Mortality and Long-Term Outcome of Neonates with Congenital Heart Disease and Acute Perinatal Stroke:A Population-Based Case-Control Study

Objective:Neonates with congenital heart disease(CHD)and perinatal stroke have high mortality and survivors are at risk for poor long-term neurodevelopmental outcome.The aim of this study was to assess the risk factors and outcome of neonates with both CHD and MRI-confirmed perinatal stroke(Study Group)and compare those to the risk factors and outcome of infants matched for CHD without stroke(Control-1)and of infants matched for MRI-confirmed stroke without CHD(Control-2).Methods:We conducted a population-based case-control study enrolling 28 term neonates with CHD and MRI-confirmed acute perinatal stroke born between 2007–2017 in the Central-Hungarian Region.Each of the control groups included 56 infants.The Bayley Scales of Infant Development-II,the Brunet-Lézine test and the Binet Intelligence scales-V were used for neurodevelopmental follow-up at a median age of 61 months.Results:Mortality was highest in the Study Group(25%compared to 5%and 2%,respectively,p=0.001).Adverse neurodevelopmental outcome was prevalent in the Study(53%)and Control-2 Groups(52%,p=0.03).Significantly different parameters among the three groups included Apgar scores,mode of delivery,gestational age at birth,cardiac interventions and twin pregnancy.In a multivariable regression analysis adjusted for clinically relevant parameters,patients in the Study Group had significantly higher odds for mortality compared to patients in the Control-1 Group(OR:6.595%CI:1.1–39.4).Conclusions:Neonates with perinatal stroke and CHD are at a higher risk for dying compared to neonates with CHD without stroke.In addition,the stroke-associated direct insult to the brain likely plays an important role in the development of neurodevelopmental morbidity in these patients.

Lactate reloaded–reevaluation of the importance of lactate monitoring in the management of adult sepsis in the emergency department

For about a quarter of a century,monitoring lactate levels and/or lactate clearance has been an unquestionable cornerstone in sepsis management.The elevated lactate level appeared to be an independent predictor of mortality,and the consequent metabolic acidosis was thought to explain a number of pathophysiological changes seen in septic shock.Recent physiological and clinical findings seem to challenge the adverse role of lactic acidosis in sepsis.Evidence suggests that lactate levels are not necessarily directly proportional to either tissue or cellular hypoxia,and conversely,despite high lactate levels,increased peripheral tissue oxygen pressure can be measured in adult patients with septic shock.According to the most recent understanding of in vitro and in vivo evidence,the elevated lactate level in sepsis might be a normal reaction due to adrenergic stress with potential beneficial/protective physiological effects,as well.On the one hand,burning lactic may help fuel the body during critical illness,but on the other hand,with a slight drop in pH,the body may counteract certain deleterious changes during the dysregulated host response;reduce the chances of reperfusion myocardial injury,and improve tissue oxygenation by shifting the haemoglobin dissociation curve to the right.Understanding the pathophysiological process in sepsis resulting in elevated lactate levels may aid management in an emergency,medicine,and intensive care settings.With more in-depth physiological knowledge,physicians may inevitably surpass normalisation heuristics and deliver personalized rather than protocolised sepsis resuscitation.