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CARDIOVASCULAR ANESTHESIA

A Comparison Among Portal Lactate, Intramucosal Sigmoid pH, and CO₂ (PaCO₂ – Regional PCO₂) as Indices of Complications in Patients Undergoing Abdominal Aortic Aneurysm Surgery

Abele Donati, MD^*, Oriana Cornacchini, MD^*, Silvia Loggi, MD^*, Sandro Caporelli, MD^*, Giovanna Conti, MD^*, Stefano Falcetta, MD^*, Francesco Alò, MD, Gabriele Pagliariccio, MD, Elisabetta Bruni, MD^*, Jean-Charles Preiser, MD PhD, and Paolo Pelaia, MD^*

*Department of Neuroscience, Anesthesia and Intensive Care Unit, and Department of Vascular Surgery, Marche Polytechnique University, Ancona, Italy; and Department of Intensive Care, University Hospital of Liege, Liege, Belgium

Address correspondence and reprint requests to Abele Donati, MD, Rianimazione Clinica, Ospedale Regionale Torrette, Via Conca 1, 60020 Torrette, Ancona, Italy. Address e-mail to donati{at}indi.it

Our aim in this observational, prospective, noncontrolled study was to detect, in 29 patients who underwent abdominal aortic aneurysm (AAA) surgery, correlations between the incidence of postoperative organ failure and intraoperative changes in arterial and portal blood lactate; changes in intramucosal sigmoid pH (pHi); differences between sigmoid PCO₂ and arterial PCO₂ (CO₂); and hemoglobin (Hb). Hb, arterial blood lactate concentrations, pHi, and CO₂ (air tonometry) were recorded at the start of anesthesia (T0), before aorta clamping (T1), 30 minutes after clamping (T2), and at the end of surgery (T3). Portal venous lactate concentrations were recorded at T1 and T2. Patients were stratified into two groups: group A patients had no postoperative organ failure, and group B patients had one or more organ failures. As compared with group A (n = 16), group B patients (n = 13) had a lower pHi value at T2 and T3 and a higher CO₂ at T3. A pHi value of <7.15 was a predictor of organ failure, with a sensitivity of 92.3%, a specificity of 68.8%, and positive and negative predictive values of 70.6% and 91.7%, respectively, whereas a CO₂ value of >28 mm Hg predicted later organ failure with a sensitivity of 92.3%, a specificity of 62.5%, and positive and negative predictive values of 66.6% and 90.9%, respectively. Portal venous lactate concentrations were larger in group B at T2 (P < 0.001), and an increase 5 g/dL predicted later postoperative organ failure with a sensitivity of 92.3%, a specificity of 100%, and positive and negative predictive values of 100% and 94.1%, respectively. The comparison of the receiving operator characteristic curves to test the discrimination of each variable and the logistic regression analysis revealed that the increase in portal lactate was the best predictor for the development of postoperative organ failure. Hb concentration was significantly smaller in group B at T0 (13.8 ± 1.0 g/dL versus 12.2 ± 2.2 g/dL) and T2 (10.9 ± 1.2 g/dL versus 9.1 ± 1.9 g/dL). In conclusion, both pHi and CO₂ are reasonably sensitive prognostic indices of organ failures after AAA surgery, but they are less specific and accurate than portal venous lactate.

IMPLICATIONS: Although older studies cannot correlate with outcome, this study is the first comparison of the values of three indirect markers of gut ischemia—portal venous lactate concentration, intramucosal intestinal pH, and gradient between regional and arterial PCO₂—as predictors of organ failure after surgery for abdominal aortic aneurysm.

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