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. 2020 Apr 13:2:92-99.
doi: 10.1016/j.xjtc.2020.04.001. eCollection 2020 Jun.

Associations between oxygen delivery and cardiac index with hyperlactatemia during cardiopulmonary bypass

Ignazio Condello  1 , Giuseppe Santarpino  2   3   4 , Giuseppe Nasso  1 , Marco Moscarelli  1 , Flavio Fiore  1 , Giuseppe Speziale  1
Affiliations

Associations between oxygen delivery and cardiac index with hyperlactatemia during cardiopulmonary bypass

Ignazio Condello et al. JTCVS Tech. .

Abstract

Objective: Metabolism management plays an essential role during cardiopulmonary bypass (CPB). There are different metabolic management devices integrated to heart-lung machines; the most commonly used and accepted metabolic target is indexed oxygen delivery (DO2i) (280 mL/min/m2) and cardiac index (CI) (2.4 L/min/m2), which can be managed independently or according to other metabolic parameters. Our objective was to compare lactate production during CPB procedures using different metabolic management: DO2i in relation to indexed oxygen extraction ratio (O2ERi) and CI in relation to mixed venous oxygen saturation (SvO2).

Methods: Data on 500 CPB procedures were retrospectively collected in a specialized regional tertiary cardiac surgery center in Italy between September and 2012 and November 2019. In group A, the DO2i with 280 mL/min/m2 target in relation to O2ERi 25% was used; in group B, CI with 2.4 L/min/m2 target in relation to SvO2 75% was used. During CPB, serial arterial blood gas analyses with blood lactate and glucose determinations were obtained. Hyperlactatemia (HL) was defined as a peak arterial blood lactate concentration >3 mmol/L. The postoperative outcome of patients with or without HL was compared.

Results: Eight pre- and intraoperative factors were found to be significantly associated with peak blood lactate level during CPB at univariate analysis. HL (>3 mmol/L) was detected in 15 (6%) patients of group A and in 42 (16.8%) patients of group B (P = .022); hyperglycemia (>160 mg/dL) was found in 23 (9.2%) patients of group A and in 53 (21.2%) patients of group B (P = .038). Patients with HL during CPB had a significant increase in serum creatinine value, higher rate of prolonged mechanical ventilation time and intensive care unit stay. A cutoff of DO2i <270 mL/min/m2 in relation to O2ERi >35% in group A and a cutoff of CI <2.4 L/min/m2 in relation to SvO2 <65% in group B were found to have a positive predictive value of 80% and 75% for HL, respectively. A cutoff of DO2i >290 mL/min/m2 in relation to O2ERi 24% in group A and a cutoff of CI >2.4 L/min/m2 in relation to SvO2 >75% in group B were found to have a negative predictive value of 78% and 62% for HL, respectively.

Conclusions: This retrospective observational analysis showed that management of DO2i in relation to O2ERi was 16% more specific in terms of negative predictive value for HL during CPB compared with the use of CI in relation to SvO2. Group A reported a significant reduction in the incidence of intraoperative lactate peak, correlated with postoperative reduction of serum creatinine value, mechanical ventilation time, and intensive care unit stay, compared with group B.

Keywords: CI, cardiac index; CPB, cardiopulmonary bypass; DO2i, indexed oxygen delivery; HL, hyperlactatemia; Hb, hemoglobin; Hct, hematocrit; ICU, intensive care unit; O2ERi, indexed oxygen extraction ratio; SvO2, venous oxygen saturation; cardiac index; cardiopulmonary bypass; hyperlactatemia; oxygen delivery.

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Figures

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Graphical abstract
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Sensitivity/specificity curves for cardiac index, indexed oxygen delivery, indexed oxygen extraction ratio, and mixed venous oxygen saturation.
Video 1
Video 1
Ignazio Condello, PhD, summarizes the results of the study and explains the relevance of the research for the readers of the Journal. Video available at: https://www.jtcvs.org/article/S2666-2507(20)30189-9/fulltext.
Figure 1
Figure 1
Receiver operating characteristic curves for lactate peak prediction based on target indexed oxygen delivery (DO2i), indexed oxygen extraction ratio (O2ERi), cardiac index (CI), and mixed venous oxygen saturation (SvO2).
Figure 2
Figure 2
Lactate and glucose trend according to the distribution of target indexed oxygen delivery (DO2i) level and indexed oxygen extraction ratio (O2ERi) during cardiopulmonary bypass.
Figure 3
Figure 3
Lactate and glucose trend according to the distribution of cardiac index (CI) level and mixed venous oxygen saturation (SvO2) during cardiopulmonary bypass.
Figure 4
Figure 4
Negative predictive value (NPV) and positive predictive value (PPV) of hyperlactatemia. The receiver operating characteristic curve analysis shows that oxygen delivery (DO2) >280 mL/min/m2 in relation to indexed oxygen extraction ratio (O2ERi) 25% is more specific and sensitive than the calculated cardiac index (CI), and is 16 times higher as a predictive value for values <3 mmol/dL lactates. SvO2, Mixed venous oxygen saturation.
Figure 5
Figure 5
Data on 500 cardiopulmonary bypass (CPB) procedures were retrospectively collected, the management of indexed oxygen delivery (DO2i) in relation to indexed oxygen extraction ratio (O2ERi) follow the CPB was more specific in terms of negative predictive value for hyperlactatemia compared with the use of cardiac index (CI) in relation to mixed venous oxygen saturation (SvO2). That management can correlate with postoperative better outcome especially in terms of serum creatinine, mechanical ventilation time and intensive care unit stay.
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