摘要
目的 探讨血乳酸水平对合并糖尿病脓毒症患者预后的预测价值.方法 回顾性分析2015年4月至2016月11月复旦大学附属中山医院重症医学科（ICU）收治的所有脓毒症患者的临床资料,纳入年龄〉18岁、住院时间〉24 h者.记录患者入院当日动脉血乳酸、血肌酐（SCr）、白细胞计数（WBC）、血小板计数（PLT）、序贯器官衰竭评分（SOFA）、3 d内最低氧合指数（PaO2/FiO2）、是否行机械通气、有无糖尿病病史、是否使用双胍类药物、是否病因处理、是否行连续性肾脏替代治疗（CRRT）.根据血乳酸水平将患者分为高乳酸组（乳酸〉2 mmol/L）和低乳酸组（乳酸≤2 mmol/L）;根据是否合并糖尿病进一步分组.对各组患者进行Kaplan-Meier生存曲线分析;用多因素Cox回归分析各指标对预后的影响因素.结果 106例脓毒症患者中男性76例,女性30例;年龄（68.1±14.7）岁;低乳酸组51例患者中合并糖尿病7例,高乳酸组55例患者中合并糖尿病12例.与低乳酸组比较,高乳酸组患者年龄大,SOFA评分高,行病因处理比例低（均P〈0.05）.糖尿病脓毒症患者血乳酸水平与无糖尿病脓毒症患者比较差异无统计学意义（mmol/L：3.03±2.73比2.81±2.40,P〉0.05）.Kaplan-Meier生存曲线分析显示,高乳酸组90 d生存率明显低于低乳酸组（56.36%比90.20%,χ2=0.697,P=0.008）;无糖尿病高乳酸组患者生存期较短,且90 d生存率明显低于无糖尿病低乳酸组（58.14%比90.90%,χ2=7.152,P=0.007）;糖尿病高乳酸组90 d生存率与糖尿病低乳酸组比较差异无统计学意义（50.00%比85.71%,χ2=0.012,P=0.914）.多因素Cox回归分析显示,血乳酸是影响脓毒症患者预后的独立危险因素〔优势比（OR）=3.863,95%可信区间（95%CI）=1.237~12.060,P=0.020〕.按是否合并糖尿病分层后,血乳酸是影响无糖尿病脓毒症患者预后的独立危险因素（OR=4.816,95%CI=1.407~15.824,P=0.010）,而对糖尿病脓毒症患者的预后无影响（OR=0.000,95%CI=0.000~1.103,P=0.270）.结论 血乳酸水平对于是否合并糖尿病脓毒症患者的预测价值不同,在无糖尿病的脓毒症患者中血乳酸水平与预后相关,而在合并糖尿病的脓毒症患者中血乳酸水平对预后的预测价值需进一步研究,可能需调高血乳酸的分界点.
Objective To evaluate the prognostic value of blood lactate （Lac） level in sepsis patients with or without diabetes.Methods 106 patients admitted to intensive care unit （ICU） of Zhongshan Hospital Affiliated to Fudan University from April 2015 to November 2016 were enrolled. The patients with age 〉 18 years and the length of hospital stay 〉 24 hours were included. Records including blood Lac, serum creatinine （SCr）, white blood cell count （WBC）, platelet count （PLT）, sequential organ failure assessment （SOFA） on the first day of admission; minimum oxygen index （PaO2/FiO2） in 3 days after admission; mechanical ventilation, whether there was a history of diabetes, usage of biguanides, etiology control treatment, usage of continuous renal replacement therapy （CRRT） were collected. According to the level of blood Lac patients were divided into high Lac group （Lac 〉 2 mmol/L） and low Lac group （Lac ≤ 2 mmol/L）;based on their diabetic history, sepsis patients were divided into the diabetes group and non-diabetes group. The survival curve of each group was analyzed by Kaplan-Meier regression analysis, and the factors influencing the prognosis were analyzed by multivariate Cox regression analysis.Results There were 76 males and 30 females sepsis patients, with an average age of （68.1±14.7） years old. In the 51 patients of low Lac group, there were 7 patients who suffered from diabetes. While in the 55 patients of high Lac group, there were 12 patients who suffered from diabetes. Compared with low Lac group, high Lac group had a higher age, higher SOFA score, and a lower proportion of patients who had the treatment of etiology control （allP 〈 0.05）. There was no significant difference of blood Lac in sepsis patients with diabetes and those without diabetes （mmol/L： 3.03±2.73 vs. 2.81±2.40,P 〉 0.05）. Kaplan-Meier survival curve analysis showed that the 90-day survival rate in the high Lac group was significantly lower than that in the low Lac group （56.36% vs. 90.20%,χ2 = 0.697,P = 0.008）. The high Lac group without diabetes had lower survival rate, and the 90-day survival rate was significantly lower than that of the low Lac group without diabetes （58.14% vs. 90.90%,χ2 = 7.152,P = 0.007）; there was no significant difference in 90-day survival rate between the high Lac group and the low Lac group with diabetes （50.00% vs. 85.71%,χ2 = 0.012,P = 0.914）. Multivariate Cox regression analysis showed that blood Lac was an independent risk factor for the prognosis of sepsis patients [odds ratio （OR） = 3.863, 95% confidence interval （95%CI） = 1.237-12.060,P = 0.020]. After stratification according to their diabetic history, the blood Lac was an independent risk factor for the prognosis of sepsis patients without diabetes （OR = 4.816, 95%CI = 1.407-15.824, P = 0.010）, but the blood Lac had no effect on the prognosis of sepsis patients with diabetes （OR = 0.000, 95%CI =0.000-1.103,P = 0.270）.Conclusions The predictive value of blood Lac on sepsis patients with or without diabetes was different. The blood Lac was related with the prognosis of sepsis patients without diabetes, while further study should be conducted for the prognostic value of blood Lac in sepsis patients with diabetes, and it＇s possible to increase the cut-off-point of Lac level in these patients.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2017年第8期689-693,共5页
Chinese Critical Care Medicine
基金
上海市科研计划项目（16ZR1405600）
关键词
脓毒症
高乳酸血症
糖尿病
血乳酸
生存率
预后
Sepsis
Hyperlactacidemia
Diabetes
Blood lactate
Survival rate
Prognosis
