Factors associated with increased lactate levels in cardiac surgeries: scoping review

Teixeira, Fernanda de Castro; Fernandes, Thatiane Evelyn de Lima; Leal, Karena Cristina da Silva; Ribeiro, Katia Regina Barros; Dantas, Daniele Vieira; Dantas, Rodrigo Assis Neves

doi:10.1590/0034-7167-2023-0117

Fernanda de Castro Teixeira

conception or design of the study/research

Universidade Federal do Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil

https://orcid.org/0000-0002-6056-0435

Thatiane Evelyn de Lima Fernandes

analysis and/or interpretation of data

Universidade Federal do Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil

https://orcid.org/0000-0001-6533-9572

Karena Cristina da Silva Leal

analysis and/or interpretation of data

Universidade Federal do Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil

https://orcid.org/0000-0002-8857-6666

Katia Regina Barros Ribeiro

final review with critical

intellectual participation in the manuscript

Universidade Federal do Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil

https://orcid.org/0000-0002-3513-7483

Daniele Vieira Dantas

final review with critical

intellectual participation in the manuscript

Universidade Federal do Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil

https://orcid.org/0000-0003-0307-2424

Rodrigo Assis Neves Dantas Corresponding author: Rodrigo Assis Neves Dantas, E-mail: rodrigoenf@yahoo.com.br

final review with critical

intellectual participation in the manuscript

Universidade Federal do Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil

https://orcid.org/0000-0002-9309-2092

Corresponding author: Rodrigo Assis Neves Dantas, E-mail: rodrigoenf@yahoo.com.br

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Alexandre Balsanelli

Source	Syntax
Scopus	ALL (thoracic AND surgery AND lactic AND acid) AND ALL (cardiopulmonary AND bypass AND postoperative AND period) AND ALL (mortality) AND (LIMIT-TO (OA, “all”))
PubMed PMC	(((Thoracic Surgery AND Lactic Acid)) AND (cardiopulmonary bypass and Postoperative period)) AND Mortality
Web of Science	((ALL=(Thoracic Surgery AND Lactic Acid)) AND ALL=(cardiopulmonary bypass AND Postoperative period)) AND ALL=(Mortality)
Science Direct	(Thoracic Surgery AND Lactic Acid) AND (cardiopulmonary bypass and Postoperative period) AND Mortality
Scientific Electronic Library Online	(Thoracic Surgery AND Lactic Acid) AND (cardiopulmonary bypass and Postoperative period) AND (Mortality)
Cochrane Library	Thoracic Surgery AND Lactic Acid in Title Abstract Keyword AND cardiopulmonary bypass and Postoperative period in Title Abstract Keyword AND Mortality in Title Abstract Keyword
Latin American and Caribbean Literature in Health Sciences	ALL (thoracic AND surgery AND lactic AND acid) AND ALL (cardiopulmonary AND bypass AND postoperative AND period) AND ALL (mortality) AND (LIMIT-TO (OA, “all”))
Wiley Online Library	“Thoracic Surgery AND Lactic Acid” anywhere and “cardiopulmonary bypass and Postoperative period” anywhere and “Mortality” anywhere
Cumulative Index to Nursing and Allied Health Literature	(Thoracic Surgery AND Lactic Acid) AND (cardiopulmonary bypass and Postoperative period) AND Mortality
Catalog of Theses and Dissertations	(Thoracic Surgery AND Lactic Acid) AND (cardiopulmonary bypass and Postoperative period) AND (Mortality)

Year/ Country/ Reference	Type of cardiac surgery/ Average CPB time	Main factors associated with increased lactate	Outcome
2022/ China(¹⁵15 Zhan YF, Shi Q, Pan YC, Zheng BS, Ge YP, Luo TG, et al. Sufentanil: a risk factor for lactic acidosis in patients after heart valve surgery. J Cardiothorac Surg. 2022;17(1):233. https://doi.org/10.1186/s13019-022-01986-5 https://doi.org/10.1186/s13019-022-01986... )	Heart valve surgery/ 140 min	Hypoperfusion, intraoperative sufentanil infusion rate, use of epinephrine	Inadequate intraoperative sufentanil infusion rate is an independent risk factor for acidosis.
2022/ Morocco(¹⁶16 Seghrouchni A, Atmani N, Moutakiallah Y, Belmekki A, Bekkali YE, Houssa MA. Does severe hyperlactatemia during cardiopulmonary bypass predict a worse outcome?. Ann Med Surg. 2021;73:103198. https://doi.org/10.1016/j.amsu.2021.103198 https://doi.org/10.1016/j.amsu.2021.1031... )	Valvular surgery, coronary artery bypass grafting, combined procedure, adult congenital anomalies and aortic surgery/ 120 min	Hypoperfusion of body tissues and hypoxia cellular, duration of CPB, severe hemodilution	Blood lactate levels above 5 mmol/L at the end of CPB are associated with worse outcomes.
2022/ Turkey(¹⁷17 Özmen R, Bozguney M, Tekin AI, Eroglu T, Tuncay A. Impact of Single versus Double Clamp Technique on Blood Lactate Levels and Postoperative Complications in Coronary Artery Bypass Surgery. Braz J Cardiovasc Surg. 2022;37(1)55-64. https://doi.org/10.21470/1678-9741-2020-0025 https://doi.org/10.21470/1678-9741-2020-... )	Myocardial revascularization/ Time not reported	Kidney injury, ischemic stroke, hyperglycemia, and blood transfusion	Longer CPB time was associated with higher lactate levels and increased mortality.
2020/ Spain(¹⁸18 Camacho CG, Paz AJ, Franco CL, Hervás MJ, Otero AM. Continuous ultrafiltration during extracorporeal circulation and its effect on lactatemia: a randomized controlled trial. PLoS One. 2020;15(11). https://doi.org/10.1371/journal.pone.0242411 https://doi.org/10.1371/journal.pone.024... )	Valve, coronary and aortic replacement surgeries/ 102 min	Hemodilution and CPB time	Reduction in lactatemia resulted in a decrease in morbidity and mortality in the intensive care unit.
2020/ Japan(¹⁹19 Ezaka M, Tsukamoto J, Matsuo K, Kin N, Yamaoka K. Hyperlactatemia of dialysis-dependent patients after cardiac surgery impacts on in-hospital mortality: a two-center retrospective study. JA Clin Rep. 2020;6(1):47. https://doi.org/10.1186/s40981-020-00348-1 https://doi.org/10.1186/s40981-020-00348... )	Valve surgeries, CABG, aortic surgeries/Time not reported	Age, preoperative history of HF, surgery time, CPB time, aortic clamping, and use of adrenaline	Early onset of a maximum arterial lactate concentration greater than 4.5 mmol/L was significantly associated with in-hospital mortality.
2019/ Poland(²⁰20 Duchnowski P, Hryniewiecki T, Kuśmierczyk M, Szymański P. The usefulness of perioperative lactate blood levels in patients undergoing heart valve surgery. Kardiochir Torakochirurgia Pol. 2019;16(3):114-7. https://doi.org/10.5114/kitp.2019.88599 https://doi.org/10.5114/kitp.2019.88599... )	Heart valve surgery/ 122 min	Tissue hypoperfusion	The blood lactate level measured one day after the operation was an independent predictor of death at a 30-day follow-up.
2018/ Germany(²¹21 Piot J, Hébrard A, Durand M, Payen JF, Albaladejo P. An elevated respiratory quotient predicts complications after cardiac surgery under extracorporeal circulation: an observational pilot study. J Clin Monit Comput. 2019;33(1):145-53. https://link.springer.com/article/10.1007/s10877-018-0137-0 https://link.springer.com/article/10.100... )	Unspecified type of surgery/ 129 min	Tissue hypoxia, drug therapy, hypothermia	Excess base severely reduced on ICU admission is superior to lactate levels for predicting ICU mortality.
2018/ Germany(²²22 Zante B, Reichenspurner H, Kubik M, Kluge S, Schefold JC, Pfortmueller CA. Base excess is superior to lactate-levels in prediction of ICU mortality after cardiac surgery. PLoS One. 2018;13(10):e0205309. https://doi.org/10.1371/journal.pone.0205309 https://doi.org/10.1371/journal.pone.020... )	Type of surgery not mentioned/5 to 10 min	CPB time	In patients who received CPB for two hours or more, venous lactate and partial pressure of carbon dioxide in the blood were higher than baseline values.
2017/ Saudi Arabia(²³23 Nazer RI, Alburikan KA. Metformin is not associated with lactic acidosis in patients with diabetes undergoing coronary artery bypass graft surgery: a case control study. BMC Pharmacol Toxicol. 2017;38(18). https://doi.org/10.1186/s40360-017-0145-6 https://doi.org/10.1186/s40360-017-0145-... )	Myocardial revascularization / 100 min	Tissue anoxia caused by increased vasopressor support after surgery	Elevated lactic acid levels appear to be directly related to tissue anoxia caused by increased vasopressor support after surgery.
2017/ United Kingdom(²⁴24 Yusuff HO, Zochios V. Lactic Acidosis and Mitral Valve Surgery: defining the relationship. J Cardiothorac Vasc Anesth. 2018;32(2):644-5. https://doi.org/10.1053/j.jvca.2017.09.033 https://doi.org/10.1053/j.jvca.2017.09.0... )	Mitral valve surgery/ Time not reported	CPB times, epinephrine use, preoperative atrial fibrillation, and preoperative heart failure	A high level of hyperlactatemia (7 mmol/L) was associated with mortality, but the majority of those who died did not have high levels upon admission to the ICU.
2016/ Canada(²⁵25 Mak NT, Igbal S, Varennes B, Khwaja K. Outcomes of post-cardiac surgery patients with persistent hyperlactatemia in the intensive care unit: a matched cohort study. J Cardiothorac Surg. 2016;11:33. https://doi.org/10.1186/s13019-016-0411-5 https://doi.org/10.1186/s13019-016-0411-... )	Myocardial revascularization and/or valve surgery/ 130 min	Tissue hypoperfusion	Mortality is proposed to be secondary to a state of ongoing hypoperfusion.
2016/ United States(²⁶26 Andersen LW, Holmberg MJ, Berg KM, Chase M, Cocchi MN, et al. Thiamine as an adjunctive therapy in cardiac surgery: a randomized, double-blind, placebo-controlled, phase II trial. Crit Care. 2016:14;20:92. https://doi.org/10.1186/s13054-016-1245-1 https://doi.org/10.1186/s13054-016-1245-... )	Myocardial revascularization and valve surgery/Time not reported	Low ejection fraction, age, reoperation, diabetes, hypertension	No difference was found in the postoperative period in relation to lactate levels and its association with mortality.
2015/ Saudi Arabia(²⁷27 Soliman R, Fouad E, Belghith M, Abdelmageed T. Conventional hemofiltration during cardiopulmonary bypass increases the serum lactate level in adult cardiac surgery. Ann Card Anaesth. 2016;19(1):45-51. https://doi.org/10.4103/0971-9784.173019 https://doi.org/10.4103/0971-9784.173019... )	Not reported in study	Hemofiltration during CPB	Hemofiltration during CPB leads to hemoconcentration, increased serum lactate and inotropic support.
2015/ China(²⁸28 Zhang Z, Ni H. Normalized lactate load is associated with development of acute kidney injury in patients who underwent cardiopulmonary bypass surgery. PLoS One. 2015;10(3). https://doi.org/10.1371/journal.pone.0120466 https://doi.org/10.1371/journal.pone.012... )	Lung bypass surgery/ 83 min	Administration of lactated Ringer’s solution, distributive shock, type B hyperlactatemia	There was no direct causal relationship between lactate index and mortality.
2015/ Netherlands(²⁹29 Ottens TH, Nijsten MW, Hofland J, Dieleman JM, Hoekstra M, Dijk D, et al. Effect of high-dose dexamethasone on perioperative lactate levels and glucose control: a randomized controlled trial. Crit Care. 2015;19(1):41. https://doi.org/10.1186/s13054-015-0736-9 https://doi.org/10.1186/s13054-015-0736-... )	Unspecified surgery/ 148 min	High dose of intraoperative dexamethasone	High doses of intraoperative dexamethasone increased postoperative lactate and glucose levels within the first 15 hours of ICU admission.
2013/ Brazil(³⁰30 Hajjar LA, Almeida JP, Fukushima JT, Rhodes A, Vincent JL, Osawa EA, et al. High lactate levels are predictors of major complications after cardiac surgery. J Thorac Cardiovasc Surg. 2013;146(2):455-60. https://doi.org/10.1016/j.jtcvs.2013.02.003 https://doi.org/10.1016/j.jtcvs.2013.02.... )	Not mentioned in the study	A threshold of 3 mmol/L within 6 hours of ICU admission and 2 mmol/L	After 6 hours of ICU admission, lactate level predicts postoperative complications such as 30-day all-cause mortality and severe morbidity after cardiac surgery in adult patients.
2011/ Australia(³¹31 Dong MF, Ma ZS, Wang JT, Chai SD, Tang PZ, Wang LX. Impact of peripherally established cardiopulmonary bypass on regional and systemic blood lactate levels. Heart Lung Circ. 2012;21(3):154-8. https://doi.org/10.1016/j.hlc.2011.10.014 https://doi.org/10.1016/j.hlc.2011.10.01... )	Unreferenced type/ 50 to 100 min	Increase in lactate associated with CPB time	In patients who received CPB for two hours or more, venous lactate and PvCO₂ were higher than baseline values.
2011/ India(³²32 Kapoor P, Mandal B, Chowdhury U, Singh S, Kiran U. Changes in myocardial lactate, pyruvate and lactate-pyruvate ratio during cardiopulmonary bypass for elective adult cardiac surgery: early indicator of morbidity. J Anaesthesiol Clin Pharmacol. 2011;27(2):225-32. https://doi.org/10.4103/0970-9185.81819 https://doi.org/10.4103/0970-9185.81819... )	Myocardial revascularization and valve surgery/ > 60 min	CPB time	Pre-CPB myocardium, lactate value 2.9 mmol/l, myocardial pyruvate value of 0.07 mmol/l can predict post-CPB inotropic need with good sensitivity and specificity.
2006/ Sweden(³³33 Svenmarker S, Häggmark S, Ostman M. What is a normal lactate level during cardiopulmonary bypass?. Scand Cardiovasc J. 2006;40(5):305-11. https://doi.org/10.1080/14017430600900261 https://doi.org/10.1080/1401743060090026... )	Myocardial revascularization/ 90.2 min	Age, use of vasoactive drugs, CPB time, aortic clamping time	In patients who met the criteria for hyperlactatemia, in-hospital mortality was 13.3%, compared with 2.2% for the entire cohort.

RISK FACTORS	CITATIONS IN STUDIES
Age	1
Sex	2
Comorbidities	3
Extracorporeal circulation time	9
Surgery time	2
tissue hypoperfusion	13
distributive shock	1
Hyperglycemia	1
Cardiac insufficiency	3
Lactate source lungs	1
Low splenic circulation	1
Low hemoglobin	1
Anoxia time	5
Accelerated glycolysis	2
Peripheral arterial disease	1
Vasoactive drugs	1
Corticosteroid use	6
Low ejection fraction	1
Kidney dysfunction	3
Use of the intra-aortic balloon	3
Blood transfusion	1
Hemodilution	3
Ineffective liver clearance	1
Ineffective cardioplegia	3
Hypothermia	2

Standard	Advances	Gaps	Evidence for practice	Search recommendations
Hypoperfusion/Tissue hypoxia	The important role of perioperative tissue hypoxia in the development of postoperative complications	Some factors related to sample size, data and validity compromise the quality of the studies.	The study is relevant for helping and alerting the healthcare team about possible complications after heart surgery.	It is necessary to carry out additional studies in this line to guarantee the results of the data.
CPB time	Prolonged CPB time and other factors are associated with early and late postoperative hyperlactatemia.	Studies with small samples of participants, harmful to inferring results	The study contributes to the health team’s performance regarding postoperative results, depending on the patient’s physiological needs.	More research on this topic with larger sample sizes is needed.
Use of drugs	Inadequate intraoperative infusion of high-dose medications is an independent risk factor for lactic acidosis after cardiac surgery.	Few studies address the relationship between specific drugs and increased lactate.	Evaluates the risk-benefit of intraoperative drug use.	Studies with different drug therapy approaches are needed for a more comprehensive investigation.

[1] Corresponding author: Rodrigo Assis Neves Dantas, E-mail: rodrigoenf@yahoo.com.br

Brasil

Brasil

Factors associated with increased lactate levels in cardiac surgeries: scoping review

Factores relacionados a la elevación del nivel de lactato en cirugías cardíacas: revisión de ámbito

ABSTRACT

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Methods:

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Conclusions: