Changes in blood lactate levels after major elective abdominal surgery and the association with outcomes: a prospective observational study

doi:10.1016/j.jss.2013.04.056

Journal of Surgical Research

Volume 184, Issue 2, October 2013, Pages 1059-1069

https://doi.org/10.1016/j.jss.2013.04.056 Get rights and content

Abstract

Background

Prolonged elevated blood lactate levels strongly correlate with poor outcomes in a variety of critically ill patients. We hypothesized that the dynamic postoperative changes in blood lactate levels during the first 24 h were significantly associated with postoperative morbidity and mortality in patients undergoing elective major abdominal surgery.

Materials and methods

We performed a single-center prospective observational study of 114 consecutive patients undergoing elective major abdominal surgery from September 2009 to December 2010. Blood lactate was determined postoperatively at 6 h intervals during the first 24 h. In-hospital complications and deaths occurring within 30 d of enrollment were included in the data analysis.

Results

A total of 88 postoperative complications were recorded in 51 patients (44.7%). There was a significant difference in blood lactate levels among patients with no, minor, and major complications (ANOVA, Groups, P < 0.001; time, P < 0.001; groups × time interaction, P = 0.014). The accuracy of lactate levels to predict both overall and major complications increased postoperatively from 0 h to 24 h. Using a multivariate analysis, the time-weighted average lactate was independently predictive of both overall (OR 7.108, 95% CI 2.271–22.249, P = 0.001) and major (OR 3.277, 95% CI 1.363–7.877, P = 0.008) postoperative complications, and lactate clearance at 0–24 h (OR 0.217, CI 0.077–0.616, P = 0.004) was independently predictive of major postoperative complications. The optimal time-weighted average lactate cutoff value for complication prediction was 1.46 mmol/L; below this level, both overall and major complication rates were significantly reduced, which was true even after adjusting for potential confounding factors.

Conclusions

The dynamic changes in blood lactate levels during the first 24 postoperative h were significantly associated with complications after major elective abdominal surgery. This result warrants a “golden hour and silver day” perspective of early resuscitation in this patient cohort.

Introduction

Despite considerable advances in surgical techniques and perioperative care, significant morbidity and mortality still remains after major abdominal surgery, particularly in patients with advanced age and poor physiological reserve and patients undergoing emergency surgery [1]. The etiology of postoperative complications is complex, but poor tissue perfusion and oxygenation caused by impaired microvascular flow, which can contribute to organ system dysfunction development, remains a major cause [2], [3], [4], [5], [6]. Clinical and hemodynamic parameters, such as blood pressure, urine output, and central venous pressure are unreliable or late signs of inadequate tissue perfusion and, hence, have limited value in risk-stratifying patients and guiding timely therapy [7]. Theoretically, an important mechanism of adaptation to marginal tissue perfusion and oxygen delivery is an increased oxygen extraction ratio from arterial blood, which would inevitably result in decreased venous oxygen saturation [6]. Clinically, mixed venous oxygen saturation (SvO₂) or its surrogate, central venous oxygen saturation (ScvO₂), has been proposed to be indicators of balance between tissue oxygen delivery and consumption, and low ScvO₂/SvO₂ have been associated independently with an increased risk of complications in high-risk surgical patients [6], [8], [9]. However, ScvO₂/SvO₂ monitoring is an invasive measurement and requires time, expertise, and specialized equipment, all of which collectively limit their wide use in clinical practice [10], [11].

Another important adaptive mechanism to survive tissue hypoxia caused by hypoperfusion is increased production of lactate by anaerobic glycolysis [12]. The subsequent elevation of blood lactate is easy to measure. There was a strong correlation between the severity of microvascular alterations and blood lactate levels [2], [5], and blood lactate clearance was shown to be significantly associated with improved microcirculatory flow [13]. These results indicated that blood lactate can reliably reflect the adequacy of tissue perfusion and oxygenation [7], [14]. Many studies have confirmed that increased blood lactate levels at admission were independently associated with morbidity and mortality in critically ill patients, irrespective of arterial hypotension and that, over time, early changes in these levels can predict patient outcomes [14], [15], [16], [17], [18], [19], [20], [21]. Consistent with those observations, previous observational studies (including ours) have suggested that the initial lactate level [15], [16], [18] and lactate clearance time (time to the normalization of blood lactate) [18], [19] may be useful in predicting outcomes after major abdominal surgery. Furthermore, one interventional study has suggested that interventions that attempt to keep serum lactate levels <1.7 mmol/L by adjusting intravenous fluid administration intraoperatively and up to 72 h postoperatively may be associated with reduced morbidity rates after major elective abdominal surgery [22]. However, most of the above-mentioned observational studies in abdominal surgery included a variable mix of both elective and emergency procedures. Given that in the critically ill the prognostic performance of lactate is dependent upon both time [23] and the admitting diagnosis [24], the prognostic values of lactate have yet to be determined in a homogeneous group of patients undergoing elective abdominal surgery. In addition, microcirculatory alteration in patients undergoing major elective surgery is most obvious within the first 24 h postoperatively, and its severity is significantly associated with outcomes [2], [3], [4], [5]. However, the association between changes in blood lactate concentration during the first 24 postoperative h and postoperative morbidity after major abdominal surgery has not yet been investigated. We hypothesized that the dynamic postoperative changes in blood lactate levels during the first 24 h were significantly associated with postoperative morbidity and mortality in patients undergoing elective major abdominal surgery.

The purpose of this paper was to study the relationship between the dynamic changes in blood lactate concentration during the first 24 h postoperatively and the postoperative complications in patients undergoing major elective abdominal surgery. Several indices of lactate homeostasis in the first 24 postoperative h (i.e., peak lactate, lactime [the time during which hyperlactatemia is present], time-weighted average lactate [LAC_TW], and lactate clearance at different time intervals), in addition to lactate levels at specified time points, were examined to determine their ability to predict postoperative complications.

Section snippets

Study design and patients

This study was approved by the human studies ethics committee at the Affiliated Hospital of Jianghan University, and written informed consent was obtained from the patients or their next of kin. In this single-center prospective observational study, which was conducted at the Affiliated Hospital of Jianghan University from September 2009 to December 2010, we enrolled all consecutive adult patients (aged >18 years) who were scheduled for major elective abdominal surgery. Major abdominal surgery

Results

During the study period, 174 patients underwent 177 major elective abdominal procedures. Only the primary surgery was registered in this study, and re-operations after the index surgery (n = 3) were excluded. A further 60 were excluded: refusal of admission to the SICU (n = 49), liver insufficiency (n = 6), chronic renal insufficiency (n = 2), and surgery (n = 2) or ICU admission (n = 1) within the mo prior to the operation. Data were collected from 114 patients. Two (1.7%) patients were

Discussion

Elevated blood lactate levels commonly result from acute tissue hypoperfusion and anaerobic metabolism and has been shown to be a surrogate for oxygen debt or oxygen deficit accumulated over time [7], [12], [14], [28], [29]. Our previous retrospective study showed that the initial blood lactate level was significantly associated with postoperative complications and could independently predict in-hospital morbidity after major abdominal surgery [15]. However, this finding was not the case in our

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To assess the prevalence of preoperative acidosis and lactatemia in elderly patients having hip fracture surgery and their association with post-operative mortality.
Retrospective cohort study.
Single tertiary medical center.
Patients ≥65 years having first traumatic hip fracture surgery between 2018 and 2021.
90-day postoperative mortality.
In total, 1267 patients were included in the primary analysis (mean (SD) age 83(8) years; 802 (69%) females; median [Interquartile Range (IQR)] American Society of Anesthesiologists (ASA) physical score 3 [2,3]). Of these, 1227 were available for the multivariable analyses. Median [IQR] time from hospitalization to surgery was 28 [20, 42] hours. All-cause 90-day mortality rate was 9% (N = 114). The incidence of preoperative acidosis (pH < 7.35) and lactatemia (>1.2 mmol/L) was significantly higher among non-survivors. Mortality was highest in patients with both acidosis and lactatemia (19.1% compared to 4.4% among patients with neither). In a multivariable model, pH <7.35 and lactate >1.2 mmol/L remained independent predictors of 90-day mortality, with adjusted odds ratio (aOR) (95%CI) of 1.99 (1.31 to 3.04) and 2.32 (1.44 to 3.74), respectively, p = 0.001 for both. Time from hospitalization to surgery was not associated with mortality after adjustment for metabolic indices, aOR 1.00 (0.99, 1.00).
Preoperative acidosis and lactatemia are common among patients ≥65 years having hip fracture surgery and are associated with 90-day all-cause mortality. Time from hospital admission to surgery is not an independent risk factor, once adjusted for metabolic indices. Future studies should evaluate whether the increased risk associated with preoperative metabolic disturbances is modifiable.
Postoperative hyperlactataemia and preoperative cardiopulmonary exercise testing in an elective noncardiac surgical cohort: a retrospective observational study
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Blood lactate concentration in the postoperative period is a marker of physiological stress and a predictor of complications and mortality. Cardiopulmonary exercise testing (CPET) is a common preoperative risk stratification tool. We aimed to investigate the association between preoperative CPET results and postoperative lactate concentration with postoperative mortality after major noncardiac surgery.
We analysed data from patients undergoing major noncardiac surgery in a tertiary UK centre between 2007 and 2014 who had preoperative CPET and postoperative lactate measurements. Univariate and multivariate analyses were performed to assess the association between lactate concentration, CPET results, or both and mortality.
We analysed data from 1075 patients. A mean lactate concentration >2 mM in the first 12, 24, and 48 h after surgery was associated with odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day mortality of 3.9 (2.1–7.3; P<0.005), 4.5 (2.4–8.4; P<0.005), and 6.1 (3.3–11.5; P<0.005), respectively. The dichotomous CPET variable, ventilatory equivalence for CO₂ (V̇E/V̇_co2; cut-off 34), was associated with increased risk of 30-day mortality (OR 2.5; 95% CI: 1.3–4.8; P<0.005). In a multivariable model, hyperlactataemia and poor V̇E/V̇_co2 retained their significant associations with 30- and 90-day mortality when adjusted for age, BMI, and surgical risk. When looking at the combined effect of the dichotomous hyperlactataemia in the first 24 h (cut-off 2 mM) and preoperative V̇E/V̇_co2, the OR for 30-day mortality was 11.53 (95% CI: 4.6–28.8; P≤0.005).
Our study suggests that postoperative hyperlactataemia and preoperative poor V̇E/V̇_co2 are independently associated with an increased risk of mortality after major noncardiac surgery.
Effects of intraoperative adrenergic administration on postoperative hyperlactatemia in open colon surgery: an observational study
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Citation Excerpt :
Postoperative Hyperlactatemia (PO-HL) is a common condition with a multifactorial origin that is associated with poor clinical outcomes in surgical patients.1,2 PO-HL has been documented most extensively in patients recovering from cardiac or major abdominal surgery.3–8 Lactate has traditionally been viewed as a global marker of perfusion, as lactate levels increase when the oxygen demand exceeds supply.9–13
Postoperative Hyperlactatemia (PO-HL) is a frequent condition associated with poor prognosis. In recent years, there has been growing evidence that adrenergic stimulation may contribute to increased lactate levels. The use of adrenergic agonists for the control of intraoperative hypotension is frequent, and its impact on the development of PO-HL is unknown.
To evaluate whether the use of intraoperative adrenergic agents is associated with the occurrence of PO-HL.
This was a prospective observational study. The inclusion criteria were undergoing elective open colon surgery, being ≥60 years old and signing informed consent. The exclusion criteria were cognitive impairment, unplanned surgery, and anticipated need for postoperative mechanical ventilation. Baseline and intraoperative variables were collected, and arterial lactate data were collected at baseline and every 6 hours postoperatively for 24 hours. Hyperlactatemia was defined as lactate >2.1 mEq.L^-1.
We studied 28 patients, 61% of whom developed hyperlactatemia. The variables associated with PO-HL in the univariate analysis were anesthetic time, the total dose of intraoperative ephedrine, and lower intraoperative central venous oxygen saturation (ScvO₂). Multivariate analysis confirmed the association between the use of ephedrine (p = 0.004), intraoperative hypotension (p = 0.026), and use of phenylephrine (p = 0.001) with PO-HL.
The use of intraoperative ephedrine, phenylephrine and intraoperative hypotension were independently associated with the development of PO-HL. This finding should lead to new studies in this field, as well as a judicious interpretation of the finding of a postoperative increase in lactate levels.
Lactate: Where Are We Now?
2020, Critical Care Clinics
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In clinical practice, lactate clearance has been used to describe the change in lactate levels over time. Although technically not correct,4,42 the use of lactate clearance has been stimulated by studies linking the relative decrease of lactate levels over time to the patient’s response to therapy and ultimately outcome.43–48 In summary, almost in any context of critical illness, decreases in lactate levels following start of treatment are associated with improved outcome.49
Elevated lactate impairs the efficacy of antiviral treatment on post-hepatectomy survival for advanced stage hepatitis B virus – related hepatocellular carcinoma
2019, Clinics and Research in Hepatology and Gastroenterology
Citation Excerpt :
Thus, anything influencing the function of mitochondria or oxygen supply could reduce the activity of Krebs cycle and therefore accelerate the conversion of pyruvate to lactate [32,35]. Recently, some studies have reported that the value of lactate would increase after hepatectomy due to the hypoperfusion resulted from intraoperative inflow occlusion and low central venous pressure management, and the elevated lactate is considered as an early predictor of post-operative adverse outcomes [21,22,33,35,36]. Similarly in this study, patients with high level of lactate had a worse OS and RFS compared with patients with low level of lactate, and the factors BCLC stage, inflow occlusion, and blood transfusion could predict the increase of lactate in multivariate analysis.
Nucleoside and nucleotide analogues (NAs) have a risk of mitochondrial toxicity and then inducing the increase of lactate. We aim to evaluate the impact of lactate on the effects of NAs therapy in hepatitis B virus-related hepatocellular carcinoma (HCC) patients after curative liver resection.
Five hundred and fifty-seven HBV-related HCC patients were divided into the treatment and control group according to whether they received NAs therapy or not. Perioperative and prognosis data were retrospectively reviewed.
The treatment group had a better overall survival rate (OS) than the control group (P = 0.017). The recurrence-free survival rate (RFS) did not significantly differ between the two groups (P = 0.174). NAs could improve the OS of early stage HCC patients (P = 0.028), as well as the OS of advanced stage HCC patients with low level of lactate in subgroup analysis stratified against the level of lactate (P = 0.037). Advanced stage HCC patients in the treatment group had a higher value of lactate than those in the control group (P = 0.024). Besides, advanced stage HCC patients had a higher value of lactate than early stage HCC patients in the treatment group (P < 0.001), as well as in the control group (P < 0.001).
NAs could improve the long-term outcomes of HBV-related HCC patients after curative liver resection. However, the improvement effect of NAs therapy is counteracted by the adverse effect of elevated lactate in advanced stage HBV-related HCC patients.
The incidence and outcome of hyperlactatemia in patients admitted to the intensive care unit after elective surgery
2018, American Journal of Surgery
Citation Excerpt :
It is also possible that local ischemia occurs by surgical procedures such as the pringle maneuver during hepatectomy. Postoperative reasons for hyperlactatemia include oxygen consumption increase as a result of awakening from anesthesia, withdrawing from mechanical ventilation, pain related to surgical procedures, low body temperature, prolonged intraoperative tissue under-perfusion, blood loss, release of endogenous stress hormones, and postoperative catecholamine administration.26,27 Some of these potential reasons are inevitable and do not seem to be related to poor outcome.
Although hyperlactatemia is often developed in critically ill patients, it is unclear whether hyperlactatemia is associated with poor prognosis for surgical ICU (SICU) patients.
We performed a retrospective analysis in an academic hospital in Tokyo. The maximum lactate was defined as the highest value within the SICU stay. The primary outcome was the composite outcome of in-hospital mortality, re-admission to the SICU or admission to the general ICU and emergency reoperation.
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The odds ratio was similar between moderate and severe hyperlactatemia, so the cause and meaning of hyperlactatemia might be different among patients with elective surgery.

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Shock/Sepsis/Trauma/Critical careChanges in blood lactate levels after major elective abdominal surgery and the association with outcomes: a prospective observational study

Abstract

Background

Materials and methods

Results

Conclusions

Introduction

Section snippets

Study design and patients

Results

Discussion

Ann Thorac Surg

J Surg Res

Chest

Yes Chest

Crit Care Clin

Am J Surg

Am J Surg

Surgery

Chest

The higher risk general surgical patient: towards improved care for a forgotten group

Report of the Royal College of Surgeons of England/Department of Health Working Group on the perioperative care of the higher risk general surgical patient

Microvascular flow and tissue oxygenation after major abdominal surgery: association with post-operative complications

Intensive Care Med

Microvascular dysfunction in the surgical patient

Curr Opin Crit Care

Role of central and mixed venous oxygen saturation measurement in perioperative care

Anesthesiology

Hemodynamic monitoring in shock and implications for management. International Consensus Conference, Paris, France, 27–28 April 2006

Intensive Care Med

Multicentre study on peri- and postoperative central venous oxygen saturation in high-risk surgical patients

Crit Care

Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial

JAMA

Lactate as a marker of energy failure in critically ill patients: hypothesis

Crit Care

Shock/Sepsis/Trauma/Critical care
Changes in blood lactate levels after major elective abdominal surgery and the association with outcomes: a prospective observational study