摘要
目的探讨早期乳酸清除率与体外循环心脏术后患者预后的关系。方法前瞻性观察并收集我院2006年3月至2010年2月体外循环心脏手术73例患者的临床资料。收集资料包括：（1）术前因素：性别、年龄、术前诊断、术前NYHA分级、APACHE11评分及左心室舒张末期内径。（2）术中因素：手术时间、主动脉阻断时间。（3）术后因素：术后出血量、机械通气时间以及术后6h血流动力学及氧代谢指标：心率（HR）、中心静脉压（CVP）、肺毛细血管嵌顿压（PAWP）、心输出量指数（CI）、动脉血乳酸、6h动脉血乳酸清除率、动脉血氧分压（PaO2）、混合静脉血氧饱和度（SvO2）、氧输送指数（DO2I）、氧耗指数（VO2I）及全身氧提取率（O2ext）。将患者分为存活组和死亡组，高乳酸清除率组（乳酸清除率〉30％）和低乳酸清除率组。首先应用单因素相关分析，筛选出两组有统计学意义的参数，然后再对这些参数进行多元回归分析，从中找出体外循环心脏术后死亡的独立危险因素。结果高乳酸清除率组病死率[4．55％（2／44）]明显低于低乳酸清除率组[34．48％（10／29）]，差异有统计学意义（X^2：11．889，P〈0．01）。单因素相关分析显示存活组与死亡组间APACHEⅡ评分[（16．9±2．9）分比（19．2±2．6）分，t=2．537]，左心室舒张末期内径[（53．9±5．6）mm比（63．8±4．6）mm，t=5．847]，主动脉阻断时间[（101．2±4-34．2）rain比（122．7±22．7）min，t=2．078]，术后出血量[（464．0±158．8）ml比（603．2±159．5）ml，t=2．773]，机械通气时间[（22．6±5．1）h比（28．8±5．2）h，t=3．857]，动脉血乳酸[（3．5±1．3）mmol／L比（5．1±1．5）mmol／L，t=3．912]，动脉血乳酸清除率[（38．8±17．4）％比（14．6±9．7）％，t：4．846]，Sv02[（69．1±4．2）％比（59．2±6．9）％，t=5．847]差异有统计学意义（P〈0．05或P〈0．001）。多元回归分析昴示动脉向乳酸清除率、芹心宰舒张末期内径县体外循环心脏术后死亡的两个独立危险因素，优势比（OR）分别为7．773（95％CI1．364-44．306，P〈0．05），15．186（95％CI2．758-83．162，P〈0．01）。结论早期血乳酸清除率可以作为评价体外循环心脏术后患者预后的重要指标。
Objective To investigate the correlation between the prognosis and the early lactate clearance in patients with postcardiac surgery undergoing cardiopulmonary bypass. Methods The clinical data of 73 patients who underwent postcardiotomy undergoing Cardiopulmonary bypass in SuBei Hospital of Jiangsu Provience,from March 2006 to February 2010, were prospectively collected and analyzed. The collection data including ： （ 1 ） Preoperative factors ： including gender, age, diagnosis preoperative, NYHA grade, APACHE II score and left ventricular end-diastolic diameter. （2） Operative factors： operation time, block aorta time. （3） Postoperation factors ： hemorrhage volume, mechanical ventilation time, and factors of hemodynamics and oxygen metabolism at 6 hour postoperative ：heart rate（HR） ,central venous pressure（CVP） ,pulmonary capilary wedged pressure（ PCWP）, cardiac output index（CI）, arterial blood lactic acid,6 h lactate clearance, partial pressure of oxygen （ PO2 ）, mixed venous oxygen saturation （ SvO2 ）, oxygen delivery index （ DO2 I）, oxygen consume index （VO2I） , oxygen extraction ratio（ O2ext）. Patients were divided into survival group, control group, high level of lactate clearance group（ lactate clearance rate 〉 30% ） and low level of lactate clearance group. Firstly, the data analyzed with process of single variable analysis and some parameters, which showed the significant difference, were sorted out from two groups. Then these parameters were put to the Logistic regression analysis. Consequently, the independent risk factors of death of postcardiac surgery could be found. Results The mortality in high lactate clearance group （4.55% [2/44] ） was significantly less than the low lactate group （ 34.48% [ 10/29 ] ） （ X2 = 11. 889, P 〈 0. 01 ）. The single variable analysis had shown that there were significant difference on APACHEⅡ score （ [ 16.9 ± 2.9 ] vs [ 19.2 ± 2.6 ], t = 2. 537 ）, left ventricular end-diastolic diameter（ [53.9 ± 5.6 ] mm vs [ 63.8 ± 4. 6 ] ram, t = 5. 847 ）, block aorta time （ [ 101.2 ＋ 34.2 ] rain vs [ 122. 7 ± 22. 7 ] min, t = 2. 078 ）, hemorrhage volume （ [ 464. 0 ＋ 158.8 ] ml vs [ 603.2 ＋ 159. 5 ] ml, t = 2. 773 ）, mechanical ventilation time （ [ 22. 6 ± 5.1 ] h vs [ 28. 8 ± 5.2 ] h, t = 3. 857 ）, arterial blood lactic acid （ [ 3.5 ± 1.3 ] mmol/L vs [ 5.1 ± 1.5 ] mmol/L,t = 3. 912） ,lactate clearance （ [ 38.8 ± 17.4 ] % vs [ 14. 6 ± 9. 7 ] %, t = 4. 846） ,and SvO2（ [69. 1 ±4. 2]% vs [59.2 ±6.9]% ,t =5. 847） （P 〈0. 05 or P 〈0. 001） between survival group and control group. Multiple regression analysis showed that lactate clearance and left ventrieular end- diastolic diameter were the two independent risk factors of death, and the odds ratio （OR） were 7. 773 （95% CI 1.364 -44.306,P 〈0.05） and 15. 186（95% CI 2.758 - 83. 162,P 〈0. O1）.Conclusion Early lactate clearance rate can be used as an important indicator to evaluate the prognosis of patients with postcardiae surgery undergoing cardiopulmonary bypass.
出处
《中国综合临床》
2012年第4期340-343,共4页
Clinical Medicine of China
基金
江苏省“333高层次人才培养工程”基金资助（2007-58）
关键词
心脏术后
乳酸清除率
预后
Postcardiac surgery
Lactate clearance
Prognosis
