乳酸和乳酸清除率对危重病患者预后的意义

Prognostic significance of lactate and lactate clearance to critical illness

目的探讨血乳酸水平和乳酸清除率对危重病患者预后的早期评估作用。方法分析北京大学人民医院286例高乳酸血症患者的临床、实验室资料及预后情况，分析不同乳酸水平的病死率、APACHEⅡ评分差异；根据人院7d内的转归分为存活组、死亡组，比较两组pH、HCO3-、BE、Lac等参数的差异，并对严重高乳酸血症进行上述分析，比较存活与死亡组乳酸清除率、APACHEⅡ评分的差异；对严重高乳酸血症患者按照乳酸清除率分为高、低清除率组，比较两组间参数的差异。结果按乳酸水平分层（≥2，〈4mmol／L；≥4，〈10mmol／L；≥10mmol／L），其对应的病死率分别为14．04％、46．67％、78．79％，随着乳酸上升，pH失代偿比例上升，APACHEⅡ评分增加，病死率也上升。存活组与死亡组之间的乳酸、乳酸清除率、APACHEⅡ评分均差异有统计学意义（P〈0．01）。高、低乳酸清除率组间治疗6h后APACHEⅡ评分、病死率差异具有统计学意义（P〈0．01）；两组乳酸和初始APACHEⅡ评分差异无统计学意义（P〉0．05）。乳酸与APACHEⅡ评分呈正相关（r=0．868，P〈0．01），乳酸清除率与APACHEⅡ评分呈负相关（r=-0．823，P〈0．01）。结论乳酸分层、早期乳酸清除率对评估危重患者预后有重要价值，结合动态APACHEⅡ评分，三者能更好地指导临床治疗、评价预后。

Objective To investigate the prognostic significance of serum lactate level and lactate clearance rate for critical illness patients. Methods Two hundred and eighty - six patients with hyperlactacidemia were investigated by analyzing the clinical data, laboratory data and outcomes. Comparison of mortality rate and APACHE Ⅱ score between different stratified levels of serum lactate was carried out. The blood pH, HCO3 - , BE, and Lac were compared between survivors and non - survivors in terms of in - hospital death in seven days after admission. The above variables of blood gas analysis were studied in patients with severe hyperlactacidemia as well as the different lactate clearance rates and APACHE Ⅱ scores were compared between survivors and non - survivors. The mortality rates and APACHE Ⅱ scores were compared between high and low lactate -clearance rate groups. Results The mortality rates of different stratified levels of serum lactate （ ≥2, 〈4 retool/L; ≥4, 〈 10mmol/Li ≥10 mmol/L） were 14. 04.%, 46. 67%, 78. 79%, respectively. As the serum level of lactate increased, the deeompensation rate of pH, APACHE Ⅱ score and mortality rate increased consequently. Compared with non - survivors, survivors had a higher lactate clearance rate （P 〈 0. 01 ）, and lower APACHE II score （P 〈 0. 01 ）. The high - clearance group had lower mortality rate and 6 - hour APACHE Ⅱ score compared with the low - clearance group （ P 〈 0. 01 ）, but the initiate levels of serum lactate and APACHE II scores were not noticeably different between the two groups （ P 〉 0.05 ）. Serum lactate level had a significant positive relationship with APACHE II score （r = 0. 868, P 〈 0 . 01 ）, but lactate clearance rate had a significant reverse relationship with APACHE Ⅱ score （ r = - 0： 823, P 〈 0. 01 ）. Conclusions Both serum lactatelevels and early lactate clearance rate had high prognostic value for critical illness patients, and in combination with changes in APACHE Ⅱ score, they could guide clinical treatment and give precise evaluation of the prognosis.