Trekova N A, Akselrod B A, Yudichev I I, Gus'kov D A, Markin A V, Popov A M
Anesteziol Reanimatol. 2016 Sep;61(5):324-329.
The frequency and the causes for the development of hyperlactatemia during operations on the heart and aorta in conditions of cardiopulmonary bypass (CB) is not adequately described in the literature.
To study the clinical significance of the lactate dynamics in arterial blood depending on the source ofpathology, stages of operation, basic parameters of cardiopulmonary bypass, the characteristics of the post-perfusion period, and to identify ways to prevent the development of intraoperative hyperlactatemia in surgical interventions on the heart and aorta.
420 adult cardiac surgery patients operated on the heart and ascending aorta were examined. All patients were operated on under balanced General anesthesia, CB in hypothermic or normothermic mode. Lactate level in arterial blood and the frequency of hyperlactatemia were analyzed at the following stages of operation: after induction of anesthesia, prebypass period, during CB, in the postbypass period and at the time of admission of the patient in the ICU. During CB we analyzed the duration of the CB, the degree of hemodilution, calculated value of oxygen delivery. Oxygen consumption was recorded in the current mode, the monitor CDI-500. Hyperlactatemia was considered the concentration of lactate above 3 mmol/L.
Preperfusion period in all groups of cardiac surgery patients was characterized by a normal level of blood lactate in the absolute majority ofpatients, the frequency of hyperlactatemia did not exceed 1%. Hemodynamic stability was achieved without the use of catecholamines by optimizing volemia and heart rate. While CB showed a trend of increasing lactate on average in comparison with the previous period in patients operated on the heart. Duration CB less than 3 hours was not a factor in the development of hyperlactatemia, provided that oxygen delivery in all patients during perfusion exceeded 300 ml/min/m2, hematocrit ofperfusate at the end of CB was at 25-27% in most patients. To maintain it at a large hemodilution the ultrafiltration hemoconcentration was used. The frequency of hyperlactatemia was 3%. A significant increase in lactate concentration at the end of the CB to 3.39k1,3 mmol/l (range of 2.1-7.2 mmol/l) on the background of metabolic acidosis found only in patients with circulatory arrest due to receipt of blood products of anaerobic glycolysis after the resumption of the CB. They have frequency of hyperlactatemia risen to 29%. The lac- tate average value at admission ofpatients in the ICU with application of 50-60% ofpatients in dopamine/dobutrex at a dose of 5 mcg/kg/min and reaching the targets of transfusion therapy was slightly higher in the baseline period and corresponded to the upper level of normal values. Only during operations on the aortic arch under conditions of circulatory arrest, the concentration of lactate at the end of the operation was 3,4+1,1 mmol/l with a tendency to decrease in comparison with the period of the CB. From 88 to 93% patients during operations on the heart and ascending aorta without circulatory arrest and 64% ofpatients after operations on the aortic arch with circulatory arrest were admitted to the ICU with a normal lactate level in arterial blood Conclusion. The duration ofperfusion less than 3 hours in the conditions of these indicators preservation is not a risk factor for the development of hyperlactatemia. In postbypass period during operations on the heart and aorta without circulatory arrest about 90% ofpatients transferred to the intensive care unit (ICU) with normal values of lactate. During operations on the aortic arch with circulatory arrest about 60% ofpatients have normal levels of lactate at admission from the operating room to the ICU.
文献中对在体外循环（CB）条件下进行心脏和主动脉手术期间高乳酸血症发生的频率及原因描述不足。
研究取决于病理来源、手术阶段、体外循环基本参数、灌注后时期特点的动脉血中乳酸动态变化的临床意义，并确定在心脏和主动脉手术干预中预防术中高乳酸血症发生的方法。
对420例接受心脏和升主动脉手术的成年心脏外科患者进行检查。所有患者均在平衡全身麻醉下、低温或常温模式的体外循环下进行手术。在手术的以下阶段分析动脉血中的乳酸水平及高乳酸血症的频率：麻醉诱导后、体外循环前阶段、体外循环期间、体外循环后阶段以及患者入住重症监护病房（ICU）时。在体外循环期间，我们分析了体外循环的持续时间、血液稀释程度、计算得出的氧输送值。用监测仪CDI - 500以当前模式记录氧消耗情况。高乳酸血症定义为乳酸浓度高于3 mmol/L。
所有心脏外科患者组的体外循环前阶段，绝大多数患者的血乳酸水平正常，高乳酸血症的频率不超过1%。通过优化血容量和心率，在不使用儿茶酚胺的情况下实现了血流动力学稳定。与心脏手术患者的前一阶段相比，体外循环期间乳酸平均呈上升趋势。体外循环持续时间少于3小时并非高乳酸血症发生的因素，前提是所有患者在灌注期间的氧输送超过300 ml/min/m²，大多数患者体外循环结束时灌注液的血细胞比容为25 - 27%。为在大量血液稀释时维持该水平，采用了超滤血液浓缩法。高乳酸血症的频率为3%。仅在因体外循环恢复后接受无氧糖酵解血液制品而出现循环骤停的患者中，发现体外循环结束时乳酸浓度显著升高至3.39±1.3 mmol/L（范围为2.1 - 7.2 mmol/L），且伴有代谢性酸中毒，此时他们的高乳酸血症频率升至29%。应用多巴胺/多巴酚丁胺剂量为5 mcg/kg/min且达到输血治疗目标的患者中，50 - 60%的患者入住ICU时的乳酸平均值在基线期略高，且对应正常值上限。仅在循环骤停条件下进行主动脉弓手术期间，手术结束时乳酸浓度为3.4±1.1 mmol/L，与体外循环期相比有下降趋势。在无循环骤停的心脏和升主动脉手术中，88%至93%的患者以及在有循环骤停的主动脉弓手术后64%的患者入住ICU时动脉血乳酸水平正常。结论：在这些指标保持的情况下，灌注持续时间少于3小时并非高乳酸血症发生的危险因素。在无循环骤停的心脏和主动脉手术的体外循环后阶段，约90%的患者以正常乳酸值转入重症监护病房（ICU）。在有循环骤停的主动脉弓手术期间，约60%的患者从手术室转入ICU时乳酸水平正常。
