of agreement: -18.4% to 26.4%). The mean serum lactate from the nonfemoral and femoral CVCs was 2.84 +/- 4.0 and 2.72 +/- 3.2, respectively (P = .15). CONCLUSIONS This study revealed a significant difference between paired samples of Scv(O(2)) and Sfv(O(2)). More than 50% of Scv(O(2)) and Sfv(O(2)) values diverged by > 5%. Sfv(O(2)) is not always a reliable substitute for Scv(O(2)) and should not routinely be used in protocols to help guide resuscitation.
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Affiliation(s)
- Danielle L Davison
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC 20037, USA
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Ranucci M, Isgrò G, Romitti F, Mele S, Biagioli B, Giomarelli P. Anaerobic Metabolism During Cardiopulmonary Bypass: Predictive Value of Carbon Dioxide Derived Parameters. Ann Thorac Surg 2006; 81:2189-95. [PMID: 16731152 DOI: 10.1016/j.athoracsur.2006.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 12/27/2005] [Accepted: 01/03/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hyperlactatemia during cardiopulmonary bypass (CPB) is a common event and is associated to a high morbidity and mortality after cardiac operations. The present study is aimed to identify the possible predictors of hyperlactatemia during CPB among a series of oxygen and carbon dioxide derived parameters measured during CPB. METHODS This is a prospective observational study on 54 patients undergoing cardiac surgery with CPB. Hyperlactatemia was defined as an arterial lactate concentration higher than 3 mMol/L. Serial blood lactate assays have been performed during CPB, and their association to a number of oxygen and carbon dioxide derived parameters was explored. RESULTS Arterial blood lactate concentration was positively correlated to the CPB duration, the carbon dioxide elimination, and the respiratory quotient, and negatively correlated to the presence of the aortic cross-clamping, the body surface area, the ratio between the oxygen delivery and the carbon dioxide production, and the arterial oxygen saturation. Predictors of hyperlactatemia during CPB are a carbon dioxide production higher than 60 mL.min(-1).m(-2), a respiratory quotient higher than 0.9, and a ratio between oxygen delivery and carbon dioxide production lower than 5. CONCLUSIONS Carbon dioxide derived parameters are representative of hyperlactatemia during CPB, as a result of the carbon dioxide produced under anaerobic conditions through the buffering of protons by the bicarbonate system. The carbon dioxide elimination rate measured at the exhaled site of the oxygenator may be used for an indirect assessment of the metabolic state of the patient.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic Anesthesia, Policlinico San Donato, Milan, Italy.
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14
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Li J, Van Arsdell GS, Zhang G, Cai S, Humpl T, Caldarone CA, Holtby H, Redington AN. Assessment of the relationship between cerebral and splanchnic oxygen saturations measured by near-infrared spectroscopy and direct measurements of systemic haemodynamic variables and oxygen transport after the Norwood procedure. Heart 2006; 92:1678-85. [PMID: 16621884 PMCID: PMC1861229 DOI: 10.1136/hrt.2005.087270] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the clinical utility of near-infrared spectroscopic (NIRS) monitoring of cerebral (ScO2) and splanchnic (SsO2) oxygen saturations for estimation of systemic oxygen transport after the Norwood procedure. METHODS ScO2 and SsO2 were measured with NIRS cerebral and thoracolumbar probes (in humans). Respiratory mass spectrometry was used to measure systemic oxygen consumption (O2). Arterial (SaO2), superior vena caval (SvO2) and pulmonary venous oxygen saturations were measured at 2 to 4 h intervals to derive pulmonary (Qp) and systemic blood flow (Qs), systemic oxygen delivery (DO2) and oxygen extraction ratio (ERO2). Mixed linear regression was used to test correlations. A study of 7 pigs after cardiopulmonary bypass (study 1) was followed by a study of 11 children after the Norwood procedure (study 2). RESULTS Study 1. ScO2 moderately correlated with SvO2, mean arterial pressure, Qs, DO2 and ERO2 (slope 0.30, 0.64. 2.30, 0.017 and -32.5, p < 0.0001) but not with SaO2, arterial oxygen pressure (PaO2), haemoglobin and O2. Study 2. ScO2 correlated well with SvO2, SaO2, PaO2 and mean arterial pressure (slope 0.43, 0.61, 0.99 and 0.52, p < 0.0001) but not with haemoglobin (slope 0.24, p > 0.05). ScO2 correlated weakly with O2 (slope -0.07, p = 0.05) and moderately with Qs, DO2 and ERO2 (slope 3.2, 0.03, -33.2, p < 0.0001). SsO2 showed similar but weaker correlations. CONCLUSIONS ScO2 and SsO2 may reflect the influence of haemodynamic variables and oxygen transport after the Norwood procedure. However, the interpretation of NIRS data, in terms of both absolute values and trends, is difficult to rely on clinically.
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Affiliation(s)
- J Li
- The Cardiac Program, The Hospital for Sick Children, Toronto, Ontario, Canada
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15
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Li J, Zhang G, Holtby HM, McCrindle BW, Cai S, Humpl T, Caldarone CA, Williams WG, Redington AN, Van Arsdell GS. Inclusion of oxygen consumption improves the accuracy of arterial and venous oxygen saturation interpretation after the Norwood procedure. J Thorac Cardiovasc Surg 2006; 131:1099-107. [PMID: 16678596 DOI: 10.1016/j.jtcvs.2005.10.057] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Revised: 10/05/2005] [Accepted: 10/10/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Management strategy for the postoperative Norwood neonate has been formulated from models that have estimated oxygen consumption (VO2). Superior vena caval oxygen saturation (SVO2), systemic arterial and superior vena caval oxygen saturation difference (Sa-VO2), and oxygen excess factor (Omega = arterial oxygen saturation/Sa-VO2) have been used as indirect indicators to estimate systemic blood flow (Qs) and oxygen delivery (DO2). We sought to examine the correlation of the indirect indicators to VO2-derived measures of oxygen transport. METHODS Respiratory mass spectrometry was used to continuously measure VO2 after the Norwood procedure (n = 13). Measured saturations and the direct Fick equation were used to obtain pulmonary blood flow, Qs, DO2, and oxygen extraction ratio (ERO2) values. Correlations to SVO2, Sa-VO2, and Omega were sought. RESULTS There was a close correlation of SVO2, Sa-VO2, and Omega to ERO2 (r = 0.92, 0.96, and 0.97, respectively; P < .0001). Correlation to Qs and DO2 was variable (r = 0.39 to 0.78, respectively; P < .0001). Correlation to VO2 was poor but significant (r = 0.24 to 0.40, P < .0001). Inclusion of VO2 improved the correlation to Qs and DO2 (r = 0.66 to 0.97, P < .0001). CONCLUSIONS The close correlation of SVO2, Sa-VO2, and Omega to ERO2 indicates that each is a measure of the balance of DO2 and extraction. The significant but less reliable correlation to DO2 and VO2 indicates the values for SVO2, Sa-VO2, and Omega do not discriminate between the contribution of DO2 and VO2. Measured VO2 and hemodynamics may improve the optimization of postoperative management strategy in the individual neonate.
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Affiliation(s)
- Jia Li
- Cardiac Program, the Hospital for Sick Children, Toronto, Ontario, Canada
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Basaran M, Sever K, Kafali E, Ugurlucan M, Sayin OA, Tansel T, Alpagut U, Dayioglu E, Onursal E. Serum Lactate Level Has Prognostic Significance After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2006; 20:43-7. [PMID: 16458212 DOI: 10.1053/j.jvca.2004.10.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2004] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The determination of postoperative course after cardiac surgery has always been a challenging issue. It is more sophisticated in the pediatric age group. The aim of this investigation was to identify whether increased concentrations of lactate in arterial blood has a predictive value for postoperative morbidity and mortality after heart surgery. METHODS From May 2002 to June 2003, 60 infants operated on at the authors' institution were included in this prospective study. The patients were divided into 2 groups according to their respective postoperative serum lactate values. After the stabilization period in the intensive care unit (first 3 hours postoperatively), samples for serum lactate were obtained from arterial blood at 3 (t1), 6 (t2), and 12 hours (t3) postoperatively. The patients were subdivided into 2 groups according to their respective mean serum lactate values. A value of 4.8 mmol/L (3 times the normal upper limit) was chosen as a threshold for serum lactate. The patients with a mean value of greater than 4.8 mmol/L (group 1) were compared with the remaining group of patients (group 2). The relationship between serum mean lactate level and intraoperative and postoperative clinical variables was evaluated. RESULTS Among the patients in this study, 26 (43.3%) had a serum mean lactate level more than 4.8 mmol/L and 34 (56.7%) had a level of 4.8 mmol/L or less. Age, aortic cross-clamping time, cardiopulmonary bypass time, and the lowest hematocrit during cardiopulmonary bypass were significant variables that influenced the postoperative serum mean lactate level. Six patients died in the postoperative period and 54 infants survived. The hospital mortality was significantly higher in group 1 than in group 2 (19.0% v 2.9%; p = 0.037, kappa = 0.179). Multivariate analysis revealed that serum mean lactate level correlated significantly with inotrope score, intubation time, and intensive care unit stay. CONCLUSIONS Blood lactate concentration of 4.8 mmol/L or higher during the early postoperative hours identifies a group of patients with increased risk of postoperative morbidity and mortality.
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Affiliation(s)
- Murat Basaran
- Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey
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Goldstein JI, Goldstein KA, Wardwell K, Fahrner SL, Goonan KE, Cheney MD, Yeager MP, Guyre PM. Increase in plasma and surface CD163 levels in patients undergoing coronary artery bypass graft surgery. Atherosclerosis 2003; 170:325-32. [PMID: 14612214 DOI: 10.1016/s0021-9150(03)00297-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although haptoglobin polymorphism has been shown to be a genetic risk factor in coronary artery disease, its mechanisms of action are incompletely defined. Recently, a macrophage scavenger receptor for the uptake of haptoglobin-hemoglobin (Hp-Hb) complexes was cloned and designated CD163. Macrophage expression of CD163 is increased by glucocorticoids, IL-10 and IL-6. To better understand the in vivo response of CD163 to an inflammatory stimulus and glucocorticoid treatment, we studied 18 patients who underwent elective coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). We report a rapid increase in plasma levels of soluble CD163 by 1 h post-declamping the aorta during CABG surgery with CPB. Furthermore, we demonstrate significant increases in monocyte CD163 on post-operative day 1; 14-fold for patients pre-treated with methylprednisolone and 3-fold for those who did not receive exogenous glucocorticoids. These findings show CD163 to be rapidly mobilized in response to systemic inflammatory stimuli and to be affected significantly by glucocorticoids in vivo. The proposed role of CD163 as a Hp-Hb scavenger and anti-inflammatory molecule, in conjunction with the results of this study, make CD163 an intriguing target for potential manipulation of the acute response to inflammation.
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MESH Headings
- Acute-Phase Proteins/biosynthesis
- Adult
- Aged
- Aged, 80 and over
- Antigens, CD/biosynthesis
- Antigens, CD/blood
- Antigens, Differentiation, Myelomonocytic/biosynthesis
- Antigens, Differentiation, Myelomonocytic/blood
- Antigens, Surface/biosynthesis
- Cardiopulmonary Bypass
- Coronary Artery Bypass/adverse effects
- Enzyme-Linked Immunosorbent Assay
- Female
- Flow Cytometry
- Glucocorticoids/pharmacology
- Humans
- Male
- Methylprednisolone/pharmacology
- Middle Aged
- Monocytes/metabolism
- Receptors, Cell Surface/biosynthesis
- Receptors, Cell Surface/blood
- Systemic Inflammatory Response Syndrome/etiology
- Systemic Inflammatory Response Syndrome/metabolism
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Tønnessen TI. Detection of hypoperfusion: read your patient's hand. Crit Care Med 2003; 31:2407-8. [PMID: 14501978 DOI: 10.1097/01.ccm.0000084862.72867.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Soller BR, Idwasi PO, Balaguer J, Levin S, Simsir SA, Vander Salm TJ, Collette H, Heard SO. Noninvasive, near infrared spectroscopic-measured muscle pH and Po2 indicate tissue perfusion for cardiac surgical patients undergoing cardiopulmonary bypass*. Crit Care Med 2003; 31:2324-31. [PMID: 14501963 DOI: 10.1097/01.ccm.0000086999.21673.6a] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether near infrared spectroscopic measurement of tissue pH and Po2 has sufficient accuracy to assess variation in tissue perfusion resulting from changes in blood pressure and metabolic demand during cardiopulmonary bypass. DESIGN Prospective clinical study. SETTING Academic medical center. SUBJECTS Eighteen elective cardiac surgical patients. INTERVENTION Cardiac surgery under cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS A near infrared spectroscopic fiber optic probe was placed over the hypothenar eminence. Reference Po2 and pH sensors were inserted in the abductor digiti minimi (V). Data were collected every 30 secs during surgery and for 6 hrs following cardiopulmonary bypass. Calibration equations developed from one third of the data were used with the remaining data to investigate sensitivity of the near infrared spectroscopic measurement to physiologic changes resulting from cardiopulmonary bypass. Near infrared spectroscopic and reference pH and Po2 measurements were compared for each subject using standard error of prediction. Near infrared spectroscopic pH and Po2 at baseline were compared with values during cardiopulmonary bypass just before rewarming commenced (hypotensive, hypothermic), after rewarming (hypotensive, normothermic) just before discontinuation of cardiopulmonary bypass, and at 6 hrs following cardiopulmonary bypass (normotensive, normothermic) using mixed-model analysis of variance. Near infrared spectroscopic pH and Po2 were well correlated with the invasive measurement of pH (R2 =.84) and Po2 (R 2 =.66) with an average standard error of prediction of 0.022 +/- 0.008 pH units and 6 +/- 3 mm Hg, respectively. The average difference between the invasive and near infrared spectroscopic measurement was near zero for both the pH and Po2 measurements. Near infrared spectroscopic Po2 significantly decreased 50% on initiation of cardiopulmonary bypass and remained depressed throughout the bypass and monitored intensive care period. Near infrared spectroscopic pH decreased significantly during cardiopulmonary bypass, decreased significantly during rewarming, and remained depressed 6 hrs after cardiopulmonary bypass. Diabetic patients responded differently than nondiabetic subjects to cardiopulmonary bypass, with lower muscle pH values (p =.02). CONCLUSIONS Near infrared spectroscopic-measured muscle pH and Po2 are sensitive to changes in tissue perfusion during cardiopulmonary bypass.
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Affiliation(s)
- Babs R Soller
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
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20
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Zweier JL, He G, Samouilov A, Kuppusamy P. EPR spectroscopy and imaging of oxygen: applications to the gastrointestinal tract. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 530:123-31. [PMID: 14562710 DOI: 10.1007/978-1-4615-0075-9_12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
EPR imaging has emerged as an important tool for noninvasive three-dimensional (3D) spatial mapping of free radicals in biological tissues. Spectral-spatial EPR imaging enables mapping of the spectral information at each spatial position, and, from the observed linewidth, the localized tissue oxygenation can be mapped. We report the application of EPR imaging techniques enabling 3D spatial and spectral-spatial EPR imaging of small animals. This instrumentation, along with the use of a biocompatible charcoal oximetry-probe suspension, enabled 3D spatial imaging of the gastrointestinal (GI) tract, along with mapping of oxygenation in living mice. By using this technique, the oxygen tension was mapped at different levels of the GI tract from the stomach to the rectum. The results clearly show the presence of a marked oxygen gradient from the proximal to the distal GI tract, which decreases after respiratory arrest. This technique for in vivo mapping of oxygenation is a promising method, enabling the noninvasive imaging of oxygen within the normal GI tract. This method should be useful in determining the alterations in oxygenation associated with disease.
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Affiliation(s)
- Jay L Zweier
- Center For Biomedical EPR Spectroscopy and Imaging, Davis Heart and Lung Research Institute, Ohio State University College of Medicine, Columbus, Ohio, USA
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21
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Weiss M, Schulz G, Fasnacht M, Balmer C, Fischer JE, Gerber AC, Bucher HU, Baenziger O. Transcutaneously measured near-infrared spectroscopic liver tissue oxygenation does not correlate with hepatic venous oxygenation in children. Can J Anaesth 2002; 49:824-9. [PMID: 12374712 DOI: 10.1007/bf03017416] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To compare transcutaneous near-infrared spectroscopic (NIRS) measured liver tissue oxygenation with hepatic vein oxygen saturation (SvhO2) in children undergoing cardiac catheterization. METHODS A NIRS optode (containing an emitter and a receiver of near-infrared light) was placed directly below the right costal arch above the palpable liver in 40 children aged 0.02 to 7.28 yr (median: 1.8 yr). Spatially resolved spectroscopic measured tissue oxygenation index (TOI) was recorded using the NIRO-300. Paired blood samples from the hepatic vein were taken under radiological control for determination of SvhO2 in a co-oxymeter. TOI values were compared with hepatic vein oxygenation, with simultaneously obtained arterial oxygen saturation (SaO2), inferior vena cava SO2 and hemoglobin concentration using simple linear and multi-regression analysis. RESULTS TOI values ranged from 35% to 73% (58.6 +/- 8.4%); SvhO2 from 32% to 80% (58.4 +/- 14.4%), and arterial SO2 from 54% to 100% (90.0 +/- 11.4%). TOI and hepatic vein oxygen saturation failed to correlate (r = 0.052/P = 0.752). A regression model containing arterial saturation (Delta R2 = 0.177) and the ratio of pulmonary to systemic resistance (Delta R2 = 0.095) explained 27.3% of the observed variance in TOI. In this model, hepatic vein oxygen saturation was no longer significant; explaining only 3.4% of the variance. No other variable retained a significant association. CONCLUSION Transcutaneously measured NIRS tissue oxygenation with an optode placed over the palpable liver does not correlate with SvhO2. The value is dominated by non-hepatic variables such as arterial saturation and vascular resistances.
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Affiliation(s)
- Markus Weiss
- Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland.
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Hayashida N, Teshima H, Tayama E, Chihara S, Enomoto N, Kawara T, Aoyagi S. Influence of colforsin daropate hydrochloride on internal mammary artery grafts. Circ J 2002; 66:372-6. [PMID: 11954952 DOI: 10.1253/circj.66.372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The effect of colforsin daropate hydrochloride (colforsin), a water-soluble forskolin derivative, on blood flow in internal mammary artery (IMA) grafts was evaluated in a prospective randomized study of 26 patients undergoing coronary artery bypass grafting. Patients were randomized to receive either colforsin treatment (colforsin; n=14) or no colforsin treatment (control; n=14). Administration of colforsin (0.5mg x kg(-1) min(-1)) was started after induction of anesthesia and was continued for 6 h. IMA blood flow and hemodynamic measurements were assessed perioperatively. During cardiopoulmonary bypass (CPB), perfusion flow was adjusted to 2.5 L/m2 and IMA free blood flow was measured. IMA blood flow was also measured 1 h after CPB by an ultrasonic flow meter. Systemic vascular resistance was significantly lower in the colforsin group during and after CPB. IMA blood flow was significantly greater in the colforsin group than in the control group during (44 +/- 2 vs 33 +/- 3 ml min-1 x m(-2), p=0.02) and after CPB (38 +/- 6 vs 20 +/- 3ml x min(-1) m(-2), p=0.01). IMA blood flow 1 h after CPB correlated inversely with concurrent systemic vascular resistance (r=-0.61, p=0.001). Intraoperative administration of colforsin daropate hydrochloride caused potent vasodilation, resulting in an increase in IMA blood flow. The results indicate that the regimen can be used perioperatively in patients undergoing coronary artery bypass grafting.
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Okano N, Hiraoka H, Owada R, Fujita N, Kadoi Y, Saito S, Goto F, Morita T. Hepatosplanchnic oxygenation is better preserved during mild hypothermic than during normothermic cardiopulmonary bypass. Can J Anaesth 2001; 48:1011-4. [PMID: 11698321 DOI: 10.1007/bf03016592] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To assess and compare the effects of normothermic and mild hypothermic cardiopulmonary bypass (CPB) on hepatosplanchnic oxygenation. METHODS We studied 14 patients scheduled for elective coronary artery bypass graft surgery who underwent normothermic (>35 degrees C; group I, n=7) or mild hypothermic (32 degrees C; group II, n=7) CPB. After induction of anesthesia, a hepatic venous catheter was inserted into the right hepatic vein to monitor hepatic venous oxygen saturation (ShvO(2)) and hepatosplanchnic blood flow by a constant infusion technique that uses indocyanine green. RESULTS The ShvO(2) decreased from a baseline value in both groups during CPB and was significantly lower at ten minutes and 60 min after the onset of CPB in group I (39.5 +/- 16.2% and 40.1 +/- 9.8%, respectively) than in group II (61.1 +/- 16.2% and 61.0 +/- 17.9%, respectively; P <0.05). During CPB, the hepatosplanchnic oxygen extraction ratio was significantly higher in group I than in group II (44.0 +/- 7.2% vs 28.7 +/- 13.1%; P <0.05). CONCLUSION Hepatosplanchnic oxygenation was better preserved during mild hypothermic CPB than during normothermic CPB.
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Affiliation(s)
- N Okano
- Department of Anesthesiology, Saitama Cardiovascular and Pulmonary Center, Saitama, Japan.
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Sack FU, Reidenbach B, Dollner R, Schledt A, Gebhard MM, Hagl S. Influence of steroids on microvascular perfusion injury of the bowel induced by extracorporeal circulation. Ann Thorac Surg 2001; 72:1321-6. [PMID: 11603454 DOI: 10.1016/s0003-4975(01)02930-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Extracorporeal circulation is associated with gastrointestinal complications. By means of intravital microscopic methods, we investigated whether preoperative treatment with steroids can attenuate the impairment of the bowel microcirculation. METHODS In 20 pigs, a partial left heart bypass (pLHB) was established. A loop of the terminal ileum was exteriorized for intravital-microscopic observation. Seven sham-operated animals served as controls. In 13 animals, pLHB was established for 2 hours with a flow rate of 2,000 mL per minute; 7 of the animals received 20 mg/kg body weight prednisolone preoperatively. The microcirculatory network was analyzed before, during pLHB, and 2 hours after bypass. RESULTS Despite unchanged macro-hemodynamics, pLHB resulted in a significant microvascular perfusion injury of the small bowel. Arteriolar vasoconstriction and a reduction of perfused capillaries per unit area (functional capillary density) to 30% of prebypass values could be found. Blood cell velocities were reduced in submucuous collecting venules. In the steroid-treated animals, the functional capillary density remained normal. In addition, arteriolar vasoconstriction could be prevented. CONCLUSIONS Treatment with prednisolone largely prevents the microcirculatory alterations in the small bowel induced by extracorporeal circulation.
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Affiliation(s)
- F U Sack
- Department of Cardiac Surgery, University of Heidelberg, Germany.
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Yamaura K, Akiyoshi K, Irita K, Taniyama T, Takahashi S. Effects of olprinone, a new phosphodiesterase inhibitor, on gastric intramucosal acidosis and systemic inflammatory responses following hypothermic cardiopulmonary bypass. Acta Anaesthesiol Scand 2001; 45:427-34. [PMID: 11300380 DOI: 10.1034/j.1399-6576.2001.045004427.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Phosphodiesterase (PDE) III inhibitors have both an inotropic and a peripheral vasodilatory effect, and also inhibit the activation of macrophages. Thus a newly developed PDE III inhibitor, olprinone, could modify gastric intramucosal pH (pHi), systemic oxygen consumption, and systemic inflammatory responses in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS We studied 23 patients. In 15 patients, olprinone (0.1 or 0.2 microg x kg(-1) x min(-1)) was administered from the commencement of CPB until their admission to the ICU. The other 8 patients received placebo. The pHi and regional CO2 tension (PrCO2) were assessed by a capnometric air tonometry. Systemic inflammatory responses were evaluated by serum interleukin-6 (IL-6), IL-10, and leucocyte counts. RESULTS The pHi and PCO2-gap, the difference between PrCO2 and arterial CO2 tension (PaCO2), showed a transient decrease and an increase after CPB, respectively. Although olprinone did not affect pHi, olprinone at 0.2 microg x kg(-1) x min(-1) significantly lessened post-CPB increase in PCO2-gap. Olprinone at 0.2 microg x kg(-1) x min(-1) significantly increased IL-10 and reduced the extent of leucocytosis, while it did not affect IL-6 levels. At the same dosage, olprinone also lessened the surge in systemic oxygen uptake index (VO2) and augmented the increase in mixed oxygen saturation (SvO2) both of which occurred after CPB. At 0.1 microg x kg(-1) x min(-1), however, olprinone did not show any significant effect. CONCLUSION Our results suggest that olprinone at 0.2 microg x kg(-1) x min(-1) suppresses gastric intramucosal acidosis and systemic inflammation following CPB.
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Affiliation(s)
- K Yamaura
- Department of Anaesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Yamaura K, Okamoto H, Akiyoshi K, Irita K, Taniyama T, Takahashi S. Effect of low-dose milrinone on gastric intramucosal pH and systemic inflammation after hypothermic cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2001; 15:197-203. [PMID: 11312479 DOI: 10.1053/jcan.2001.21954] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the usefulness of low-dose milrinone on gastric intramucosal pH (pHi) and systemic inflammation in patients undergoing hypothermic cardiopulmonary bypass (CPB). DESIGN Prospective randomized study. SETTING University hospital. PARTICIPANTS Twenty patients scheduled for cardiac surgery. INTERVENTIONS Ten patients were administered a low dose of milrinone, 0.25 microg/kg/min, from the initiation of CPB to 1 hour after admission to the intensive care unit. The other patients were administered saline. Supplemental inotropes and intravenous fluid were given to obtain adequate mean arterial blood pressure and pulmonary artery occlusion pressure. MEASUREMENTS AND RESULTS Gastric pHi and carbon dioxide pressure (PCO2) were assessed by capnometric air tonometry. The difference between PCO2 and arterial carbon dioxide pressure (PaCO2), PCO2-gap, was also examined. Systemic inflammatory responses were evaluated by serum interleukin-6 and leukocyte counts. Hemodynamics, oxygen delivery index, and oxygen uptake index were monitored with catheters in the radial and pulmonary arteries (thermodilution). The hepatic venous blood flow and left ventricular flow were measured using transesophageal echocardiography. Milrinone prevented gastric intramucosal acidosis, detected as a decrease in pHi or an increase in PCO2-gap, without affecting hepatic venous blood flow. Increases in interleukin-6, leukocyte count, and oxygen uptake index, all of which developed after CPB, were significantly less in the milrinone group than in the control group. CONCLUSION These results suggest that in patients undergoing hypothermic CPB, supplemental low-dose milrinone prevents gastric intramucosal acidosis and increases in some markers of systemic inflammation.
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Affiliation(s)
- K Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Abstract
Gastric tonometry has proved to be a sensitive but not specific predictor of outcome in the critically ill. The data accumulated to date indicate that those patients able to achieve or maintain a normal gastric mucosal pH do better than those who do not. In addition, therapy aimed at improving an abnormal gastric mucosal pH has proved to be less successful. These findings may simply indicate that tonometry identifies those "responders" and "nonresponders," as becomes increasingly apparent in populations of critical care patients receiving interventional therapy. Gastric tonometry has undergone a number of methodologic changes over the last decade, seeing a switch from saline to automated gas tonometry. Along with this switch of methodology has come a deeper scrutiny of the indices used to assess gut perfusion. Most studies (including all the interventional ones) have used gastric mucosal pH. The newer indices of gut luminal PCO2 (PgCO2) referenced to arterial CO2 (PgCO2-PaCO2) or end tidal CO2 (PgCO2-PeCO2), although relatively well validated, remain to be proven as predictors of outcome or guides to interventional therapy. If we take a fresh look at the interventional trials in intensive care patients, there is a very definite trend toward benefit in the protocol groups, although they are generally reported as negative studies. There is much to be accomplished, however, before we accept the gastric tonometer as a routine tool with which to guide therapy based on gastrointestinal perfusion, including a greater understanding of gastrointestinal physiology and, as ever, the call for an adequately powered prospective randomized controlled trial to evaluate the clinical utility of gas tonometry.
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Affiliation(s)
- M A Hamilton
- Center for Anesthesia, Middlesex Hospital, and Center for Anesthesia, University College, London, UK
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Soybir N, Tekin S, Koner O, Arat S, Karaoglu K, Sarioglu T. Gastric tonometer monitoring in infants undergoing repair of coarctation of the aorta. J Cardiothorac Vasc Anesth 2000; 14:672-5. [PMID: 11139107 DOI: 10.1053/jcan.2000.18323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate gastric tonometer monitoring for splanchnic hypoperfusion in infants during surgical intervention for aortic coarctation, especially within aortic cross-clamp periods. DESIGN A prospective study. SETTING Cardiovascular intensive care unit in a university hospital. PARTICIPANTS Fourteen infant patients after elective, uncomplicated repair of coarctation of the aorta. INTERVENTIONS After the anesthesia induction, a 7F tonometry catheter was inserted into the stomach oropharyngeally. Gastric carbon dioxide, arterial blood gases, blood pressure of upper extremities, and hematocrit values were measured in 5 different time intervals. Time periods were as follows: T1 (after the anesthesia induction), T2 (before aortic cross-clamp), T3 (immediately after aortic cross-clamp removal), T4 (40 minutes after aortic cross-clamp removal), and T5 (as the patient reached the intensive care unit). Intramucosal pH was measured by means of the Henderson-Hasselbach equation. The mean values of all parameters were calculated. According to T1 time, T2, T3, T4, and T5 times were compared with Student's t-test. MEASUREMENTS AND MAIN RESULTS Mean aortic cross-clamp time was 19.4 +/- 6.6 minutes. Intramucosal pH values of T3 (p < 0.001) and T4 (p < 0.01) were found to be lower than values of T1. The gastric carbon dioxide values of T3 were significantly higher than T1 (p < 0.01), and bicarbonate and arterial pH values of T3 were significantly lower (p < 0.01). There were no significant differences in other parameters over time intervals. CONCLUSION Splanchnic hypoperfusion exists during aortic cross-clamping in infant aortic coarctation surgery, and the tonometric catheter is considered to be a safe method for monitoring this hypoperfusion.
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Affiliation(s)
- N Soybir
- Department of Anesthesiology, Istanbul Memorial Hospital, Turkey
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Demers P, Elkouri S, Martineau R, Couturier A, Cartier R. Outcome with high blood lactate levels during cardiopulmonary bypass in adult cardiac operation. Ann Thorac Surg 2000; 70:2082-6. [PMID: 11156124 DOI: 10.1016/s0003-4975(00)02160-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND High blood lactate levels during cardiopulmonary bypass (CPB) are associated with tissue hypoperfusion and may contribute to postoperative complications or death. The objective of this study was to determine an association between blood lactate levels during CPB and perioperative morbidity and mortality. METHODS We reviewed 1,376 patients who underwent cardiac operation with CPB. Patients with abnormal preoperative blood lactate levels were excluded (n = 101). Blood lactate concentration during CPB, clinical data, and perioperative events were recorded. RESULTS Peak blood lactate levels of 4.0 mmol/L or higher during CPB were present in 227 patients (18.0%). Postoperative mortality was higher in this group than in the patients who had peak blood lactate levels of less than 4.0 mmol/L during CPB (11.0% versus 1.4%; p < 0.001, relative risk [RR] = 9.0). Postoperative hemodynamic instability occurred in 29.5% of patients with elevated levels of lactate during CPB compared with 10.9% of patients with lower lactate levels (p < 0.001, RR = 3.4). Overall, major postoperative complications occurred in 43.2% and 21.8% of patients in each group, respectively (p < 0.001, RR = 2.7). Logistic regression analysis revealed that peak blood lactate levels of 4.0 mmol/L or higher during CPB were strongly associated with postoperative mortality (p = 0.0001) and morbidity (p = 0.013). CONCLUSIONS Blood lactate concentration of 4.0 mmol/L or higher during CPB identifies a subgroup of patients with increased risk of postoperative morbidity and mortality.
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Affiliation(s)
- P Demers
- Department of Surgery, Montreal Heart Institute, Quebec, Canada
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Koga I, Stiernstrom H, Christiansson L, Wiklund L. Intraperitoneal tonometry for detection of regional enteric ischaemia. Acta Anaesthesiol Scand 2000; 44:985-90. [PMID: 10981577 DOI: 10.1034/j.1399-6576.2000.440815.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective of this study was to test the hypothesis that intraperitoneal tonometry can be a specific monitor for ischaemia in the small intestine. METHODS Twelve pigs were anaesthetized and mechanically ventilated. The celiac artery (CA), the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA) were identified. Tonometry catheters were positioned intraperitoneally at three different locations where blood supply varied. One at a time of the mesenteric arteries was occluded, producing regional ischaemia in different splanchnic organs. RESULTS Regional PCO2 (Pr CO2) increased significantly in the intestinal region, in the small intestine, only during the SMA clamping. In the epigastric region, i.e. in the space between the liver and the stomach, PrCO2 increased significantly only during CA clamping. CONCLUSION Intraperitoneal tonometry in the intestinal region can be a specific monitor of ischaemia in the small intestine. INVESTIGATION The care and handling of the animals was in accordance with legislation by the Swedish Board of Agriculture.
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Affiliation(s)
- I Koga
- Department of Anaesthesiology and Intensive Care, Uppsala University Hospital, Sweden
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Ohki S, Kunimoto F, Isa Y, Tsukagoshi H, Ishikawa S, Ohtaki A, Takahashi T, Koyano T, Oriuchi N, Morishita Y. Changes in gastric intramucosal pH and circulating blood volume following coronary artery bypass grafting. Can J Anaesth 2000; 47:516-21. [PMID: 10875714 DOI: 10.1007/bf03018942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To determine the changes in gastric intramucosal pH (pHi) following coronary artery bypass grafting (CABG) in comparison with systemic hemodynamic variables and circulating blood volume (BVc). METHODS Twenty patients who underwent CABG under mild hypothermic cardiopulmonary bypass (CPB) were included. Hemodynamic variables and the values of pHi were obtained at 3,6, 12 and 24 hr after admission to the intensive care unit (ICU). The pHi was measured by gastric tonometric catheter. The BVc was measured by carbon monoxide (CO)-labeled hemoglobin (CO-Hb) dilution method (CO method) at 6 and 24 hr after ICU admission. RESULTS Systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI) decreased with time. Systemic oxygen delivery index (DO2I) and systemic oxygen consumption index (VO2I) showed a gradual increase during the study period. By contrast, pHi decreased to the lowest value (7.26+/-0.05) at six hours and returned to normal levels (7.34+/-0.04) at 24 hr after ICU admission. Changes in BVc between six and 24 hr ranged from -242 ml to 978 ml (mean, 334+/-338 ml). The pHi increased in patients whose BVc increased by > 300 ml. Mean fluid balance was negative in this period (-386+/-667 ml; range, -1786 - + 423 ml). CONCLUSION The pHi showed the lowest value at six hours and returned to normal at 24 hr after ICU admission. The pHi increased with the decrease in vascular resistance and with the increases in BVc in this period. The improvement of pHi, an indicator of splanchnic perfusion, appears to be related to systemic vasodilatation and an increase in BVc.
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Affiliation(s)
- S Ohki
- Second Department of Surgery, Gunma University School of Medicine, Maebashi, Japan.
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Cox CS, Allen SJ, Sauer H, Frederick J. Effects of selectin-sialyl Lewis blockade on mesenteric microvascular permeability associated with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2000; 119:1255-61. [PMID: 10838545 DOI: 10.1067/mtc.2000.105262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Cardiopulmonary bypass is associated with an inflammatory response that is associated with a neutrophil-mediated microvascular barrier injury. We studied the effects of blocking neutrophil-endothelial tethering on microvascular permeability and edema formation during cardiopulmonary bypass. Using a selectin antagonist that prevents interactions with their ligands, we hypothesized that there would be less neutrophil infiltration into the tissue and a reduction in microvascular permeability and edema formation. METHODS A canine mesenteric lymphatic fistula was created to measure Starling forces and to determine microvascular permeability. Normothermic, atrial-femoral cardiopulmonary bypass was initiated (70-90 mL. kg(-1). min(-1)). Intestinal tissue water was determined with microgravimetry. Ileal tissue myeloperoxidase was measured as an index of neutrophil tissue infiltration. One experimental group received the selectin antagonist TBC 1269 before the initiation of bypass, and the control group received saline solution. RESULTS There was a modest increase in microvascular permeability in both groups, as evidenced by significantly increased transvascular protein clearance and a trend toward a decrease in reflection coefficient. There were no differences in the experimental group compared with the control group. Ileal tissue myeloperoxidase levels were lower in the experimental group than in the control group. CONCLUSIONS The selectin antagonist TBC 1269 reduces neutrophil infiltration into the ileum without altering ileal microvascular permeability or edema associated with cardiopulmonary bypass.
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Affiliation(s)
- C S Cox
- Department of Surgery, Division of Pediatric Surgery, and the Center for Lymphatic and Microvascular Studies at the University of Texas-Houston, Medical School, Houston, Texas, USA.
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Cox CS, Brennan M, Allen SJ. Impact of hetastarch on the intestinal microvascular barrier during ECLS. J Appl Physiol (1985) 2000; 88:1374-80. [PMID: 10749832 DOI: 10.1152/jappl.2000.88.4.1374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The effects of hetastarch on microvascular fluid flux were determined in anesthetized dogs undergoing extracorporeal life support (ECLS) with a roller pump and membrane oxygenator. ECLS with a lactated Ringer priming solution resulted in a decrease in microvascular protein reflection coefficient and an increase in transvascular protein clearance. Use of a 6% hetastarch priming solution attenuated the decrease in microvascular protein reflection coefficient and blunted the increase in transvascular protein clearance. Ileal tissue water increased in the group treated with the lactated Ringer priming solution compared with the group treated with 6% hetastarch. The effective plasma-to-interstitial colloid osmotic pressure gradient was greater in the group treated with hetastarch than in the group treated with lactated Ringer solution. Hetastarch decreases the edema associated with ECLS. The reduction in edema is due to the maintenance of the plasma-to-interstitial colloid osmotic pressure gradient and the reduction in the microvascular permeability to protein.
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Affiliation(s)
- C S Cox
- Department of Surgery, Department of Anesthesiology, and Center for Microvascular and Lymphatic Studies, Medical School, University of Texas-Houston, Houston, Texas 77030, USA.
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Iribe G, Yamada H, Matsunaga A, Yoshimura N. Effects of the phosphodiesterase III inhibitors olprinone, milrinone, and amrinone on hepatosplanchnic oxygen metabolism. Crit Care Med 2000; 28:743-8. [PMID: 10752824 DOI: 10.1097/00003246-200003000-00023] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To measure the hepatic venous oxygen saturation in patients after cardiac surgery and to compare the effects of olprinone (OLP), a newly synthesized phosphodiesterase III inhibitor, with those of milrinone (MIL) and amrinone (AMR) on hepatosplanchnic oxygen dynamics. Phosphodiesterase III inhibitors are used to improve the hemodynamic state after cardiac surgery. However, the effect of these agents on the hepatosplanchnic circulation has not been investigated thoroughly. DESIGN Prospective, randomized study. SETTING University hospital intensive care unit (ICU). PATIENTS Twenty-nine patients undergoing elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS In each patient, a 7.5-Fr oximeter catheter was placed in the hepatic vein via the right femoral vein. Catheterization was completed before admission to the ICU, and the study was performed 8 to 24 hrs after surgery, after obtaining stable systemic hemodynamics in the ICU. The patients were assigned randomly to three groups, and they received one of three drugs for 2 hrs (OLP group, 0.3 microg/kg/min of OLP; MIL group, 0.5 microg/kg/min of MIL; AMR group, 10 microg/kg/min of AMR). The authors did not change the patient's hemodynamic interventions, including catecholamines and vasodilators, throughout the study period. Arterial and hepatic venous blood gas data and hemodynamic data (via a pulmonary artery catheter) were obtained before and after drug infusion. Using these data, the authors calculated systemic oxygen delivery and consumption, the systemic oxygen extraction ratio and the hepatosplanchnic oxygen extraction ratio, and the change in hepatosplanchnic blood flow using Fick's equation. Although the increases in cardiac index were not significantly different among the three groups, hepatic venous oxygen saturation increased significantly only in the OLP group (from 47.1% +/-2.6% to 57.0% +/- 1.5% in the OLP group, from 48.4% +/- 2.3% to 50.9% +/- 2.6% in the MIL group, and from 49.8% +/- 3.6% to 50.8% + +/-.7% in the AMR group). The calculated hepatosplanchnic blood flow change was significantly larger in the OLP group than in the other groups (30.1% +/- 5.7% in the OLP group, 9.3% +/- 5.1% in the MIL group, and 2.6% +/- 6.5% in the AMR group). CONCLUSIONS These results suggest that OLP enhances hepatosplanchnic blood flow and thus may be beneficial in protecting the hepatosplanchnic organs after cardiac surgery.
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Affiliation(s)
- G Iribe
- Division of Intensive Care Medicine, Kagoshima University Hospital, Kagoshima-shi, Japan
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Li J, Schulze-Neick I, Lincoln C, Shore D, Scallan M, Bush A, Redington AN, Penny DJ. Oxygen consumption after cardiopulmonary bypass surgery in children: determinants and implications. J Thorac Cardiovasc Surg 2000; 119:525-33. [PMID: 10694613 DOI: 10.1016/s0022-5223(00)70132-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to assess oxygen consumption and its determinants in children shortly after undergoing cardiopulmonary bypass operations. METHODS Twenty children, aged 2 months to 15 years (median, 3.75 years), undergoing hypothermic cardiopulmonary bypass operations were studied during the first 4 hours after arrival in the intensive care unit. Central and peripheral temperatures were monitored. Oxygen consumption was continuously measured by using respiratory mass spectrometry. Oxygen delivery was calculated from oxygen consumption and arterial and mixed venous oxygen contents, which were sampled every 30 minutes. Oxygen extraction was derived by the ratio of oxygen consumption and oxygen delivery. Arterial blood lactate levels were measured every 30 minutes. RESULTS There was a correlation between oxygen consumption and age in patients older than 3 months (r = -0.76). Mean oxygen consumption increased by 14.7% during the study. The increase in oxygen consumption was correlated with the increase in central temperature (r = 0.73). Nine patients had an arterial lactate level above 2 mmol/L on arrival. There were no significant differences in oxygen consumption, oxygen delivery, and oxygen extraction between the group with lactate levels between 2 and 3 mmol/L and the groups with normal lactate levels both on arrival and at 2 hours. One patient with a peak lactate level of 6.8 mmol/L had initially low oxygen delivery (241.3 mL. min(-1). m(-2)). CONCLUSIONS During the early hours after a pediatric cardiac operation, the increase in oxygen consumption is mainly attributed to the increase in central temperature. Oxygen consumption is negatively related to age. Mild lactatemia is common and does not appear to reflect oxygen delivery or oxygen consumption or a more complicated recovery.
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Affiliation(s)
- J Li
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Munoz R, Laussen PC, Palacio G, Zienko L, Piercey G, Wessel DL. Changes in whole blood lactate levels during cardiopulmonary bypass for surgery for congenital cardiac disease: an early indicator of morbidity and mortality. J Thorac Cardiovasc Surg 2000; 119:155-62. [PMID: 10612775 DOI: 10.1016/s0022-5223(00)70231-5] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Our objective was to evaluate the change in lactate level during cardiopulmonary bypass and the possible predictive value in identifying patients at high risk of morbidity and mortality after surgery for congenital cardiac disease. METHODS We prospectively studied lactate levels in 174 nonconsecutive patients undergoing cardiopulmonary bypass during operations for congenital cardiac disease. Arterial blood samples were taken before cardiopulmonary bypass, during cardiopulmonary bypass (cooling and rewarming), after cardiopulmonary bypass, and during admission to the cardiac intensive care unit. Complicated outcomes were defined as open sternum as a response to cardiopulmonary instability, renal failure, cardiac arrest and resuscitation, extracorporeal membrane oxygenation, and death. RESULTS The largest increment in lactate level occurred during cardiopulmonary bypass. Lactate levels decreased between the postbypass period and on admission to the intensive care unit. Patients who had circulatory arrest exhibited higher lactate levels at all time points. Nonsurvivors had higher lactate levels at all time points. A change in lactate level of more than 3 mmol/L during cardiopulmonary bypass had the optimal sensitivity (82%) and specificity (80%) for mortality, although the positive predictive value was low. CONCLUSIONS Hyperlactatemia occurs during cardiopulmonary bypass in patients undergoing operations for congenital cardiac disease and may be an early indicator for postoperative morbidity and mortality.
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Affiliation(s)
- R Munoz
- Department of Cardiology, Children's Hospital, Boston, Massachusetts, USA.
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Ackland G, Grocott MPW, Mythen MG. Understanding gastrointestinal perfusion in critical care: so near, and yet so far. Crit Care 2000; 4:269-81. [PMID: 11094506 PMCID: PMC137256 DOI: 10.1186/cc709] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2000] [Accepted: 08/08/2000] [Indexed: 02/08/2023] Open
Abstract
An association between abnormal gastrointestinal perfusion and critical illness has been suggested for a number of years. Much of the data to support this idea comes from studies using gastric tonometry. Although an attractive technology, the interpretation of tonometry data is complex. Furthermore, current understanding of the physiology of gastrointestinal perfusion in health and disease is incomplete. This review considers critically the striking clinical data and basic physiological investigations that support a key role for gastrointestinal hypoperfusion in initiating and/or perpetuating critical disease.
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Affiliation(s)
- Gareth Ackland
- Centre for Anaesthesia, University College London, London, UK
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Müller M, Boldt J, Schindler E, Sticher J, Kelm C, Roth S, Hempelmann G. Effects of low-dose dopexamine on splanchnic oxygenation during major abdominal surgery. Crit Care Med 1999; 27:2389-93. [PMID: 10579253 DOI: 10.1097/00003246-199911000-00011] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To study the influence of low-dose dopexamine on splanchnic oxygenation during major abdominal surgery. DESIGN Prospective, randomized, placebo-controlled study. SETTING University hospital. PATIENTS Eighteen adult patients undergoing elective major abdominal surgery. INTERVENTIONS The patients received either dopexamine at 1 microg/kg/min (group A, n = 9) or 0.90% saline as control (group B, n = 9). MEASUREMENTS AND RESULTS To assess the splanchnic oxygenation, intestinal tissue PO2 (PtissO2) and gastric intramucosal Pco2 (PmucCO2) were measured, and the PCO2 gap (PmucCO2 - PaCO2) was calculated at baseline (T1) and after an infusion period of 60 mins (T2). There was no difference between the groups in the global oxygen transport parameters. Low-dose dopexamine increases PtissO2 on the serosal side of the small bowel (deltaPtissO2, 17+/-24 mm Hg in group A vs. -5+/-10 in group B). The changes in PtissO2 at the serosal side of the colon after dopexamine demonstrated a nonsignificant increase (deltaPtissO2, 7+/-11 mm Hg in group A vs. -11+/-23 mm Hg in group B). In both groups, the Pco2 gap (group A, 6+/-7 mm Hg [T1] and 5+/-6 mm Hg [T2], vs. group B, 9+/-10 mm Hg [T1] and 12+/-10 mm Hg [T2]) remained unchanged compared with the baseline. CONCLUSION It is concluded that low-dose dopexamine improves PtissO2 at the serosal side of the gut, preferably at the small bowel. However, low-dose dopexamine did not improve gastric PmucCO2.
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Affiliation(s)
- M Müller
- Department of Anaesthesiology and Intensive Care Medicine, Justus-Liebig-University, Giessen, Germany
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Lebuffe G, Decoene C, Pol A, Prat A, Vallet B. Regional Capnometry with Air-Automated Tonometry Detects Circulatory Failure Earlier Than Conventional Hemodynamics After Cardiac Surgery. Anesth Analg 1999. [DOI: 10.1097/00000539-199911000-00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lebuffe G, Decoene C, Pol A, Prat A, Vallet B. Regional Capnometry with Air-Automated Tonometry Detects Circulatory Failure Earlier Than Conventional Hemodynamics After Cardiac Surgery. Anesth Analg 1999. [DOI: 10.1213/00000539-199911000-00003] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Keenan SP, Guyatt GH, Sibbald WJ, Cook DJ, Heyland DK, Jaeschke RZ. How to use articles about diagnostic technology: gastric tonometry. Crit Care Med 1999; 27:1726-31. [PMID: 10507590 DOI: 10.1097/00003246-199909000-00005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Periodic diagnostic tests and continuous and intermittent monitoring are integral to critical care medicine. The focus of this article is understanding the impact of existing diagnostic technology, as well as that of new diagnostic technology. DATA SYNTHESIS We use literature about gastric tonometry to illustrate eight steps for assessing the value of diagnostic technology. METHODS These steps focus on how the technology works in the laboratory, its range of uses and diagnostic accuracy, its impact on healthcare workers, the decision making process, and patient outcomes, as well as issues of access, cost, and application in your own setting. CONCLUSIONS Awareness of the scope and quality of research evaluating new and existing diagnostic technology is central to modern critical care practice.
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Affiliation(s)
- S P Keenan
- Department of Medicine, University of Western Ontario Faculty of Health Sciences Centre, London, Canada
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Abstract
The purpose of inflammation is to combat various agents that may injure the tissues. Conditions such as CPB can often cause systemic inflammation and dysfunction of major organs. Pulmonary, renal, myocardial and intestinal function may suffer various degrees of impairment during and after cardiac surgery. Although changes in major organs usually remain clinically insignificant, severe organ failure is not uncommon. The process of systemic inflammation proceeds through activation of serum proteins, activation of leucocytes and endothelial cells, secretion of cytokines, leucocyte-endothelial cell interaction, leucocyte extravasation and tissue damage. Several anti-inflammatory strategies have already been used, some of which have given promising results pertaining to further reduction in the rate of the inflammation-related complications in cardiac surgical patients.
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Affiliation(s)
- G Asimakopoulos
- Cardiothoracic Unit, Imperial College School of Medicine at Hammersmith Hospital, London, UK.
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McNicol L, Andersen LW, Liu G, Doolan L, Baek L. Markers of splanchnic perfusion and intestinal translocation of endotoxins during cardiopulmonary bypass: effects of dopamine and milrinone. J Cardiothorac Vasc Anesth 1999; 13:292-8. [PMID: 10392680 DOI: 10.1016/s1053-0770(99)90266-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate markers of splanchnic perfusion and the extent of endotoxemia during cardiopulmonary bypass (CPB) and to compare the effects of dopamine and milrinone on both splanchnic perfusion and endotoxemia. DESIGN Prospective, randomized, blinded study. SETTING University teaching hospital. PARTICIPANTS Twenty-four patients scheduled for elective coronary artery bypass graft surgery (CABG). INTERVENTIONS Patients were allocated to receive placebo (eight patients), dopamine (eight patients), or milrinone (eight patients) during CPB, and at seven times intraoperatively assays were performed of arterial and hepatic venous endotoxin levels, as well as measurements and/or calculations of intramucosal gastric pH (pHi), arterial and hepatic venous lactate-pyruvate ratio (lac/pyr), and hepatic venous oxygen saturation (S(HV)O2). MEASUREMENTS AND MAIN RESULTS Both splanchnic and systemic endotoxin levels increased significantly, and this was unaffected by either dopamine or milrinone. Gastric pHi did not change, and there were only modest increases in lac/pyr, which remained within the normal range of less than 10 in both splanchnic and systemic blood. In the placebo group, S(HV)O2 decreased at the onset of CPB and also significantly decreased during rewarming and at the end of CPB and surgery. In the dopamine-treated patients, S(HV)O2 was greater compared with placebo and milrinone during both hypothermic and rewarming phases. CONCLUSION Endotoxemia occurs during routine CPB. Neither pHi nor lac/pyr values showed adverse change, but hepatic venous oximetry may be a more sensitive indicator of splanchnic dysoxia in that S(HV)O2 was reduced during rewarming. Whether dopamine or milrinone confer protection against splanchnic ischemia remains uncertain.
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Affiliation(s)
- L McNicol
- Department of Anaesthesia, Austin and Repatriation Medical Centre, Melbourne, Australia
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Hepatosplanchnic perfusion. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199906000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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He G, Shankar RA, Chzhan M, Samouilov A, Kuppusamy P, Zweier JL. Noninvasive measurement of anatomic structure and intraluminal oxygenation in the gastrointestinal tract of living mice with spatial and spectral EPR imaging. Proc Natl Acad Sci U S A 1999; 96:4586-91. [PMID: 10200306 PMCID: PMC16376 DOI: 10.1073/pnas.96.8.4586] [Citation(s) in RCA: 275] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
EPR imaging has emerged as an important tool for noninvasive three-dimensional (3D) spatial mapping of free radicals in biological tissues. Spectral-spatial EPR imaging enables mapping of the spectral information at each spatial position, and, from the observed line width, the localized tissue oxygenation can be mapped. We report the development of EPR imaging instrumentation enabling 3D spatial and spectral-spatial EPR imaging of small animals. This instrumentation, along with the use of a biocompatible charcoal oximetry-probe suspension, enabled 3D spatial imaging of the gastrointestinal (GI) tract, along with mapping of oxygenation in living mice. By using these techniques, the oxygen tension was mapped at different levels of the GI tract from the stomach to the rectum. The results clearly show the presence of a marked oxygen gradient from the proximal to the distal GI tract, which decreases after respiratory arrest. This technique for in vivo mapping of oxygenation is a promising method, enabling the noninvasive imaging of oxygen within the normal GI tract. This method should be useful in determining the alterations in oxygenation associated with disease.
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Affiliation(s)
- G He
- Molecular and Cellular Biophysics Laboratories, Department of Medicine, Division of Cardiology and the EPR Center, Johns Hopkins Medical Institutions, Baltimore, MD 21224, USA
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Christiansen CL, Ahlburg P, Jakobsen CJ, Andresen EB, Paulsen PK. The influence of propofol and midazolam/halothane anesthesia on hepatic SvO2 and gastric mucosal pH during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1998; 12:418-21. [PMID: 9713730 DOI: 10.1016/s1053-0770(98)90195-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Because propofol is known to reduce vascular resistance, the objective of this study was to compare the indices of hepatosplanchnic circulation and oxygenation during cardiopulmonary bypass (CPB) in patients anesthetized with either propofol or midazolam/halothane. DESIGN A prospective, randomized, nonblinded study. SETTING A university hospital. PARTICIPANTS Twenty patients undergoing cardiac surgery with CPB. INTERVENTIONS Nine patients were anesthetized with propofol/fentanyl/pancuronium and 11 patients were anesthetized with midazolam/halothane/fentanyl/pancuronium. All patients had a nasogastric tonometer tube and two fiberoptic thermodilution catheters inserted; one in the pulmonary artery and one in the upper right hepatic vein. During bypass, SvO2s were measured from the venous line of the heart-lung machine. MEASUREMENTS AND MAIN RESULTS Gastric mucosal pH (pHi) was measured prebypass, 30 minutes after the start of CPB, and just before weaning off CPB. Hepatic SvO2 (HSvO2) values were recorded every 5 minutes. The pH gap was less at 30 minutes of hypothermic CPB in the propofol group. In the midazolam/halothane group, the HSvO2 decreased after the start of rewarming, whereas in the propofol group the values remained almost at the prebypass levels. At the end of rewarming, the HSvO2 was almost identical in the two groups. CONCLUSION Propofol preserved the HSvO2 during CPB and produced a more optimal relationship between the hepatosplanchnic blood flow and oxygen consumption.
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Bacher A, Mayer N, Rajek AM, Haider W. Acute normovolaemic haemodilution does not aggravate gastric mucosal acidosis during cardiac surgery. Intensive Care Med 1998; 24:313-21. [PMID: 9609408 DOI: 10.1007/s001340050573] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Acute normovolaemic haemodilution with subsequent autologous blood transfusion after surgery is widely used to reduce homologous blood requirements during cardiac surgery. The hypothesis tested was whether a low intraoperative haematocrit (Hct) resulting from haemodilution decreases gastric mucosal pH (pHi). DESIGN Prospective clinical investigation. SETTING University Hospital of Vienna, Austria. PATIENTS 16 consecutive patients scheduled for elective cardiac surgery. INTERVENTIONS The patients were randomly assigned to one of two groups: In 10 patients (group 1), 500 ml of blood was withdrawn and stored after anaesthesia induction. An equal amount of 6% hydroxyethyl starch was simultaneously infused. After discontinuation of cardiopulmonary bypass (CPB), the autologous blood unit was transfused. Six patients (group 2), who were not subjected to haemodilution and autologous blood transfusion served as controls. In all patients, a gastric tonometry probe was inserted. MEASUREMENTS AND RESULTS Measurements of pHi and Hct were performed before and after acute normovolaemic haemodilution, during pulsatile hypothermic (30-32 degrees C) CPB, after rewarming, and 30 min after autologous blood transfusion in group 1, and at corresponding time intervals in group 2. Repeated measures analysis of variance and the Mann-Whitney U test were used for statistical analysis. Data are presented as means +/- standard error of the mean. Haemodilution in group 1 caused a significant and persistent decrease in Hct (after haemodilution in group 1 34 +/- 1 vs 40 +/- 1% in group 2). In both groups, pHi decreased during rewarming and after termination of CPB. However, in group 1, pHi was better preserved than in group 2 (rewarming: 7.44 +/- 0.02 vs 7.34 +/- 0.04; after CPB: 7.38 +/- 0.03 vs 7.28 +/- 0.02; p < 0.05). CONCLUSIONS Acute normovolaemic haemodilution does not aggravate gastric mucosal acidosis during cardiac surgery.
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Affiliation(s)
- A Bacher
- Department of Anaesthesiology and General Intensive Care, University of Vienna, Austria.
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Hamulu A, Atay Y, Yağdi T, Dişçigil B, Bakalim T, Büket S, Bilkay O. Effects of flow types in cardiopulmonary bypass on gastric intramucosal pH. Perfusion 1998; 13:129-35. [PMID: 9533119 DOI: 10.1177/026765919801300208] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to determine the relationship between splanchnic perfusion and oxygen consumption, and flow types in cardiopulmonary bypass (CPB), by measuring gastric intramucosal pH. Twenty patients undergoing elective open-heart surgery were prospectively randomized to receive either pulsatile or nonpulsatile flow during CPB. Gastric intramucosal pH was measured using gastric tonometry. A flowmeter was used to measure the inferior caval vein flow. A catheter was inserted through the femoral vein to sample blood from the iliac vein. Systemic vascular resistance index, gastric intramucosal pH, inferior caval vein flow and arterial, inferior vena caval and iliac venous blood gases were recorded at different times. Gastric intramucosal pH decreased in all patients; only in the nonpulsatile group was this decrease statistically significant. After 45 min of CPB, the pH was 7.37 +/- 0.03 compared with the prebypass value of 7.48 +/- 0.04 (p = 0.00016). After weaning from CPB, the pH was 7.358 +/- 0.02 compared with the prebypass value (p = 0.000037). At 2 h post-operatively the pH was 7.416 +/- 0.025 (p = 0.02). Systemic vascular resistance index rose in all patients during bypass in both groups. These changes did not have any statistical significances and after weaning from bypass returned to prebypass levels. We conclude that nonpulsatile flow in CPB is associated with reduced gastric intramucosal pH and the measurement of intramucosal pH during open-heart surgery provides important information about splanchnic perfusion.
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Affiliation(s)
- A Hamulu
- Department of Cardiovascular Surgery, Ege University Medical Faculty, Bornova, Izmir
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Bonham MJ, Abu-Zidan FM, Simovic MO, Windsor JA. Gastric intramucosal pH predicts death in severe acute pancreatitis. Br J Surg 1998. [PMID: 9448612 DOI: 10.1046/j.1365-2168.1997.02852.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study tested the hypothesis that gastric intramucosal pH (pHi) can predict death in severe acute pancreatitis. METHODS Seventeen consecutive patients with predicted severe acute pancreatitis were studied prospectively. Four died from complications related to pancreatitis. Gastric pHi was measured by nasogastric tonometry at least every 12 h for the first 48 h after admission and then on a daily basis during the first week. RESULTS The lowest pHi recorded during the first 48 h was significantly less in those admitted to the intensive care unit than that in those who remained on the surgical ward (P = 0.0015) and in nonsurvivors compared with the survivors (P = 0.009). A receiver-operator characteristic curve defined a pHi of 7.25 as the optimal cut-off point to predict death (sensitivity 100 per cent, specificity 77 per cent, overall predictive value 82 per cent). CONCLUSION These results suggest that splanchnic ischaemia may be an important determinant of outcome in patients with severe acute pancreatitis.
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Affiliation(s)
- M J Bonham
- Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, New Zealand
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