围术期先天性心脏病患儿动脉血乳酸水平的变化及临床意义

Variations of arterial lactate in children with congenital heart disease in perioperative period and its clinical significance

目的探讨小儿体外循环下心脏手术后动脉血乳酸的动态变化规律及其对指导治疗和预后评估的意义。方法回顾性分析6岁以下体外循环心脏手术后病例1286例，患儿均在体外循环前、体外循环中、体外循环后、返回重症监护病房（ICU）即刻及4、8、12、24、48、72h测量动脉血乳酸水平，以中位数（下四分位数，上四分位数）表示。根据转归分为康复组（1265例）和死亡组（21例），采用SPSS19．0软件进行统计学处理。结果死亡组各时间点乳酸水平均显著高于康复组，差异均有统计学意义（P均〈0．01）。低体质量和术后12h乳酸水平升高是独立危险因素。术后12h乳酸水平每增加1．0mmol／L，死亡风险增加162．8％。而体质量每增加1kg，死亡风险减少25．8％。体外循环前和返回ICU即刻乳酸水平升高，死亡风险也增加30％，但差异无统计学意义。结论先天性心脏病患儿围术期乳酸水平的动态监测是评估病情严重程度、指导治疗和判断预后的敏感指标。围术期乳酸水平升高时，病死率升高。而术后12h乳酸水平升高是独立危险因素，显著增加死亡风险。

Objective To explore the distribution of arterial lactate in children with congenital heart disease in perioperative period, its dynamic variation and its relationship with prognosis. Methods In this paper, perioperative ar- terial lactate level was dynamically monitored in 1 286 children （6 years old and under） with congenital heart disease. According to the prognosis, 1 265 subjects were assigned to rehabilitation group,and 21 subjects to mortality group. The arterial blood of all subjects was collected before cardiopulmonary bypass （CPB） , during CPB, and after CPB, and at 0, 4,8,12,24,48 and 72 hours after the subjects returned to intensive care unit （ICU）. Data analysis was performed using SPSS 19.0 software package. Results The lactate levels at time had a positively skewed distribution. The mortality rates for lactate levels measured at these time points showed highly significant differences （ all P 〈 0. 01 ）. Logistic re- gression analysis was performed, indicating the subjects＇ low body weights and elevated lactate level measured 12 hours after surgery were independent risk factors. Twelve hours after surgery,for every 1.0 mmol/L increase in lactate level, the mortality risk rose by 162.8%, while for every 1 kg increase in body weight, the mortality risk was reduced by 25.8%. The elevated lactate levels measured before CPB and immediately after returning to ICU also increased the mor- tality risk by 30%, but they were not statistically significant. Conclusions The dynamic monitoring of lactate level in the perioperative period in children with congenital heart disease was a sensitive indicator to assess severity, to guide treatments,and for the prognosis. When the lactate level in the perioperative period increased, the mortality rate in- creased as well. The elevated lactate level measured 12 hours after surgery was an independent risk factor that signifi- cantly increased the mortality rate.