Evaluation of Blood Lactate Level as a Predictor of In-hospital Morbidity and Mortality in Patients Undergoing Surgery for Bowel Perforation: A Prospective Cohort Study

Abstract

Introduction: Perforation peritonitis is associated with significant Morbidity and Mortality (M&M). The predictive performance of blood lactate levels and their clearance varies depending on the timing of measurement, and the optimal time for measurement remains unclear. Aim: To evaluate perioperative lactate levels and their clearance as predictors of in-hospital M&M in bowel perforation surgery. Materials and Methods: The present prospective cohort study was conducted in the Department of Anaesthesiology and Critical Care, Pt. BD Sharma PGIMS, Rohtak, Haryana, India, from March 2023 to December 2023. Study was conducted on 40 adult patients undergoing surgery for bowel perforation, and clinical and various laboratory parameters were observed from admission until discharge. Baseline and perioperative lactate levels were recorded up to 24 hours postoperatively. The association of M&M with different scores such as the Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Mannheim Peritonitis Index (MPI), as well as, lactate levels and lactate clearance, was assessed. The diagnostic accuracy of lactate levels and lactate clearance at different time points in the perioperative period to predict M&M was calculated, and finally, the ‘Bidirectional Stepwise Selection’ (BSS) was used to select the most useful predictor of M&M. Results: Total 40 participants were included in the study, of which 34 were males and 6 were females. The overall M&M rates were 50% and 30%, respectively. On univariate analysis, there was a significant difference between non survivors and survivors in terms of age (50.92 vs 38.07 years, p-value=0.004), APACHE II score (10.00 vs 6.46, p-value=0.028), preoperative serum creatinine (1.41 vs 1.13 mg/dL, p-value=0.043), 24-hour postoperative lactate (4.75 vs 1.54 mmol/L, p-value=0.005), and lactate clearance (-28.97 vs 24.83%, p-value=0.03). Patients with or without morbidity showed a significant difference in age (47.7 vs 36.15 years, p-value=0.005), MPI score (22.45 vs 18.6, p-value=0.048), preoperative serum creatinine (1.40 vs 1.03 mg/dL, p-value=0.028), and 24-hour postoperative lactate (3.65 vs 1.35, p-value=0.002). In BSS analysis, age and 24-hour postoperative lactate were identified as good predictors of M&M, with the latter being the best predictor. Conclusion: The incidence of M&M is quite high in perforation peritonitis. Among all predictors, 24-hour postoperative lactate is the strongest predictor of M&M and may be useful in risk stratification and optimising treatment accordingly.

Keywords

• acute physiology and chronic health evaluation ii
• gastrointestinal perforation
• mannheim peritonitis index
• peritonitis
• postoperative
• sequential organ failure assessment