Significado biológico y utilidad clínica del lactato en la sepsis / Biological significance and clinical utility of lactate in sepsis

La sepsis es un problema global de salud y la progresión hacia el shock séptico se asocia con un incremento marcado de la morbimortalidad. En este escenario, el aumento del lactato plasmático demostró ser un indicador de gravedad y un predictor de mortalidad, y suele interpretarse casi exclusivamente como marcador de baja perfusión tisular. Sin embargo, últimamente se produjo un cambio de paradigma en la exégesis del metabolismo y propiedades biológicas del lactato. En efecto, la adaptación metabólica al estrés, aun con adecuado aporte de oxígeno, puede justificar la elevación del lactato circulante. Asimismo, otras consecuencias fisiopatológicas de la sepsis, como la disfunción mitocondrial, se asocian con el desarrollo de hiperlactatemia sin que necesariamente se acompañen de baja perfusión tisular. Interpretar el origen y la función del lactato puede resultar de suma utilidad clínica en la sepsis, especialmente cuando sus niveles circulantes fundamentan las medidas de reanimación.

Sepsis is a global health problem; progression to septic shock is associated with a marked increase in morbidity and mortality. In this setting, increased plasma lactate levels demonstrated to be an indicator of severity and a predictor of mortality, and are usually interpreted almost exclusively as a marker of low tissue perfusion. However, a recent paradigm shift has occurred in the exegesis of lactate metabolism and its biological properties. Indeed, metabolic adaptation to stress, even with an adequate oxygen supply, may account for high circulating lactate levels. Likewise, other pathophysiological consequences of sepsis, such as mitochondrial dysfunction, are associated with the development of hyperlactatemia, which is not necessarily accompanied by low tissue perfusion. Interpreting the origin and function of lactate may be of great clinical utility in sepsis, especially when circulating lactate levels are the basis for resuscitative measures.

Sepsis and septic shock: epidemiology, clinical parameters, and prognostic factors in a brazilian intensive care unit / Sepse e choque séptico: epidemiologia, parâmetros clínicos e fatores prognósticos em uma unidade de terapia intensiva brasileira / Sepsis y shock séptico: epidemiología, parámetros clínicos y factores pronósticos en una unidad de cuidados intensivos brasileña

Sepsis is an organ dysfunction caused by a dysregulated host response to infection and is associated with high morbidity and mortality. The identification of prognostic markers in this syndrome has been a strategy to increase treatment efficacy. The objectives of this study were: 1) to describe the epidemiological and microbiological profile of septic patients and 2) to investigate the association between laboratory/clinical parameters and mortality rate, identifying prognostic markers. Using a prospective observational protocol, epidemiological, clinical and laboratory data were collected from adult patients with sepsis or septic shock admitted to a Brazilian Intensive Care Unit. During the study period, 120 patients were diagnosed with sepsis and 71.67% (n = 86) were included in the protocol. The overall mortality was 69.76% and chronic diseases were identified in 79.07% of cases. The mortality rates for sepsis and septic shock were 51.06% and 92.31%, respectively. SOFA scores on the first, third, and seventh days of hospitalization gradually increased for patients who had clinical worsening. Hyperlactatemia and hyperglycemia were identified in 45.9% and 27% of patients, respectively, and were associated with mortality. INR values greater than 1.5 or thrombocytopenia were related to 92.9% and 88.6% mortality, respectively. In the study, gender, age, ICU stay, site of infection and microbiological agent were not associated with the risk of death. However, the presence of comorbidities, high SOFA scores, three or more organ dysfunctions, and sepsis severity correlated directly with mortality rate.

A sepse é uma disfunção orgânica causada por uma resposta desregulada do hospedeiro à infecção e está associada a alta morbidade e mortalidade. A identificação de marcadores prognósticos nessa síndrome tem sido uma estratégia para aumentar a eficácia do tratamento. Os objetivos deste estudo foram: 1) descrever o perfil epidemiológico e microbiológico de pacientes sépticos e 2) investigar a associação entre parâmetros laboratoriais/clínicos e a taxa de mortalidade, identificando marcadores prognósticos. Por meio de um protocolo observacional prospectivo foram coletados dados epidemiológicos, clínicos e laboratoriais de pacientes adultos com sepse ou choque séptico internados em uma Unidade de Terapia Intensiva brasileira. No período do estudo, 120 pacientes foram diagnosticados com sepse e 71,67% (n = 86) foram incluídos no protocolo. A mortalidade geral foi de 69,76% e doenças crônicas foram identificadas em 79,07% dos casos. As taxas de mortalidade por sepse e choque séptico foram de 51,06% e 92,31%, respectivamente. Os escores SOFA no primeiro, terceiro e sétimo dias de internação aumentaram gradativamente para os pacientes que apresentaram piora clínica. Hiperlactatemia e hiperglicemia foram identificadas em 45,9% e 27% dos pacientes, respectivamente, tendo sido associadas à mortalidade. Valores de INR maiores que 1,5 ou trombocitopenia foram relacionados a 92,9% e 88,6% de mortalidade, respectivamente. No estudo, sexo, idade, permanência na UTI, local da infecção e agente microbiológico não se associaram ao risco de óbito. No entanto, a presença de comorbidades, altos escores SOFA, três ou mais disfunções orgânicas e a gravidade da sepse correlacionaram-se diretamente com a taxa de mortalidade.

La sepsis es una disfunción orgánica causada por una respuesta desregulada del huésped a la infección y se asocia a una elevada morbilidad y mortalidad. La identificación de marcadores pronósticos en este síndrome ha sido una estrategia para aumentar la eficacia del tratamiento. Los objetivos de este estudio fueron: 1) describir el perfil epidemiológico y microbiológico de los pacientes sépticos y 2) investigar la asociación entre los parámetros de laboratorio/clínicos y la tasa de mortalidad, identificando marcadores pronósticos. Mediante un protocolo observacional prospectivo, se recogieron datos epidemiológicos, clínicos y de laboratorio de pacientes adultos con sepsis o shock séptico ingresados en una Unidad de Cuidados Intensivos brasileña. Durante el período de estudio, 120 pacientes fueron diagnosticados de sepsis y el 71,67% (n = 86) fueron incluidos en el protocolo. La mortalidad global fue del 69,76% y se identificaron enfermedades crónicas en el 79,07% de los casos. Las tasas de mortalidad por sepsis y shock séptico fueron del 51,06% y el 92,31%, respectivamente. Las puntuaciones SOFA en el primer, tercer y séptimo día de hospitalización aumentaron gradualmente en los pacientes que presentaron empeoramiento clínico. La hiperlactatemia y la hiperglucemia se identificaron en el 45,9% y el 27% de los pacientes, respectivamente, y se asociaron a mortalidad. Los valores de INR superiores a 1,5 o la trombocitopenia se relacionaron con un 92,9% y un 88,6% de mortalidad, respectivamente. En el estudio, el sexo, la edad, la estancia en la UCI, el lugar de la infección y el agente microbiológico no se asociaron con el riesgo de muerte. Sin embargo, la presencia de comorbilidades, las puntuaciones SOFA elevadas, tres o más disfunciones orgánicas y la gravedad de la sepsis se correlacionaron directamente con la tasa de mortalidad.

Valor prognóstico da hiperlactatemia em pacientes admitidos com infecção em unidades de terapia intensiva: estudo multicêntrico / Prognostic value of hyperlactatemia in infected patients admitted to intensive care units: a multicenter study

RESUMO Objetivo: Avaliar a influência das características dos pacientes na hiperlactatemia em uma população admitida com infecção em unidades de terapia intensiva, bem como a influência da gravidade da hiperlactatemia na mortalidade hospitalar. Metódos: Foi realizada uma análise post hoc da hiperlactatemia no INFAUCI, um estudo nacional prospectivo, observacional e multicêntrico, que incluiu 14 unidades de terapia intensiva portuguesas. Foram selecionados pacientes admitidos com infecção em unidades de terapia intensiva com dosagem de lactato nas primeiras 12 horas de admissão. A sepse foi identificada de acordo com a definição Sepsis-2 aceita no momento da coleta de dados. A gravidade da hiperlactatemia foi classificada como leve (2 - 3,9mmol/L), moderada (4,0 - 9,9mmol/L) ou grave (> 10mmol/L). Resultados: De 1.640 pacientes admitidos com infecção, a hiperlactatemia ocorreu em 934 (57%) e foi classificada como leve, moderada e grave em 57,0%, 34,4% e 8,7% dos pacientes, respectivamente. A presença de hiperlactatemia e um maior grau de hiperlactatemia se associaram a um maior Simplified Acute Physiology Score II, a maior Índice de Comorbidade de Charlson e à presença de choque séptico. Em relação à curva Receiver Operating Characteristic do lactato para mortalidade hospitalar, foi encontrada área sob a curva de 0,64 (IC95% 0,61 - 0,72), que aumentou para 0,71 (IC95% 0,68 - 0,74) quando se combinou o Sequential Organ Failure Assessment. A mortalidade intra-hospitalar com outras covariáveis ajustadas pelo Simplified Acute Physiology Score II se associou à hiperlactatemia moderada e grave, com razão de chances de 1,95 (IC95% 1,4 - 2,7; p < 0,001) e 4,54 (IC95% 2,4 - 8,5; p < 0,001), respectivamente. Conclusão: Os níveis de lactato sanguíneo correlacionam-se independentemente com a mortalidade intra-hospitalar para graus moderados e graves de hiperlactatemia.

ABSTRACT Objective: To evaluate the influence of patient characteristics on hyperlactatemia in an infected population admitted to intensive care units and the influence of hyperlactatemia severity on hospital mortality. Methods: A post hoc analysis of hyperlactatemia in the INFAUCI study, a national prospective, observational, multicenter study, was conducted in 14 Portuguese intensive care units. Infected patients admitted to intensive care units with a lactate measurement in the first 12 hours of admission were selected. Sepsis was identified according to the Sepsis-2 definition accepted at the time of data collection. The severity of hyperlactatemia was classified as mild (2 - 3.9mmol/L), moderate (4.0 - 9.9mmol/L) or severe (> 10mmol/L). Results: In a total of 1,640 patients infected on admission, hyperlactatemia occurred in 934 patients (57%), classified as mild, moderate and severe in 57.0%, 34.4% and 8.7% of patients, respectively. The presence of hyperlactatemia and a higher degree of hyperlactatemia were both associated with a higher Simplified Acute Physiology Score II, a higher Charlson Comorbidity Index and the presence of septic shock. The lactate Receiver Operating Characteristic curve for hospital mortality had an area under the curve of 0.64 (95%CI 0.61 - 0.72), which increased to 0.71 (95%CI 0.68 - 0.74) when combined with Sequential Organ Failure Assessment score. In-hospital mortality with other covariates adjusted by Simplified Acute Physiology Score II was associated with moderate and severe hyperlactatemia, with odds ratio of 1.95 (95%CI 1.4 - 2.7; p < 0.001) and 4.54 (95%CI 2.4 - 8.5; p < 0.001), respectively. Conclusion: Blood lactate levels correlate independently with in-hospital mortality for moderate and severe degrees of hyperlactatemia.

Relación entre el tiempo de circulación extracorpórea y el pinzamiento aórtico con diferentes variables de evolución postquirúrgicas / Relationship between cardiopulmonary bypass time and aortic cross clamping time with different variables of post-surgical evolution

Resumen Justificación: La mayor cantidad de cirugías cardiacas realizadas a nivel mundial se efectúa con circulación extracorpórea y pinzamiento de la aorta, lo que conlleva una serie de alteraciones fisiopatológicas que deben ser reconocidas por el personal de salud que participa en la atención de estos pacientes. Objetivo: Describir el perfil y los factores de riesgo presentes en los pacientes sometidos a cirugía cardiaca con circulación extracorpórea, y analizar la existencia de una potencial relación entre el tiempo de circulación extracorpórea y el pinzamiento aórtico, con la aplicación de desfibrilaciones tras al pinzado de la aorta, la necesidad de soporte cardiovascular farmacológico, el comportamiento del nivel de lactato plasmático y la mortalidad. Métodos: Se desarrolló un estudio observacional y descriptivo con una muestra de 104 pacientes electivos, sometidos a intervención quirúrgica y circulación extracorpórea, en el Hospital México, desde octubre de 2016 a noviembre de 2017. Se caracterizó la población en estudio, se analizaron los factores de riesgo incluido el EuroSCORE I y II, el tiempo de circulación extracorpórea, el tiempo de pinzamiento aórtico, las desfibrilaciones posteriores al pinzamiento aórtico, e lactato inmediatamente postcirculación extracorpórea, y a las 2, 6, 24 h postquirúrgicas, el uso de soporte cardiovascular farmacológico en infusión continua posterior a la circulación extracorpórea y mortalidad a los 30 días. Resultados: La edad media fue 56,4 años, predominó el sexo masculino (69 %) y la hipertensión arterial fue el factor de riesgo más frecuente (76,07 %). Se registró un tiempo de pinzado aórtico menor a 100 min en 61 pacientes (58,65 %) y superior a ese tiempo en 43 pacientes (41,35 %). El EuroSCORE I promedio fue del 4,21 % (DE: 4,80), mientras que el EuroSCORE II fue del 2,37 % (DE: 2,41). El tiempo promedio de circulación extracorpórea fue de 129 minutos (DE: 36,88) y el de pinzado aórtico, de 94 minutos (DE:32,04). Hubo un pico de lactato a las 6 horas postquirúrgicas (5,13 mmol/L, DE:2,89); un 8,65 % de los pacientes fueron desfibrilados después del retiro de la pinza en la aorta; se utilizó soporte cardiovascular en el 16,35 % y la mortalidad quirúrgica fue del 1,92 %. Conclusiones: En el estudio, el tiempo de circulación extracorpórea y el pinzado aórtico junto con el uso de inotrópicos, vasoconstrictores, hiperlactatemia y mortalidad quirúrgica, no alcanzó una relación significativa.

Abstract Justification: Currently, the largest number of cardiac surgeries performed worldwide are performed with cardiopulmonary bypass and aortic cross clamp, which leads to a series of pathophysiological alterations that are important for health personnel involved in the care of these patients. Objective: To describe the profile and risk factors present in patients undergoing cardiac surgery with cardiopulmonary bypass and the existence of a potential relationship between the cardiopulmonary bypass time and aortic cross clamping time, with the use of post clamp defibrillations, pharmacological cardiovascular support, plasma lactate behavior and mortality. Methods: An observational and descriptive study was carried out with a sample of 104 elective patients, undergoing surgical intervention and cardiopulmonary bypass at Hospital México, from October 2016 to November 2017. The study population was characterized, risk factors were analyzed including EuroSCORE I and II, CPB time, aortic cross clamping time, post-aortic clamping defibrillation, lactate immediately after extracorporeal circulation and at 2, 6, 24 hours postoperatively, use of pharmacological cardiovascular support in continuous infusion after extracorporeal circulation and mortality at 30 days. Results: The mean age was 56.4 years, the male sex predominated (69%) and arterial hypertension was the most frequent risk factor (76.07%). Aortic cross clamp time of less than 100 min was recorded in 61 patients (58.65%) and greater than that time in 43 patients (41.35%). The average EuroSCORE I was 4.21% (SD: 4.80), while the EuroSCORE II was 2.37% (SD: 2.41). The average cardiopulmonary bypass time was 129 minutes (SD: 36.88) and aortic cross clamp time was 94 minutes (SD: 32.04). There was a lactate peak at 6 postoperative hours (5.13 mmol/L, SD: 2.89); 8.65% of patients were defibrillated after removal the clamp in the aorta; pharmacological cardiovascular support was used in 16.35% and surgical mortality was 1.92%. Conclusions: In this study, cardiopulmonary bypass time and aortic cross clamp time together with the use of inotropics, vasoconstrictors, hyperlactatemia and surgical mortality did not reach a significant relationship.

Elevated artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids / 中华危重病急救医学

Objective@#To study the influential factor of hyperlactatemia after the brain tumor craniotomy.@*Methods@#Patients who underwent selective brain tumor (including glioma, meningioma and acoustic schwannoma) craniotomyin the neurosurgery intensive care unit (NSICU) of the First Affiliated Hospital, Sun Yat-sen University from December 1st 2018 to May 20th 2019 were enrolled. The incidence of hyperlactatemia after the brain tumor craniotomy was investigated. Univariate and multivariate linear regression analysis were performed to identify the association of initial artery lactate with the operation duration, the intraoperative blood loss, the total intraoperative fluid infusion, intraoperative ringer lactate fluid infusion, intraoperative urine volume, intraoperative fluid balance, the total intraoperative corticosteroids dosage and the tumor type. Pearson method was used to analyze the correlation between lactate in arterial blood and independent related factors.@*Results@#A total of 148 patients were enrolled including 45 patients (30.41%) with glioma, 64 patients (43.24%) with meningioma, and 39 patients (26.35%) with acoustic schwannoma. The initial lactate level in arterial blood increased significantly in 148 patients, with a median of 4.80 (3.68, 5.90) mmol/L. Among them, 78 patients (52.70%) had mild elevation of lactate in arterial blood (2 mmol/L < lactate ≤ 5 mmol/L), 61 patients (41.22%) had significant elevation of lactate in arterial blood (5 mmol/L < lactate ≤ 10 mmol/L), and 2 patients (1.35%) had serious elevation of artery lactate (> 10 mmol/L). And only 7 patients (4.73%) had normal level of lactate in arterial blood (≤ 2 mmol/L). Univariate analysis showed that initial postoperative artery lactate was positively correlated with the operation duration [β = 0.556, 95% confidence interval (95%CI) was 0.257-0.855, P < 0.001] and the total intraoperative corticosteroids dosage (β = 0.477, 95%CI was 0.174-0.779, P = 0.002). There was no significant correlation between the initial postoperative artery lactate and tumor types, the intraoperative blood loss, the total fluid infusion, the ringer lactate fluid infusion, urine volume, and the fluid balance. Further multivariate linear regression analysis showed that the operation duration (β = 0.499, 95%CI was 0.204-0.795, P = 0.001) and the total intraoperative corticosteroids dosage (β = 0.407, 95%CI was 0.111-0.703, P = 0.008) were independent risk factors affecting the initial postoperative artery lactate. The correlation analysis showed that there was a significant positive correlation between lactate in arterial blood and operation time and total hormone dosage during operation (r1 = 0.289, r2 = 0.248, both P < 0.01).@*Conclusion@#Initial artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids.

Elevated artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids / 中华危重病急救医学

Objective To study the influential factor of hyperlactatemia after the brain tumor craniotomy. Methods Patients who underwent selective brain tumor (including glioma, meningioma and acoustic schwannoma) craniotomyin the neurosurgery intensive care unit (NSICU) of the First Affiliated Hospital, Sun Yat-sen University from December 1st 2018 to May 20th 2019 were enrolled. The incidence of hyperlactatemia after the brain tumor craniotomy was investigated. Univariate and multivariate linear regression analysis were performed to identify the association of initial artery lactate with the operation duration, the intraoperative blood loss, the total intraoperative fluid infusion, intraoperative ringer lactate fluid infusion, intraoperative urine volume, intraoperative fluid balance, the total intraoperative corticosteroids dosage and the tumor type. Pearson method was used to analyze the correlation between lactate in arterial blood and independent related factors. Results A total of 148 patients were enrolled including 45 patients (30.41%) with glioma, 64 patients (43.24%) with meningioma, and 39 patients (26.35%) with acoustic schwannoma. The initial lactate level in arterial blood increased significantly in 148 patients, with a median of 4.80 (3.68, 5.90) mmol/L. Among them, 78 patients (52.70%) had mild elevation of lactate in arterial blood (2 mmol/L <lactate ≤ 5 mmol/L), 61 patients (41.22%) had significant elevation of lactate in arterial blood (5 mmol/L < lactate ≤10 mmol/L), and 2 patients (1.35%) had serious elevation of artery lactate (> 10 mmol/L). And only 7 patients (4.73%) had normal level of lactate in arterial blood (≤ 2 mmol/L). Univariate analysis showed that initial postoperative artery lactate was positively correlated with the operation duration [β = 0.556, 95% confidence interval (95%CI) was 0.257-0.855, P < 0.001] and the total intraoperative corticosteroids dosage (β = 0.477, 95%CI was 0.174-0.779, P = 0.002). There was no significant correlation between the initial postoperative artery lactate and tumor types, the intraoperative blood loss, the total fluid infusion, the ringer lactate fluid infusion, urine volume, and the fluid balance. Further multivariate linear regression analysis showed that the operation duration (β = 0.499, 95%CI was 0.204-0.795, P = 0.001) and the total intraoperative corticosteroids dosage (β = 0.407, 95%CI was 0.111-0.703, P = 0.008) were independent risk factors affecting the initial postoperative artery lactate. The correlation analysis showed that there was a significant positive correlation between lactate in arterial blood and operation time and total hormone dosage during operation (r1 = 0.289, r2 = 0.248, both P < 0.01). Conclusion Initial artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids.

Elevated artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids / 中华危重病急救医学

Objective To study the influential factor of hyperlactatemia after the brain tumor craniotomy. Methods Patients who underwent selective brain tumor (including glioma, meningioma and acoustic schwannoma) craniotomyin the neurosurgery intensive care unit (NSICU) of the First Affiliated Hospital, Sun Yat-sen University from December 1st 2018 to May 20th 2019 were enrolled. The incidence of hyperlactatemia after the brain tumor craniotomy was investigated. Univariate and multivariate linear regression analysis were performed to identify the association of initial artery lactate with the operation duration, the intraoperative blood loss, the total intraoperative fluid infusion, intraoperative ringer lactate fluid infusion, intraoperative urine volume, intraoperative fluid balance, the total intraoperative corticosteroids dosage and the tumor type. Pearson method was used to analyze the correlation between lactate in arterial blood and independent related factors. Results A total of 148 patients were enrolled including 45 patients (30.41%) with glioma, 64 patients (43.24%) with meningioma, and 39 patients (26.35%) with acoustic schwannoma. The initial lactate level in arterial blood increased significantly in 148 patients, with a median of 4.80 (3.68, 5.90) mmol/L. Among them, 78 patients (52.70%) had mild elevation of lactate in arterial blood (2 mmol/L <lactate ≤ 5 mmol/L), 61 patients (41.22%) had significant elevation of lactate in arterial blood (5 mmol/L < lactate ≤10 mmol/L), and 2 patients (1.35%) had serious elevation of artery lactate (> 10 mmol/L). And only 7 patients (4.73%) had normal level of lactate in arterial blood (≤ 2 mmol/L). Univariate analysis showed that initial postoperative artery lactate was positively correlated with the operation duration [β = 0.556, 95% confidence interval (95%CI) was 0.257-0.855, P < 0.001] and the total intraoperative corticosteroids dosage (β = 0.477, 95%CI was 0.174-0.779, P = 0.002). There was no significant correlation between the initial postoperative artery lactate and tumor types, the intraoperative blood loss, the total fluid infusion, the ringer lactate fluid infusion, urine volume, and the fluid balance. Further multivariate linear regression analysis showed that the operation duration (β = 0.499, 95%CI was 0.204-0.795, P = 0.001) and the total intraoperative corticosteroids dosage (β = 0.407, 95%CI was 0.111-0.703, P = 0.008) were independent risk factors affecting the initial postoperative artery lactate. The correlation analysis showed that there was a significant positive correlation between lactate in arterial blood and operation time and total hormone dosage during operation (r1 = 0.289, r2 = 0.248, both P < 0.01). Conclusion Initial artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids.

Risk factors for postoperative hyperlactatemia in patients with type A aortic dissection / 中华麻醉学杂志

Objective To identify the risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection.Methods Medical records of patients with type A aortic dissection who underwent cardiovascular surgery from January 2012 to October 2017 were retrospectively collected.The patients were divided into hyperlactatemia group and non-hyperlactatemia group according to the occurrence of hyperlactatemia (blood lactic acid ≥6 mmol/L) at 8 h after surgery.The variables of which P values were less than 0.05 in univariate analysis would enter the logistic regression analysis to stratify the risk factors for postoperative hyperlactatemia in this type of patients.Results A total of 295 patients were included,of which 80 cases developed postoperative hyperlactatemia,and the incidence was 27.1％.Logistic regression analysis showed that preoperative acute pericardial tamponade,intraoperative deep hypothermic circulatory arrest time＞35 min) and massive transfusion of blood (＞ 1 000 ml) within 8 h after operation were independent risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection.Conclusion Preoperative acute pericardial tamponade,intmoperative deep hypothermic circulatory arrest time＞35min and massive transfusion of blood (＞ 1 000 ml) within 8 h after operation are independent risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection.

Risk factors for postoperative hyperlactatemia in patients with type A aortic dissection / 中华麻醉学杂志

Objective@#To identify the risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection.@*Methods@#Medical records of patients with type A aortic dissection who underwent cardiovascular surgery from January 2012 to October 2017 were retrospectively collected.The patients were divided into hyperlactatemia group and non-hyperlactatemia group according to the occurrence of hyperlactatemia (blood lactic acid ≥6 mmol/L) at 8 h after surgery.The variables of which P values were less than 0.05 in univariate analysis would enter the logistic regression analysis to stratify the risk factors for postoperative hyperlactatemia in this type of patients.@*Results@#A total of 295 patients were included, of which 80 cases developed postoperative hyperlactatemia, and the incidence was 27.1%.Logistic regression analysis showed that preoperative acute pericardial tamponade, intraoperative deep hypothermic circulatory arrest time>35 min) and massive transfusion of blood (>1 000 ml) within 8 h after operation were independent risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection.@*Conclusion@#Preoperative acute pericardial tamponade, intraoperative deep hypothermic circulatory arrest time>35 min and massive transfusion of blood (>1 000 ml) within 8 h after operation are independent risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection.

Blood lactate increases with the progression of mitral valve disease in dogs / Aumento de lactato sanguíneo com progressão de valvopatia mitral em cães

In dogs with congestive heart failure, the upregulated sympathetic tone causes vasoconstriction that impairs peripheral blood supply, therefore causing the accumulation of lactate. In this prospective cross-sectional study with a longitudinal component, blood lactate was quantified in 10 healthy and 34 myxomatous mitral valve disease (MMVD) dogs to investigate its potential use as a diagnostic and prognostic biomarker. While there were no differences in lactate concentration between control animals and stages B1 (3.31±0.62mmol/L) and B2 (3.32±0.46mmol/L) dogs, significant differences were found between healthy (2.50±0.69mmol/L) and both C (3.99±0.47mmol/L) and D (6.97±1.23mmol/L) animals. When a cut-off of 3.35mmol/L was used, lactate was able to distinguish dogs with normal and remodeled hearts with a sensitivity of 78.2% and specificity of 63.6%. Also, significant correlations existed between lactate and indicators of cardiac remodeling. Finally, animals with blood lactate <3.5mmol/L carried a better prognosis when compared with dogs in which lactate was >5.0mmol/L. Our results suggest that the progression of MMVD results in accumulation of lactate within the bloodstream, which is likely attributable to the impaired peripheral tissue perfusion. In MMVD dogs, blood lactate may be used as a surrogate for cardiac remodeling, and an increased concentration is associated with a worse prognosis regarding the time to evolve into congestive heart failure.(AU)

Em cães com insuficiência cardíaca congestiva, o tônus simpático hiperregulado causa vasoconstrição e interfere com o suprimento sanguíneo periférico, resultando no acúmulo de lactato. Neste estudo prospectivo transversal com um componente longitudinal, o lactato sanguíneo foi quantificado em 10 cães saudáveis e 34 cães com doença mixomatosa da valva mitral (DMVM) para investigar seu potencial como biomarcador diagnóstico e prognóstico. Embora não tenham sido identificadas diferenças na concentração de lactato entre animais controle e cães com DMVM nos estágios B1 (3,31±0,62mmol/L) e B2 (3,32±0,46mmol/L), diferenças significativas foram constatadas entre os cães saudáveis (2,50±0,69mmol/L) e cães com DMVM estágio C (3,99±0,47mmol/L) ou D (6,97±1,23mmol/L). Quando utilizado o valor de corte de 3,35mmol/L, o lactato foi capaz de diferenciar cães com corações normais daqueles com corações remodelados com sensibilidade de 78,2% e especificidade de 63,6%. Além disso, correlações significativas foram encontradas entre o lactato e os indicadores de remodelamento cardíaco. Por fim, os animais com lactato sanguíneo <3,5mmol/L tiveram prognóstico melhor comparativamente aos cães com concentrações >5,0mmol/L. Nossos resultados sugerem que a progressão da DMVM resulta no acúmulo de lactato na corrente sanguínea, fato que é provavelmente atribuído à perfusão periférica prejudicada. Em cães com DMVM, o lactato sanguíneo pode ser utilizado como indicador de remodelamento cardíaco, cuja concentração elevada está associada com pior prognóstico relativo ao tempo para evoluir para insuficiência cardíaca congestiva.(AU)

A clinical research of factors relating to hyperlactatemia for post CABG patient / 中华胸心血管外科杂志

Objective To research the factors relating to hyperlactatemia and its connections to certain combinations and the motality of post CABG patients.Methods Splitting the 1 280 cases of post OPCABG surgery patient admitted to ICU of Anzhen Hospital between March 2016 and October 2016 into two groups,including a hyperlactatemia group of 511 patients [340 males and 171 females,aged (63.81 ± 9.1)years],and a none-hyperlactatemia group of 769 samples [499 males and 270 females,aged(61.72 ± 8.97) years].Recording the pre-operative characteristics such as gender,age,medical history,heart function,and post-operative characteristics such as liver and kidney function,reintubation rate,tracheotomy treatment rate,mortality rate,IABP and ECMO usage rates,ICU and hospital stay time.Results As compare to the none-hyperlactatemia group,the hyperlactatemia group has:(1) higher reintubation rate(P =0.003) and higher tracheotomy rate (P =0.035);(2) longer mechanical ventilation time (P =0.009);(3) higher mortality rate (P =0.000);(4) longer ICU stay time (P =0.039) and hospital stay time(P =0.047).Multi factor regression discovered:pre-operative IABP(P =0.040),postoperative cadiogenic shock (P =0.030),post-operative AKI (P =0.020),post-operative liver failure (P =0.039) are the independent risk factors for post-operative hyperlactatemia of CABG patient;peak lactate time ＞ 30 h (P =0.021),post-operative level 3 AKI (P =0.030),post-operative liver failure (P =0.025),post-operative cardiogenic shock (P =0.037) are the independent risk factors for mortality of CABG post-operative hyperlactatemia patient.Conclusion After CABG operation,hyperlactatemia patients had a higher mortality rate.Timely restoring heart and important organ function to remove lactate so to reduce mortality rate is advised.

The First Korean case of combined oxidative phosphorylation deficiency-17 diagnosed by clinical and molecular investigation / 소아과

Combined oxidative phosphorylation deficiency-17 (COXPD-17) is very rare and is caused by homozygous or compound heterozygous mutations in the ELAC2 gene on chromosome 17p12. The ELAC2 gene functions as a mitochondrial tRNA processing gene, and only 4 different pathogenic mutations have been reported in ELAC2-associated mitochondrial dysfunction involving oxidative phosphorylation. Affected patients show various clinical symptoms and prognosis, depending on the genotype. We report a novel mutation in the ELAC2 gene (c.95C>G [p.Pro32Arg], het), in an infant with COXPD-17 who presented with encephalopathy including central apnea and intractable epilepsy, and growth and developmental retardation. During hospitalization, consistently elevated serum lactic acid levels were noted, indicative of mitochondrial dysfunction. The patient suddenly died of shock of unknown cause at 5 months of age. This is the first case report of COXPD-17 in Korea and was diagnosed based on clinical characteristics and genetic analysis.

Hyperlactatemia in patients undergoing adult cardiac surgery under cardiopulmonary bypass: Causative factors and its effect on surgical outcome.

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.

Prognostic markers of canine pyometra / Marcadores prognósticos na piometra canina

The pyometra is a disease that affects middle age and elderly female dogs during diestrus. Hormonal, microbiological, biochemical and hematological aspects are well described. However, few studies have evaluated the role of each in the prognosis of canine pyometra. The aim of this study was to identify markers associated with clinical worsening of dogs with pyometra. We prospectively evaluated 80 dogs with pyometra treated surgically. Group 1 consisted of dogs that were discharged within 48 hours after surgery and Group 2 consisted of those who required prolonged hospitalization or died. The findings of hematological, biochemical and blood lactate levels were compared between groups and variables such as bacterial multidrug resistance, systemic inflammatory response syndrome (SIRS), hyperlactatemia and increased creatinine were analyzed through the dispersion of frequencies between groups. Among the variables studied, the presence of SIRS and elevated serum creatinine >2.5mg/mL were effective in predicting the worsening of the disease and can be used as prognostic markers of canine pyometra...

A piometra é doença que acomete as fêmeas da espécie canina de meia-idade a idosa durante o diestro. Aspectos hormonais, microbiológicos, hematológicos e bioquímicos são bem descritos. Entretanto, são poucos os estudos que avaliam o papel de cada um desses no prognóstico da piometra canina. O objetivo deste estudo foi identificar marcadores associados ao agravamento clínico de cadelas com piometra. Foram avaliadas prospectivamente 80 cadelas com piometra tratadas cirurgicamente. O grupo 1 foi composto por cadelas que receberam alta até 48 horas de pós-operatório, e o grupo 2 por aquelas que necessitaram de internamento prolongado ou morreram. Os achados hematológicos, bioquímicos e os níveis do lactato sanguíneo foram comparados entre os grupos, e variáveis como multirresistência bacteriana, síndrome da resposta inflamatória sistêmica (SIRS), hiperlactatemia e aumento da creatinina foram analisadas por meio da dispersão de frequências entre os grupos. Entre as variáveis estudadas, a presença de SIRS e a elevação da creatinina sérica >2,5mg/mL foram eficazes em predizer o agravamento da doença e podem ser utilizadas como marcadores prognósticos da piometra canina...

Concentração de lactato sérico em ovelhas e cordeiros mestiços (1/2 Suffolk) nascidos em eutocia / Lactate blood levels in sheep and newborn lambs (1/2 suffolk) in normal delivery

O objetivo do estudo foi avaliar a concentração de lactato sanguíneo venoso em ovelhas e em cordeiros neonatos imediatamente após o parto eutócico. Foram utilizadas 14 ovelhas, sendo nove da raça Suffolk e quatro mestiças e 20 cordeiros neonatos sadios (machos e fêmeas). O efeito do sexo, da raça e do número de cordeiros por parto foi investigado, bem como a possível correlação entre a concentração de lactato materno e neonatal. Não houve diferença entre machos e fêmeas, em relação à raça (Suffolk e mestiços), contudo a concentração de lactato foi mais elevada em cordeiros gêmeos ou trigêmeos quando comparado a cordeiros uníparos. Houve correlação positiva entre a concentração materna e a neonatal, sendo que quanto maior a concentração de lactato materno, maior a concentração no cordeiro imediatamente após o parto eutócico. Os resultados do presente estudo fornecem um subsídio por meio do qual se podem comparar os níveis de lactato sanguíneo em cordeiros em estado crítico.

The aim of this study was to evaluate the venous blood lactate concentration in sheep and newborn lambs immediately after normal delivery. We used 14 ewes, nine and four Suffolk crossbred lambs and 20 healthy newborns (males and females). The effect of gender, race and number of lambs per birth was investigated, as well as the possible correlation between the concentration of maternal and newborn lactate. There was no difference between males and females or in relation to race (and Suffolk crossbred); however the concentration of lactate was higher in twin or triplet lambs when compared to single lambs. There was a positive correlation between the maternal and newborn concentration and the higher the concentration of lactate, the greater the concentration in the lamb immediately after normal delivery. The results of this study provide a base from which to compare the blood lactate levels in lambs in critical condition.

Impact of hepatic vascular inflow exclusion on postoperative arterial lactate level in patients undergoing hepatectomy / 中华普通外科杂志

Objective To investigate the impact of vascular inflow occlusion of the liver on arterial lactate level and pH value. Methods In this study, 68 patients who underwent hepatectomy from January 2006 to December 2008 were retrospectively studied. The patients were assigned to one of the three study groups according the vascular inflow status: clamping of portal vein and hepatic artery in the hepatic pedicle (n = 20), hemihepatectomy under total hemihepatic vascular exclusion (THVE, n = 22), and non-vascular occlusion (n = 26). Postoperative arterial blood gas analysis including systemic arterial lactate concentration, and liver and renal function tests were performed. Results Systemic arterial blood lactate levels significantly elevated in the portal clamping and THVE groups (5.53 ±2. 31 mmol/L and 5.62 ±2.52mmol/L, respectively), compared to the non-occlusion group (3. 37 ± 1.56 mmol/L, P < 0. 05) ;significant increase in arterial HCO3- level was observed in the THVE group in comparison to the nonocclusion group (19. 68 ± 3. 82) mmol/L vs. (21.65 ± 2. 48) mmol/L, (P < 0. 05). There were no significant differences as to the changes of pH values, liver and renal function tests between the three groups. Conclusions Vascular inflow deprivation may result in significantly increased arterial lactate level. Thus, intense surveillance of blood lactate level with prompt treatment is necessary to prevent postoperative hyperlactatemia and metabolic acidosis.