Protocol to manage high blood lactate after cardiopulmonary bypass
| Correct deficits in oxygen delivery |
|---|
| • maintain adequate circulating volume |
| • maintain haemoglobin at 120–140 g/l |
| • do not stop dopamine on first postoperative night |
| • optimise arterial oxygen saturation |
| Give paracetamol for fever and use other cooling methods as necessary (to normothermia) |
| Do not stop neuromuscular blocking drugs or wean off ventilation on first postoperative night unless there is a specific reason (for example, Fontan, Glenn), and then only with frequent reassessment of perfusion |
| Start peritoneal dialysis early if the child has generalised oedema, oliguria, or large volumes of fluid are required to maintain circulation |
| Repeat lactate at four and eight hours after intensive care unit (ICU) admission |
| If lactate is rising, or > 4 mmol/l |
| • notify the ICU consultant and cardiac surgeon |
| • check cardiac rhythm and perform echocardiography to examine cardiac function and exclude pericardial effusion |
| • optimise intravascular volume |
| Consider the following |
| • increasing dopamine to 7.5–10 μg/kg/min |
| • adding another inotrope if mean arterial pressure is low |
| • the possible detrimental effects of high dose catecholamine constrictors |
| • the need for vasodilators |
| • cardiac tamponade (as a result of mediastinal oedema or haemorrhage) |
| Frequent assessment of the child is required |
ICU admission lactate > 5 mmol/l has a 30% risk of major adverse events. Lactate at four hours > 4 mmol/l has a 45% risk of major adverse events.