Perioperative intraperitoneal metabolic markers in patients undergoing cardiac surgery with cardiopulmonary bypass: an exploratory pilot study

Abstract

Background:

Cardiopulmonary bypass and postoperative cardiac dysfunction cause splanchnic hypoperfusion resulting in intra-abdominal anaerobic metabolism and risk for gastrointestinal complications. The intra-abdominal metabolism can be monitored by intraperitoneal measurement of relevant metabolites using microdialysis. The aim of this study was to investigate the intraperitoneal metabolism using microdialysis during and after cardiopulmonary bypass at 34°C.

Methods:

In six patients undergoing elective coronary artery bypass grafting or aortic valve replacement under cardiopulmonary bypass, microdialysis was used to measure intraperitoneal and subcutaneous glucose, lactate, pyruvate, glycerol and glutamate concentrations, intraoperatively and up to 36 hours postoperatively. Arterial and central venous blood gases were analysed as were haemodynamics and the development of complications.

Results:

All patients had an ordinary perioperative course and did not develop gastrointestinal complications. The arterial, intraperitoneal and subcutaneous lactate concentrations changed during the perioperative course with differences between compartments. The highest median (interquartile range) concentration was recorded in the intraperitoneal compartment at 1 hour after the end of cardiopulmonary bypass (2.1 (1.9–2.5) mM compared to 1.3 (1.2–1.7) mM and 1.5 (1.0–2.2) mM in the arterial and subcutaneous compartments, respectively). In parallel with the peak increase in lactate concentration, the intraperitoneal lactate/pyruvate ratio was elevated to 33.4 (12.9–54.1).

Conclusion:

In cardiac surgery, intraperitoneal microdialysis detected changes in the abdominal metabolic state, which were more pronounced than could be shown by arterial blood gas analysis. Despite an uneventful perioperative course, patients undergoing low-risk surgery under cardiopulmonary bypass might be subjected to a limited and subclinical intra-abdominal anaerobic state.

Keywords

intraperitoneal microdialysis extracorporeal circulation gastrointestinal metabolism splanchnic hypoperfusion lactate pyruvate glucose glycerol glutamate

Get full access to this article

View all access options for this article.

References

Rossi

Sganga

Mazzone

et al. Cardiopulmonary bypass in man: role of the intestine in a self-limiting inflammatory response with demonstrable bacterial translocation. Ann Thorac Surg 2004; 77: 612–618.

Adamik

Kubler

Gozdzik

et al. Prolonged cardiopulmonary bypass is a risk factor for intestinal ischaemic damage and endotoxaemia. Heart Lung Circ 2017; 26: 717–723.

Ohri

Velissaris

Gastrointestinal dysfunction following cardiac surgery. Perfusion 2006; 21: 215–223.

Allen

SJ.

Gastrointestinal complications and cardiac surgery. J Extra Corpor Technol 2014; 46: 142–149.

Karhausen

Stafford-Smith

The role of nonocclusive sources of acute gut injury in cardiac surgery. J Cardiothorac Vasc Anesth 2014; 28: 379–391.

Zhang

Liu

et al. Case control study of gastrointestinal complications after cardiopulmonary bypass heart surgery. Perfusion 2009; 24: 173–178.

Sicsic

Duranteau

Corbineau

et al. Gastric mucosal oxygen delivery decreases during cardiopulmonary bypass despite constant systemic oxygen delivery. Anesth Analg 1998; 86: 455–460.

Braun

Schroeder

Buehner

et al. Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass. Acta Anaesthesiol Scand 2004; 48: 697–703.

Thorén

Jakob

Pradl

et al. Jejunal and gastric mucosal perfusion versus splanchnic blood flow and metabolism: an observational study on postcardiac surgical patients. Crit Care Med 2000; 28: 3649–3654.

10.

Habes

QLM

Linssen

Nooijen

et al. Markers of intestinal damage and their relation to cytokine levels in cardiac surgery patients. Shock 2017; 47: 709–714.

11.

Kano

Takahashi

Inoue

et al. Transition of intestinal fatty acid-binding protein on hypothermic circulatory arrest with cardiopulmonary bypass. Perfusion 2017; 32: 200–205.

12.

Solligård

Wahba

Skogvoll

et al. Rectal lactate levels in endoluminal microdialysate during routine coronary surgery. Anaesthesia 2007; 62: 250–258.

13.

Ungerstedt

Nowak

Ericzon

et al. Intraperitoneal microdialysis (IPM): a new technique for monitoring intestinal ischemia studied in a porcine model. Shock 2003; 20: 91–96.

14.

Horer

Skoog

Nilsson

et al. Intraperitoneal metabolic consequences of supraceliac aortic balloon occlusion in an experimental animal study using microdialysis. Ann Vasc Surg 2014; 28: 1286–1295.

15.

Skoog

Horer

Nilsson

et al. Intra-abdominal hypertension – an experimental study of early effects on intra-abdominal metabolism. Ann Vasc Surg 2015; 29: 128–137.

16.

Daams

Cakir

et al. Identification of anastomotic leakage after colorectal surgery using microdialysis of the peritoneal cavity. Tech Coloproctol 2014; 18: 65–71.

17.

Jansson

Redler

Truedsson

et al. Postoperative on-line monitoring with intraperitoneal microdialysis is a sensitive clinical method for measuring increased anaerobic metabolism that correlates to the cytokine response. Scand J Gastroenterol 2004; 39: 434–439.

18.

Verdant

Chierego

DeMoor

et al. Prediction of postoperative complications after urgent laparotomy by intraperitoneal microdialysis: a pilot study. Ann Surg 2006; 244: 994–1002.

19.

Sabroe

Axelsen

Ellebaek

et al. Intraperitoneal lactate/pyruvate ratio and the level of glucose and glycerol concentration differ between patients surgically treated for upper and lower perforations of the gastrointestinal tract: a pilot study. BMC Res Notes 2017; 10: 302.

20.

Konstantinos

Apostolos

Georgios

et al. Intraperitoneal microdialysis as a monitoring method in the intensive care unit. Int Surg 2014; 99: 729–733.

21.

Adluri

Singh

Skoyles

et al. Measurement of intraperitoneal metabolites during hypothermic cardiopulmonary bypass using microdialysis. Scand Cardiovasc J 2011; 45: 229–235.

22.

Zamparelli

De Paulis

Martinelli

et al. Pulsatile normothermic cardiopulmonary bypass and plasma catecholamine levels. Perfusion 2000; 15: 217–223.

23.

Hamulu

Atay

Yagdi

et al. Effects of flow types in cardiopulmonary bypass on gastric intramucosal pH. Perfusion 1998; 13: 129–135.

24.

Tao

Zwischenberger

Nguyen

et al. Gut mucosal ischemia during normothermic cardiopulmonary bypass results from blood flow redistribution and increased oxygen demand. J Thorac Cardiovasc Surg 1995; 110: 819–828.

25.

Sabroe

Ellebaek

MB and

Qvist

Intraabdominal microdialysis – methodological challenges. Scand J Clin Lab Invest 2016; 76: 671–677.

26.

Jansson

Andersson

et al. Normal values and differences between intraperitoneal and subcutaneous microdialysis in patients after non-complicated gastrointestinal surgery. Scand J Clin Lab Invest 2005; 65: 273–281.

27.

Najmaii

Redford

Larson

DF.

Hyperglycemia as an effect of cardiopulmonary bypass: intra-operative glucose management. J Extra Corpor Technol 2006; 38: 168–173.

28.

Pisarenko

OI.

Mechanisms of myocardial protection by amino acids: facts and hypotheses. Clin Exp Pharmacol Physiol 1996; 23: 627–633.

29.

Rau

Shine

Gervais

et al. Enhanced mechanical recovery of anoxic and ischemic myocardium by amino acid perfusion. Am J Physiol 1979; 236: H873–H889.

30.

Vidlund

Hakanson

Friberg

et al. GLUTAMICS – a randomized clinical trial on glutamate infusion in 861 patients undergoing surgery for acute coronary syndrome. J Thorac Cardiovasc Surg 2012; 144: 922–930.e7.

31.

Croughwell

Newman

Lowry

et al. Effect of temperature during cardiopulmonary bypass on gastric mucosal perfusion. Br J Anaesth 1997; 78: 34–38.

32.

Zou

Song

Hong

et al. Intestinal fatty acid-binding protein as a predictor of prognosis in postoperative cardiac surgery patients. Medicine 2018; 97: e11782.

33.

Jouan

Golmard

Benhamouda

et al. Gene polymorphisms and cytokine plasma levels as predictive factors of complications after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2012; 144: 467–473.e1.