Rethinking Lactate in Cardiac Surgery and Intensive Care

John Guzzi, Department of Anesthesiology, Yale School of Medicine, New Haven, CT. Electronic address: john.guzzi@yale.edu.
Ryan Salter, Wellington Regional Hospital, Wellington, New Zealand.
Stephen Pettit, Royal Papworth Hospital, Cambridge, United Kingdom.
Tyler Kelting, Perfusion Services, MaineHealth, Portland, ME.
Florian Falter, Department of Anesthesiology and Critical Care, Royal Papworth Hospital, Cambridge, United Kingdom.
Albert C. Perrino, Department of Anesthesiology, Yale School of Medicine, New Haven, CT; Department of Anesthesiology, Veterans Affairs Connecticut Healthcare System, West Haven, CT.

Abstract

Lactate has traditionally been framed as a by-product of anaerobic metabolism and a surrogate for tissue hypoxia. Contemporary physiology recasts lactate as a central fuel, shuttle, and signaling molecule, challenging long-held interpretations in cardiac surgery and intensive care. This narrative review synthesizes evidence across exercise physiology, biochemistry, cardiac anesthesia, and intensive care to reinterpret perioperative hyperlactatemia during cardiopulmonary bypass and after cardiac surgery and highlights emerging opportunities in continuous lactate monitoring.