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Prolonged Propofol Anesthesia Is Not Associated with an Increase in Blood Lactate

Prolonged Propofol Anesthesia Is Not Associated with an Increase in Blood Lactate. Anesth Analg 2009;109:1105 – 10. BACKGROUND. Propofol Infusion Syndrome (PRIS) prolonged (>48 h) high-dose (>5 mg/kg) propofol infusion metabolic acidosis lipemia fatty infiltration of liver

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Prolonged Propofol Anesthesia Is Not Associated with an Increase in Blood Lactate

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  1. Prolonged Propofol Anesthesia Is Not Associated with an Increase in Blood Lactate Anesth Analg 2009;109:1105–10

  2. BACKGROUND • Propofol Infusion Syndrome (PRIS) • prolonged (>48 h) high-dose (>5 mg/kg) propofol infusion • metabolic acidosis • lipemia • fatty infiltration of liver • myocardial dysfunction (rhabdomyolysis) • renal failure

  3. BACKGROUND • Lactic acidosis is considered an early sign of propofol infusion syndrome. • Case reports of PRIS developing even after short-term infusion in children and adults during anesthesia in operating rooms or sedation in intensive care units. • An increase in lactate and development of metabolic acidosis was apparent early, within 2–5 h after initiation of the propofol infusion.

  4. BACKGROUND • In this study, we investigated the changes in lactate and pH with propofol versus volatile anesthesia (VA) of long duration.

  5. METHODS

  6. Data Collection • demographic data age, gender, body weight, ASA classification, medical history, chronic medications • intraoperative data surgical time,type of surgery, number of vertebral levels instrumented, anesthesia duration, dose of anesthesia medications, systolic blood pressure (SBP) every 5 min

  7. Collection oflaboratory variables • Baseline within 2 h of anesthesia start time • T8 8 h after “start of anesthesia” ± 60 min

  8. RESULTS

  9. RESULTS

  10. RESULTS

  11. RESULTS

  12. RESULTS

  13. DISCUSSION • We observed higher lactate levels during VA when compared with propofol anesthesia, and suggesting that the propofol-based general anesthesia is less likely to cause lactic acidosis than VA.

  14. DISCUSSION • An alternative explanation for the difference in blood lactate levels between VA and propofol groups may be a different effect of these anesthetics on lactate metabolism, particularly on 1) lactate production, 2) lactate clearance via the liver or kidney, or 3) imbalance between both.

  15. DISCUSSION • Release of catecholamines increases lactate production and decreases lactate clearance by decreasing hepatic blood flow and activation of Na-K-ATP pumps, provoking glycolysis. • A potential explanation of an increase in lactate over time with isoflurane and sevoflurane would be an impaired liver clearance of lactate, because both VAs cause a dose-dependent decrease in hepatic blood flow.

  16. DISCUSSION • On the other hand, propofol might be expected to decrease lactate levels as it contains 10% soybean oil, which is a 10% intralipid emulsion containing a mixture of triglycerides, predominantly unsaturated fatty acids. • An infusion of free fatty acids for 2 h has been reported to inhibit glycolysis and stimulate neoglycogenesis in healthy men and diabetic patients. • Similarly,an increase of free fatty acids in blood with intralipids has been demonstrated to profoundly inhibit intrahepatic glycogenolysis and stimulate neoglycogenesis, thereby increasing intrahepatic uptake and use of lactate.

  17. DISCUSSION • Decreased oxygen delivery due to hypovolemia, hypotension, and/or anemia during anesthesia may contribute to hypoperfusion and hypoxemia of peripheral tissues, causing anaerobic metabolism and, as a result, an increase in blood lactate. • The incidence ofintraoperative hypotension was similar. Although there was a small difference in baseline SBP between the propofol and VA groups, because the incidence of chronic arterial hypertension and its treatment were similar in both groups.

  18. DISCUSSION • Patients in the VA group were slightly older (58 ± 14 yr) than in the propofol group (52 ± 15 yr). • However, age per se is not known to affect blood lactate levels.

  19. DISCUSSION • In the propofol group, patients received about one-half of the daily caloric intake. • This significant caloric intake, compared with the “fasting” VA group, may play a positive role in neoglucogenesis and use of lactate, thereby maintaining blood lactate levels within the normal range.

  20. CONCLUSIONS • During prolonged spine surgery 8 h, VA was associated with higher serum lactate, when compared with propofol infusion. • However, the exact mechanisms of our findings cannot be ascertained, and prospective studies are needed to elucidate the physiology of lactate production and elimination, and the role of propofol as a nutrient during anesthesia of long duration.

  21. Merry Christmas Happy New Year!!

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