血浆乳酸水平与成人心脏手术预后关系

Association of clinical outcomes after cardiac surgery and intra-and post-operative serum lactate levels

目的探讨术中及术后血浆乳酸水平与成人心脏直视手术预后的关系。方法回顾性总结自2011年12月至2012年5月776例成人心脏手术术中及术后48 h内血浆乳酸水平变化,对血浆乳酸水平与临床相关参数的关系进行分析。结果 (1)住院死亡22例,死亡组血浆乳酸水平自"停机前"至"IUC 36 h"的各观察时点均显著高于生存组(P <0.01);(2)与非体外循环手术相比,体外循环手术在术毕至ICU 15 h之间各观察时点血浆乳酸水平均显著上升(P <0.05);(3)体外循环和升主动脉阻断时间自"开放前"至"ICU 15 h"各观察时点,与血浆乳酸水平呈显著性正相关关系(P <0.05),深低温停循环组中停循环时间与术后血浆乳酸水平无正相关关系;(4)"开放前"至"ICU 6 h"及ICU 21 h至"ICU 30 h",血浆乳酸水平与手术时间呈显著性正相关(P <0.05);(5)术中及术后各观察时点血浆乳酸水平与对应时点血糖水平之间均呈显著性正相关关系(P均<0.001);(6)血浆乳酸水平与术后呼吸机辅助时间在"开放前"至"ICU 6 h"各观察时点呈显著性正相关(P <0.01);(7)在"开放前"至"ICU 3 h"各观察时点,血浆乳酸水平与术后ICU停留时间和术后住院时间呈显著性正相关(P <0.01);(8)术后急性肾功能不全患者"开放前"至"ICU 6 h"期间的血浆乳酸水平显著高于术后无肾功能不全的患者(P <0.05)。(9)术前、术日、术后第1天、第2天,血浆乳酸水平与白细胞计数、中性粒细胞计数及中性粒细胞比例均呈显著性正相关(P均<0.001)。结论心脏术毕至ICU 33 h各时点血浆乳酸水平均为成人心脏外科手术院内死亡的独立风险因素,是评估心脏手术预后的可靠指标。

Objective The aim of the present study was to determine whether serum lactate level (SLL) measurement during and after cardiac surgery could predict outcomes,and to assess the association between SLL and clinical outcomes of adult cardiac surgery. Methods We collected data of all consecutive 776 adult patients who underwent cardiac surgery with or without extracorporeal circulation (ECC) between December 2011 and May 2012. SLL was recorded on pre ECC,15 minutes after ECC,pre aortic cross clamp (ACC) off,end of ECC,end of surgery,immediately after intensive care unit (ICU) admission and every 3 hours in ICU until 48 hours after surgery. The relationship was evaluated among SLL and clinical data and outcomes. Results ① Twenty-two patients died in hospital. SLL was significantly elevated (P<0.01) in non-survivors at time points from pre-pump-off to 36 hours after ICU admission comparing with survivors;② Comparing with cardiac surgery without ECC,SLL was significantly elevated at time points from end of surgery to 15 hours after ICU admission in the patients undergoing ECC (all P<0.05);③ A significant positive relationship was found between SLL and duration of ECC and ACC at time points from pre ACC off to 15 hours after ICU admission (all P<0.05) ,but no significant positive relationship between SLL and duration of circulatory arrest was found in the surgery with deep hypothermic circulatory arrest (DHCA);④ A significant positive relationship was found between SLL and duration of operation at time points from pre ACC off to 12 hours after ICU admission,as well as time point 21 hours after ICU admission (all P<0.05);⑤ SLL corresponded with serum glucose level. There was a significant positive relationship in all time points between SLL and serum glucose levels (all P<0.001);⑥ There was a significant positive relationship at time points from pre ACC off to 6 hours after ICU admission (all P<0.01) between SLL and duration of postoperative ventilator assistance;⑦ There was a significant positive relationship between SLL and duration of ICU stay at time points from pre ACC off to 3 hours after ICU admission,as well as hospital stay (all P<0.01);⑧ SLL at time points from pre ACC off to 6 hours after ICU admission significantly elevated in patients with acute kidney insufficiency (all P<0.05);⑨ There was a significant positive relationship between SLL and white blood cell count before operations,immediately after ICU admission,1 and 2 days after ICU admission (all P<0.001) . Conclusion SLL at all time points from end of surgery to 33 hours after ICU admission is an independent predictor of in-hospital mortality in adult patients undergoing cardiac surgery.