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Hyperlactataemia Following Crystalloid Cardiopulmonary Bypass Priming in Paediatric Cardiac Surgery-Benign or
Philippa Jane Temple Bowers1, Michael Daley1,2, Nicole Yvette Renee Shrimpton3
1Department of Cardiac Surgery, Queensland Children's Hospital, Level 7F Clinical Directorate 501 Stanley Street, Brisbane, QLD 4101, Australia.
Insights
Postoperative hyperlactataemia in pediatric cardiac surgery patients receiving crystalloid prime may not indicate hypoxemia. However, it is associated with longer intensive care unit (ICU) stays and inotrope use.
Area of Science:
- Pediatric Cardiac Surgery
- Intensive Care Medicine
- Biochemistry
Background:
- Early hyperlactataemia after cardiac surgery can arise from various mechanisms.
- In pediatric patients, crystalloid priming of the cardiopulmonary bypass circuit is a potential cause of benign early hyperlactataemia.
Purpose of the Study:
- To review outcomes of pediatric patients who underwent cardiac surgery with crystalloid prime.
- To investigate the association between crystalloid prime and postoperative hyperlactataemia in pediatric cardiac surgery.
Main Methods:
- Retrospective review of pediatric patients undergoing cardiac surgery with crystalloid prime.
- Data collected from medical and laboratory records between November 2014 and May 2018.
Main Results:
- Of 186 eligible patients, 53% developed postoperative hyperlactataemia.
- Hyperlactataemia was linked to longer cardiopulmonary bypass and aortic cross-clamp times, and higher peak vasoactive-intestinal peptide scores (VIS).
- Patients with hyperlactataemia had longer intensive care unit (ICU) stays and inotrope duration, with fewer discharged within 24 hours.
Conclusions:
- Transient postoperative hyperlactataemia in this cohort may not signify tissue hypoxemia.
- Despite similar ventilation durations, hyperlactataemia correlated with increased inotrope use and ICU length of stay.
- Consideration should be given to discontinuing inotropes in extubated pediatric patients with crystalloid prime and early postoperative hyperlactataemia.
Background:
Various mechanisms leading to early hyperlactataemia post-cardiac surgery have been postulated. Specifically, in the paediatric population, benign early hyperlactataemia may be associated with crystalloid priming in the cardiopulmonary bypass circuit. The aim of this study was to review paediatric patients who had crystalloid prime and assess their outcomes.
Methods:
A retrospective review of paediatric patients who underwent cardiac surgery with crystalloid prime at our institution between November 2014 and May 2018 was performed. Data were collected from medical and laboratory records.
Results:
Among 569 patients, 237 (42%) received a crystalloid prime; 51 (22%) were excluded due to intraoperative hyperlactataemia. Of the remaining 186 patients, 98 (53%) developed hyperlactataemia postoperatively. Patients with hyperlactataemia had longer cardiopulmonary bypass and aortic cross-clamp times but similar Aristotle complexity scores. Patients with postoperative hyperlactataemia had higher peak VIS [median 8 (IQR 0-8) vs. 5 (IQR 0-8)] within the first 24 h (p = 0.002). However, there was no difference in the duration of ventilation between the two groups (p = 0.14). Yet only 58% of patients with hyperlactataemia were discharged from the ICU within 24 h, compared to 78% without hyperlactataemia.
Conclusions:
In this study population, transient postoperative hyperlactataemia in paediatric patients with crystalloid prime may not necessarily indicate tissue hypoxaemia. Despite a similar duration of ventilation in patients with and without hyperlactataemia, patients with hyperlactataemia had a longer duration of inotropes and ICU stay. Consideration should be given to discontinuing inotropes in patients with crystalloid prime and postoperative early hyperlactataemia once they are extubated.
