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Hyperlactataemia as a predictor of adverse outcomes post-cardiac surgery in neonates with congenital heart disease

Part of: Surgery

Published online by Cambridge University Press:  09 February 2021

Eleonore Valencia Open the ORCID record for Eleonore Valencia [Opens in a new window] ,
Steven J. Staffa ,
Meena Nathan ,
Melissa Smith-Parrish ,
Aditya K. Kaza ,
James A. DiNardo  and
Viviane G. Nasr Open the ORCID record for Viviane G. Nasr [Opens in a new window]
Eleonore Valencia
Affiliation:
Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
Steven J. Staffa
Affiliation:
Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
Meena Nathan
Affiliation:
Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
Melissa Smith-Parrish
Affiliation:
Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
Aditya K. Kaza
Affiliation:
Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
James A. DiNardo
Affiliation:
Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
Viviane G. Nasr*
Affiliation:
Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
*
Author for correspondence: Viviane G. Nasr, MD; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. E-mail: viviane.nasr@childrens.harvard.edu
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Abstract

Objective:

To evaluate the discriminative ability of hyperlactataemia for early morbidity and mortality in neonates with CHD following cardiac surgery.

Methods:

Retrospective, observational study of neonates who underwent cardiac surgery on cardiopulmonary bypass at a tertiary care children’s hospital from June 2015 to June 2019. The primary predictor was lactate. The primary composite outcome was defined as ≥1 of the following: cardiac arrest or extracorporeal membrane oxygenation within 72 hours or 30-day mortality post-operatively. The secondary outcome was the presence of major residual lesions, according to the Technical Performance Score.

Results:

Of 432 neonates, 28 (6.5%) sustained the composite outcome. On univariate analysis, peak lactate within 48 hours, increase in lactate from ICU admission through 12 hours, and single ventricle physiology were significantly associated with the composite outcome. The peak lactate occurred at a median of 2.9 hours (interquartile range: 1, 35) before the event. Through multi-variable analysis, a multi-variable risk algorithm was created. Predicted probabilities demonstrated an increasing risk based on single ventricle status and delta lactate, ranging from 1.8% (95% CI: 0.9, 3.9) to 52.4% (95% CI: 32.4, 71.7). The model had good discriminative ability for the composite outcome on receiver operating characteristic analysis (area under the curve = 0.79; 95% CI: 0.75, 0.89). Moreover, a peak lactate of 7.3 mmol/l or greater was significantly associated with the presence of a major residual lesion (odds ratios: 5.16, 95% CI: 3.01, 8.87).

Conclusions:

We present a simple, two-variable model, including delta lactate in the immediate post-operative period and single ventricle status, to prognosticate the risk of early morbidity and mortality in neonates undergoing cardiac surgery for potential intervention.

Keywords

NeonateCHDcardiac surgeryhyperlactataemiacritical care outcomes
Type
Original Article
Information
Cardiology in the Young , Volume 31 , Issue 9 , September 2021 , pp. 1401 - 1406
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Copyright
© The Author(s), 2021. Published by Cambridge University Press

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References

The STS Congenital Heart Surgery Database. Retrieved March 1, 2020; from https://www.sts.org/registries-research-center/sts-national-database/congenital-heart-surgery-database Google Scholar
Costello, JM, Pasquali, SK, Jacobs, JP, et al. Gestational age at birth and outcomes after Neonatal cardiac surgery: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Circulation 2014; 129: 2511–2517.CrossRefGoogle Scholar
Curzon, CL, Milford-Beland, S, Li, JS, et al. Cardiac surgery in infants with low birth weight is associated with increased mortality: Analysis of the Society of Thoracic Surgeons Congenital Heart Database. J Thorac Cardiovasc Surg 2008; 135: 546–551.CrossRefGoogle Scholar
O’Brien, SM, Clarke, DR, Jacobs, JP, et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg 2009; 138: 1139–1153.CrossRefGoogle ScholarPubMed
Kansy, A, Tobota, Z, Maruszewski, P, Maruszewski, B. Analysis of 14,843 neonatal congenital heart surgical procedures in the European Association for Cardiothoracic Surgery Congenital Database. Ann Thorac Surg 2010; 89: 1255–1259.CrossRefGoogle ScholarPubMed
Clancy, RR, McGaurn, SA, Wernovsky, G, et al. Preoperative risk-of-death prediction model in heart surgery with deep hypothermic circulatory arrest in the Neonate. J Thorac Cardiovasc Surg 2000; 119: 347–357.CrossRefGoogle ScholarPubMed
Schumacher, KR, Reichel, RA, Vlasic, JR, et al. Rate of increase of serum lactate level risk-stratifies infants after surgery for congenital heart disease. J Thorac Cardiovasc Surg 2014; 148: 589–595.CrossRefGoogle ScholarPubMed
Charpie, JR, Dekeon, MK, Goldberg, S, Mosca, RS, Bove, EL, Kulik, TJ. Serial blood lactate measurements predict early outcome after neonatal repair or palliation for complex congenital heart disease. J Thorac Cardiovasc Surg. 2000; 120: 73–80.CrossRefGoogle ScholarPubMed
Cheifetz, IM, Kern, FH, Schulman, SR, Greeley, WJ, Ungerleider, RM, Meliones, JN. Serum lactates correlate with mortality after operations for complex congenital heart disease. Ann Thorac Surg 1997; 64: 735–738.CrossRefGoogle ScholarPubMed
Cheung, P, Chui, N, Joffe, AR, et al. Postoperative lactate concentrations predict the outcome of infants aged 6 weeks or less after intracardiac surgery: a cohort follow-up to 18 months. J Thorac Cardiovasc Surg 2005; 130: 837–843.CrossRefGoogle ScholarPubMed
Larrazabal, LA, del Nido, PJ, Jenkins, KJ, et al. Measurement of technical performance in congenital heart surgery: a pilot study. Ann Thorac Surg 2007; 83: 179–184.CrossRefGoogle ScholarPubMed
Nathan, M, Karamichalis, J. Quality improvement: surgical performance. Technical performance score as a performance measure for congenital heart surgery. In Sellke/Sabiston and Spencer’s Surgery of the Chest, 9th edn, 2015; Chapter 134.Google Scholar
Hosmer, DW, Lemeshow, S, Sturdivant, RX. Applied Logistic Regression, 3rd edn. John Wiley & Sons, Hoboken, NJ, 2013.CrossRefGoogle Scholar
Altman, DG, Vergouwe, Y, Royston, P, Moons, KGM. Prognosis and prognostic research: validating a prognostic model. BMJ 2019; 338: 1432–1435.Google Scholar
Murtuza, B, Wall, D, Reinhardt, Z, et al. The importance of blood lactate clearance as a predictor of early mortality following the modified Norwood procedure. Eur J Cardiothorac Surg 2011; 40: 1207–1240.Google ScholarPubMed
Kalyanaraman, M, DeCampli, WM, Campbell, AI, et al. Serial blood lactate levels as a predictor of mortality in children after cardiopulmonary bypass surgery. Pediatr Crit Care Med 2008; 9: 285–288.CrossRefGoogle ScholarPubMed
Nasr, VG, Staffa, SJ, Boyle, S, et al. Predictors of increased lactate in Neonatal cardiac surgery: the impact of cardiopulmonary bypass. J Cardiothorac Vasc Anesth. Published online ahead of print, 2020 Jun 10.Google ScholarPubMed
Nathan, M, Karamichalis, JM, Liu, H, et al. Intraoperative adverse events can be compensated by technical performance in neonates and infants after cardiac surgery: a prospective study. J Thorac Cardiovasc Surg 2011; 142: 1098–1107.CrossRefGoogle ScholarPubMed
Karamichalis, JM, del Nido, PJ, Thiagarajan, RR, et al. Early postoperative severity of illness predicts outcomes after the stage 1 Norwood procedure. Ann Thorac Surg 2011; 92: 660–665.CrossRefGoogle Scholar
Mazwi, ML, Brown, DW, Marshall, AC, et al. Unplanned reinterventions are associated with postoperative mortality in neonates with critical congenital heart disease. J Thorac Cardiovasc Surg 2013; 145: 671–677.CrossRefGoogle ScholarPubMed