Ratio对食管癌术后血流动力学异常患者液体治疗的评价

Ratio for the evaluation of fluid therapy in esophageal cancer patients with hemodynamic abnormalities postoperation

目的食管癌术后常有血流动力学异常的发生,P_((cv-a))CO_2/C_((a-cv))O_2(Ratio)是一种能够反映机体无氧代谢情况的指标,本研究旨在探讨Ratio对食管癌术后血流动力学异常患者液体治疗效果的评价作用。方法回顾性研究天津医科大学总医院心胸外科2016-01-01-2017-06-30收治的食管癌切除术后合并血流动力学异常的患者69例,分为并发症组和无并发症组,比较两组术后血流动力学及血气各项指标;Logistic回归分析血流动力学异常发生的危险因素,ROC曲线计算Ratio对血流动力学异常患者发生并发症的识别能力,并通过约登指数得出cut-off值;对术后血红蛋白(Hb)、ICU住院时间、术后每小时尿量[mL/(kg·h)]、呼吸机使用时间、ΔAPACHEⅡ值等指标进行评价。结果共有29例(42%)患者发生术后并发症,并发症组术后6、12、24hRatio分别为1.7±0.2、1.8±0.2和1.7±0.2,均高于无并发症组的(1.5±0.2)、(1.6±0.2)、(1.5±0.2),差异有统计学意义,均P<0.05;并发症组术后6、12hP(cv-a)CO_2分别为(8.0±1.3)、(8.0±1.4)mmHg,均高于无并发症组的(6.7±1.3)、(6.9±1.1)mmHg,差异有统计学意义,P<0.05;并发症组术后24hLac为(1.2±0.5)mmol/L,高于无并发症组的(0.8±0.2)mmol/L,差异有统计学意义,P=0.034。Logistic回归分析显示,6hRatio为食管癌术后血流动力学异常患者发生并发症的独立危险因素(OR=2.935,95%CI:1.287~6.697,P=0.011)。以ROC曲线得出6hRatio的cut-off值为1.675(AUC=0.853±0.045,95%CI:0.766~0.941,P<0.001),重新分组,H-R组ICU住院时间[(7.8±2.0)d]较L-R组ICU住院时间[(6.5±1.1)d]明显增加,P=0.001;H-R组术后平均Hb[(94.4±10.5)g/L]较L-R组术后平均Hb[(99.6±9.3)g/L]明显降低,P=0.031;H-R组ΔAPACHEⅡ值(3.9±1.3)较L-R组ΔAPACHEⅡ值(2.5±0.9)明显升高,差异均有统计学意义,P<0.001。结论Ratio的增高与食管癌术后血流动力学异常患者发生并发症密切相关,且对其液体治疗效果有一定的评价作用。

OBJECTIVE For the occurrence of abnormal hemodynamics after esophagus cancer surgery,P（（cv-a））CO2/C（（a-cv））O2（Ratio）is an index that can reflect the anaerobic metabolism of the body.This study aimed to explore the effect of Ratio on fluid therapy in patients with hemodynamic abnormality of postoperative esophageal cancer.METHODS Sixty-nine cases of esophageal cancer with postoperative hemodynamic abnormalities from Department of Thoracic Surgery of Tianjin Medical University General Hospital between January 1,2016 and June 30,2017 were included for retrospective study,according to the presence of complications all patients were allocated into two groups：complication group and non-complication group.Comparing two groups of patients with postoperative hemodynamic parameters：mean arterial pressure（MAP）,heart rate（HR）,Central venous pressure（CVP）,blood gas parameters：SaO2,ScvO2,P（（cv-a））CO2,lactic acid（Lac）,arterial blood PH value,Ratio.Logistic regression was used to analyze risk factors related to hemodynamic abnormalities and ROC curve calculated the recognition ability on complications relevant to hemodynamic abnormalities,cut-off value from Youden index assessed the clinical indicators：length of ICU stay,postoperative average hemoglobin（Hb）,postoperative per hour average urine[mL/（kg·h）],mechanical ventilation time,ΔAPACHEⅡ values.RESULTS A total of 29（42%）patients underwent postoperative complications,with significant difference,the 6 hRatio,12 hRatio,24 hRatio of complication group were 1.7±0.2,1.8±0.2 and 1.7±0.2 respectively,which was higher than that of non-complication group with statistically significant difference,P〈0.05;the 6 hP（cv-a）CO2,12 hP（cv-a）CO2 of complication group were（8.0±1.3）mmHg,（8.0±1.4）mmHg,which was higher than that of non-complication group with statistically significant difference,P〈0.05;and the 24 hLac（1.2±0.5）mmol/L of complication group was higher than that of non-complication group（0.8±0.2）mmol/L with statistically significant difference,P=0.034.Logistic regression showed 6 hRatio was independently connected with the presence of complications in esophageal cancer patients with postoperative hemodynamic abnormalities（OR=2.935,95%CI：1.287-6.697,P=0.011）,grouping on the cut-off value 1.675（AUC=0.853±0.045,95%CI：0.766-0.941,P〈0.001）concluded from ROC curve showed that high-Ratio patients combined with longer ICU length of hospital stay（7.8±2.0）d than low-Ratio patients（6.5±1.1）d,P=0.001;high-Ratio patients combined with lower postoperative average Hb（94.4±10.5）g/L than low-Ratio patients（99.6±9.3）g/L,P=0.031;high-Ratio patients combined with higherΔAPACHEⅡ value（3.9±1.3）than low-Ratio patients（2.5±0.9）,P〈0.001.CONCLUSION The occurrence of complications in hemodynamic abnormalities patients after esophagectomy is related to an increased Ratio which can be used to evaluate fluid therapy in esophageal cancer patients with hemodynamic abnormalities postoperation.