Influences on lactate levels in children early after cardiac surgery: prime solution and age

Hyperlactataemia is often seen after cardiac surgery in children and is associated with an increased risk of adverse outcome, especially in infants and young children. However, we noticed that many older children after cardiac surgery had elevated lactate levels in the absence of other markers of oxygen debt or cardiovascular instability and had an uncomplicated postoperative course. Many older children undergo surgery without blood products being used in the cardiopulmonary bypass (CPB) circuit prime. The aim of this study was to determine whether lactate levels in children after CBP are influenced by age and/or pump prime solutions.

We studied 100 children undergoing open heart surgery in a tertiary paediatric cardiac surgical unit. Fifty children were aged 2 months to 4 years (Group 1) and 50 were aged 4 years or older (Group 2). Blood samples were obtained from an arterial catheter and serum lactate levels were collected at the time of admission to the paediatric intensive care unit (PICU) and 4 hours later. The following data were collected from the medical records or laboratory databases: weight, age, lowest haemoglobin during CPB, total bypass time, aortic cross clamp time, priming solution used, length of postoperative ventilation and PICU stay, type of surgery and occurrence of adverse perioperative events, including cardiac arrest, need for extracorporeal support or death.

All children in Group 1 had a blood prime. All children in Group 2 had a bloodless prime. Although there were differences in the types of anomalies and surgical procedures performed, there were no significant differences between the two groups in terms of surgical complexity, CBP time, aortic cross clamp time and haemoglobin during CPB. Lactate levels in children in Group 2 were higher than in Group 1. Sixteen children (32%) in Group 2 had a lactate level of > 4 mmol/L, whereas only 3 children (6%) in Group 1 had a lactate level of > 4 mmol/L (Fisher's exact test p = 0.0002). Using multivariate analysis the pump prime solution was independently associated with high lactate levels after CPB.

Lactate levels after cardiac surgery in older children who have a bloodless prime may not have the same physiological or prognostic implications as in infants who have a blood prime.