Serum Lactate Level as a Predictor for Blood Transfusion in Postpartum Hemorrhage

Objective Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. Study Design A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. Results During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001). Conclusion Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. Key Points

Comparative study of physiological changes of nil per oral vs glucose water vs free water in patients undergoing laparoscopic cholecystectomy: A randomized prospective study

The aim of this study was to compare the effect of ingestion of clear water and glucose water over 10 hours NPO in elective laparoscopic cholecystetctomy surgery.An observational study was conducted in Sir Sunderlal hospital, Banaras Hindu University. The study included ASA I-II patients undergoing laparoscopic cholecystectomy surgery. Patients undergoing general anaesthesia were included in the study. Among three groups, the control fasted in accordance to nil per os for 10 hours, second and third group received 200 mL of clear water and 200 ml of glucose water, respectively 2 hours before the surgery. Arterial Blood Gas analysis and blood glucose level was done in the immediate post-operative period. Arterial pH, serum electrolytes, serum lactate and blood glucose levels were compared for the above 3 groups. Results were given as mean ± SD. Data collected were analysed using Student’s t-test. Differences were considered statistically significant if P values were &#60;0.05. A total of 45 patients were included and 15 patients each were randomly assigned to one of the 3 groups. Patients who had 200 ml of clear water before surgery had lesser variation in serum K+ [p=0.045] and serum lactate level [p=0.001] than NPO. Patients fed with 200 ml of glucose water before surgery had lesser variation in serum K+ level [p=0.02], serum lactate level [p&#60;0.001], in Random Blood Sugar level [p&#60;0.001] and no episode of hypoglycaemia observed as compared to NPO. Patients given 200 ml of glucose water exhibited lesser variation in serum lactate level [p=0.004], in RBS level [p&#60;0.001] and no hypoglycaemic episode recorded contrary to those supplied with 200 mL of clear water. More fluctuations in extreme values of pH and serum electrolytes values observed in group A. Episodes of hypoglycaemia found more frequent in NPO and patients that received only clear water. No significant side-effects were observed in any group.We conclude that it is safe to give clear drinks 2 hours prior to surgery. Prolonged withholding of oral fluid may cause imbalance in pH, serum electrolytes and hypoglycaemia. The finding confirms the recent ASA guidelines which no longer recommends an indiscriminate ‘NPO after midnight’ policy.

An analytical observational study on the prognostic implication of postoperative serial serum lactate level for complications and predicting length of intensive therapy unit stay after major abdominal surgery

Background: Post-operative microcirculatory alteration causes hypoperfusion, tissue hypoxia and organ dysfunction, resulting in significant morbidity and mortality. Increase in serum lactate level in response to tissue hypoxia may serve as a cost effective tool to assess status of all organ dysfunction being sensitive but not organ specific and may help in early prognostication. Aim of this study was to investigate the association of blood lactate levels during the first 24 hours after surgery with postoperative morbidity and mortality, with length of ITU stay and to correlate the lactate values at various time points with different postoperative complications (POC).Methods: 150 patients undergoing elective abdominal surgery were included. Blood lactate (mmol/lit) levels were measured immediately on admission to the Intensive Therapy Unit (ITU) and at 6, 12, and 24 hours of admission. The parameters of clinical outcome included were mortality, shock, Acute kidney injury (AKI), respiratory failure, wound dehiscence and length of ITU stay. Heart Rate, Mean Arterial Pressure, spo2, Temperature and Urine output were also measured.Results: There was statistically significant difference in the lactate levels measured at the above mentioned point of time (0, 6, 12 and 24h) in cases with death and without fatal outcome, with and without respiratory failure, with and without AKI, with and without shock and in cases with and without wound dehiscence (p<0.05). There was a statistically significant difference in urine output, duration of ITU stay and duration of intubation (p<0.05).Conclusions: Increased serum lactate levels were significantly associated with postoperative complications, mortality and length of ITU stay in patients undergoing major elective abdominal surgery.

Predialysis Serum Lactate Levels Can Predict Dialysis Withdrawal in Type 1 Cardiorenal Syndrome Patients

Type 1 cardiorenal syndrome (CRS) is a complication with grave outcomes, and renal replacement therapy (RRT) is an effective rescue therapy. Serum lactate has been correlated with the risk of mortality in patients with sepsis. However, the association between serum lactate level and the prognosis of type 1 CRS patients requiring RRT is unknown. We prospectively enrolled 500 type 1 CRS patients who received RRT from August 2011 to January 2018. The 90-day mortality rate was 52.8% and the incidence rate of RRT independence was 34.8%. Lower pre-dialysis lactate was correlated with a higher rate of dialysis withdrawal and lower rate of mortality. A generalized additive model showed that 4.2 mmol/L was an adequate cut-off value of lactate to predict renal recovery. Taking mortality as a competing risk, Cox proportional hazards analysis indicated that a low lactate level (≦ 4.2 mmol/L) was an independent prognostic factor for the possibility of dialysis withdrawal, as also shown in external validation. The interaction of quick Sequential Organ Failure Assessment score and lactate was associated with dialysis dependence in a disease severity-dependent manner. In summary, we identified that pre-dialysis serum lactate level could predict the possibility of dialysis withdrawal in type 1 CRS patients.

Association between serum lactate level during cardiopulmonary resuscitation and survival in adult out-of-hospital cardiac arrest: a multicenter cohort study

We aimed to investigate the association between serum lactate levels during cardiopulmonary resuscitation (CPR) and survival in patients with out-of-hospital cardiac arrest (OHCA). From the database of a multicenter registry on OHCA patients, we included adult nontraumatic OHCA patients transported to the hospital with ongoing CPR. Based on the serum lactate levels during CPR, the patients were divided into four quartiles: Q1 (≤ 10.6 mEq/L), Q2 (10.6–14.1 mEq/L), Q3 (14.1–18.0 mEq/L), and Q4 (> 18.0 mEq/L). The primary outcome was 1-month survival. Among 5226 eligible patients, the Q1 group had the highest 1-month survival (5.6% [74/1311]), followed by Q2 (3.6% [47/1316]), Q3 (1.7% [22/1292]), and Q4 (1.0% [13/1307]) groups. In the multivariable logistic regression analysis, the adjusted odds ratio of Q4 compared with Q1 for 1-month survival was 0.24 (95% CI 0.13–0.46). 1-month survival decreased in a stepwise manner as the quartiles increased (p for trend < 0.001). In subgroup analysis, there was an interaction between initial rhythm and survival (p for interaction < 0.001); 1-month survival of patients with a non-shockable rhythm decreased when the lactate levels increased (p for trend < 0.001), but not in patients with a shockable rhythm (p for trend = 0.72). In conclusion, high serum lactate level during CPR was associated with poor 1-month survival in OHCA patients, especially in patients with non-shockable rhythm.