早期乳酸清除率对体外膜肺氧合治疗后心源性休克患者的预后评估

Prognostic significance of early lactate clearance rate for cardiogenic shock patients on extracorporeal membrane oxygenation

目的 探讨心源性休克患者行体外膜肺氧合（ECMO）治疗后早期乳酸清除率对患者预后的意义.方法 前瞻性选取2010年5月至2013年5月我院重症医学科（ICU）收治的因心源性休克而接受静脉-动脉（V-A） ECMO治疗的患者共47例.分别在接受ECMO治疗前Oh和ECMO治疗后6h测定动脉血乳酸值,计算早期（6 h）乳酸清除率.以接受ECMO治疗后90天为研究终点,将患者分为生存组（25例）和死亡组（22例）,比较两组患者早期乳酸清除率.采用受试者工作特征（ROC）曲线分析早期乳酸清除率对患者预后的评估价值.运用Kaplan-Meier法绘制患者的生存曲线,Log-rank法分析患者生存情况.多因素logistic回归分析影响患者预后的危险因素.结果 生存组早期乳酸清除率高于死亡组[（38.6±15.1）％对（14.4±13.8）％,P＜0.05].早期乳酸清除率预测患者90天死亡的ROC曲线下面积为0.869±0.075（95％ CI：0.753～0.991）,以≥20.0％作为评估预后的最佳界值点,敏感性和特异性分别为92.0％和85.0％.Kaplan-Meier生存曲线分析显示,高乳酸清除率患者（≥20.0％）和低乳酸清除率患者（＜20.0％）90天生存率分别为66.7％和35.0％,组间比较差异有统计学意义（P＜0.05）.多因素Logistic回归分析显示6h乳酸清除率（OR =3.156,95％ CI：2.326～7.253,P＜0.05）是患者死亡的独立危险因素之一.结论 早期乳酸清除率是评估接受ECMO治疗的心源性休克患者预后的重要指标.

Objective To evaluate prognostic significance of early lactate clearance rate for cardiogenic shock patients on extracorporeal membrane oxygenation（ECMO）.Methods Forty-seven patients with cardiogenic shock supported by venoarterial ECMO were prospectively enrolled from May 2010 to May 2013.Arterial blood lactate at pre-ECMO support（0 h）,at post-ECMO 6 hours（6 h） were measured and then 6 h lactate clearance rate was calculated.90 days after admission was the endpoint of research.Patients were divided into the survival group（n =25） and the death group（n =22）.6 h lactate clearance rate was compared between groups.The 6 h lactate clearance rate for predicting death was evaluated by receiver operating characteristic（ROC） curves.The surviving curve was drawn using the Kaplan-Meier method,and the survival of the patients was analyzed by the Log-rank test.Factors influencing the prognosis were analyzed by applying the multiplelogistic regression analysis.Results The 6 h lactate clearance rate was higher in survivors than in nonsurvivors [（38.6 ± 15.1） ％ vs.（14.4 ± 13.8） ％,P ＜ 0.05].The area under the ROC curve of 6 h lactate clearance rate for predicting death was 0.869 ± 0.075 （95％ CI：0.753-0.991）.The best cutoff point was 20.0％ with a sensitivity of 92.0％ and specificity of 85.0％.KaplanMeier survival analysis showed that 90 days survival rate of high lactate clearance rate group and low lactate clearance rate group were 66.7％ and 35.0％,with significant difference between the two groups（Log-rank test,P ＜ 0.05）.Multivariate logistic regression analysis showed that 6 h lactate clearance rate （OR =3.156,95 ％ CI：2.326-7.253,P ＜ 0.05） was one of the independent risk factors associated with mortality of patients on ECMO.Conclusion Early lactate clearance rate could be used as an important maker for evaluating the prognosis of cardiogenic shock patients on ECMO.