Venous saturation and the anaerobic threshold in neonates after the Norwood procedure for hypoplastic left heart syndrome

Background. Reduction in oxygen delivery can lead to organ dysfunction and death by cellular hypoxia, detectable by progressive (mixed) venous oxyhemoglobin desaturation until extraction is limited at the anaerobic threshold. We sought to determine the critical level of venous oxygen saturation to maintain aerobic metabolism in neonates after the Norwood procedure (NP) for the hypoplastic left heart syndrome (HLHS). Methods. A prospective perioperative database was maintained for demographic, hemodynamic, and laboratory data. Invasive arterial and atrial pressures, arterial saturation, oximetric superior vena cava (SVC) saturation, and end-tidal CO 2 were continuously recorded and logged hourly for the first 48 postoperative hours. Arterial and venous blood gases and cooximetry were obtained at clinically appropriate intervals. SVC saturation was used as an approximation of mixed venous saturation (SvO 2). A standard base excess (BE) less than −4 mEq/L (BElo), or a change exceeding −2 mEq/L/h (ΔBElo), were used as indicators of anaerobic metabolism. The relationship between SvO 2 and BE was tested by analysis of variance and covariance for repeated measures; the binomial risk of BElo or ΔBElo at SvO 2 strata was tested by the likelihood ratio test and logistic regression, with cutoff at p < 0.05. Results. Complete data were available in 48 of 51 consecutive patients undergoing NP yielding 2,074 valid separate determinations. BE was strongly related to SvO 2 (model R 2 = 0.40, p < 0.0001) with minimal change after adjustment for physiologic covariates. The risk of anaerobic metabolism was 4.8% overall, but rose to 29% when SvO 2 was 30% or below ( p < 0.0001). Survival was 100% at 1 week and 94% at hospital discharge. Conclusions. Analysis of acid-base changes revealed an apparent anaerobic threshold when SvO 2 fell below 30%. Clinical management to maintain SvO 2 above this threshold yielded low mortality.