血乳酸测定评估ECMO治疗的心源性休克患者预后价值

Prognostic value of arterial blood lactate for patients with cardiogenic shock receiving extracorporeal membrane oxygenation

目的探讨心源性休克应用体外膜肺氧合(ECMO)治疗期间血乳酸测定及乳酸清除率对患者预后的评估价值。方法回顾性分析2017年1月至2018年12月EICU收治的23例ECMO治疗的心源性休克患者的临床资料。其中男17例,女6例;年龄40~80岁,平均(58.1±10.3)岁。原发病有急性心肌梗死20例,重症暴发性心肌炎3例。超声心动图示左心室射血分数30.4±4.9。分别在入EICU时、ECMO置入前1 h、ECMO置入后(0、2、4、8、12、16、20、24、30、36、48 h)测定动脉血乳酸值。根据临床转归情况将患者分为生存组(10例)和死亡组(13例),比较两组患者各时点乳酸值及乳酸清除率。采用受试者工作特征(ROC)曲线分析乳酸对患者预后的评估价值。结果相比生存组,死亡组APACHE-Ⅱ评分、连续肾脏替代治疗(CRRT)应用比例更高,PH值及氧合指数更差(P<0.05)。死亡组入EICU时、ECMO前1 h及ECMO后0 h的乳酸值显著高于生存组(P<0.05)。ECMO运行期间,死亡组8 h、12 h的乳酸值显著高于生存组(P<0.05)。两组ECMO运行前、后各观察时间段内的乳酸清除率差异均无统计学意义(P>0.05)。ECMO运行第2天,生存组CRRT使用时间更短,日液体平衡更负(P<0.05)。APACHE-Ⅱ评分、入EICU时乳酸值、ECMO后8 h、12 h乳酸值对患者30天死亡均有预测价值,入EICU时乳酸值的ROC曲线下面积(AUC)为0.845,95%置信区间(95%CI):0.653~1.000;ECMO后8 h乳酸的AUC为0.836,95%CI:0.634~1.000;ECMO后12 h乳酸的AUC为0.873,95%CI:0.697~1.000;APACHE-Ⅱ评分的AUC为0.891,95%CI:0.717~1.000。以入EICU时乳酸≥7.3 mmol/L为最佳临界值时,预测预后的敏感度为72.7%,特异度为100%。结论血乳酸是评估接受ECMO治疗的心源性休克患者预后的重要指标。乳酸清除率的价值可能会受到联合CRRT治疗的影响。

Objective To investigate the prognostic value of arterial blood lactate for patients with cardiogenic shock receiving extracorporeal membrane oxygenation(ECMO).Methods A retrospective analysis was conducted.Twenty-three patients diagnosed with cardiogenic shock receiving veno-arterial(V-A)ECMO admitted to department of Emergency Intensive Care Unit(EICU)of Beijing Luhe Hospital Affiliated to Capital Medical University from January 2017 to December 2018 were enrolled.Results There were 10 cases in the survival group and 13 cases in the death group.Compared with survival group,APACHE-Ⅱscore was higher,CRRT applied higher percentage,PH and oxygenation index was worse in the death group(P<0.05).The lactate of the death group was significantly higher than that of the survival group at initial time at EICU,1 h before ECMO and 0h before ECMO(P<0.05).During the ECMO operation,lactate levels in the death group at 8 h and 12 h were significantly higher than those in the survival group(P<0.05).There was no statistically significant difference in lactate clearance rate between the two groups before and after ECMO operation in each observation period(P>0.05).On the 2nd day of ECMO operation,CRRT usage time was shorter and daily liquid balance was more negative in the survival group(P<0.05).APACHE-Ⅱscore,initial lactate at EICU,lactate at ECMO 8 h and lactate at ECMO 12 h had predictive value for 30-day death of patients.The area under ROC curve(AUC)of initial lactate at EICU was 0.845,and 95%confidence interval(95%CI)=0.653-1.000.The AUC of ECMO 8 h lactate was 0.836,95%CI:0.634-1.000.The AUC of ECMO 12 h lactate was 0.873,95%CI:0.697-1.000.The AUC of APACHE-Ⅱscore was 0.891,95%CI:0.717-1.000.The sensitivity and specificity of prognosis prediction were 72.7%and 100%when lactate was more than 7.3 mmol/L at the time of admission into EICU as the optimal critical value.Conclusion Arterial blood lactate could be used as an important marker for evaluating the prognosis of cardiogenic shock patients on ECMO.The value of lactate clearance rate may be affected by combined CRRT.