术后脑脊液乳酸水平和乳酸清除率对动脉瘤性蛛网膜下腔出血预后的预测价值

Predictive value of postoperative cerebrospinal fluid lactate level and lactate clearance rate on the prognosis of aneurysmal subarachnoid hemorrhage

目的检测动脉瘤性蛛网膜下腔出血(aSAH)术后脑脊液乳酸水平和乳酸清除率,评估其对aSAH临床转归不良的预测价值。方法收集2018-01—2020-12在上海中医药大学附属曙光医院接受手术治疗的aSAH患者125例,根据术后3个月改良Rankin量表(mRS)评分分为转归良好组(n=90例)和转归不良组(n=35例)。比较2组患者的一般资料及术后1 d、2 d和3 d的脑脊液乳酸水平和乳酸清除率。采用Logistic多因素回归分析影响aSAH转归不良的危险因素,受试者工作曲线(ROC)评估术后1 d、2 d脑脊液乳酸水平和乳酸清除率对aSAH临床转归不良的预测价值。结果转归不良组年龄、GCS评分(3~8分)、Hunt-Hess分级≥3级、改良Fisher分级≥3级、术后脑出血和术后迟发型脑缺血患者比例均高于转归良好组,组间比较差异有统计学意义(P<0.05)。术后1 d和术后2 d,转归不良组脑脊液乳酸水平均高于转归良好组(P<0.05),转归不良组术后3 d内的乳酸清除率高于转归良好组(P<0.05)。GCS评分、Hunt-Hess分级、改良Fisher分级、术后脑出血、术后迟发型脑缺血、术后1 d乳酸水平、术后2 d乳酸水平和术后3 d乳酸清除率均为影响aSAH转归不良的独立危险因素。术后1 d和术后2 d乳酸水平预测aSAH转归不良均具有临床价值,但组间比较差异无统计学意义(Z=0.856,P=0.547),术后3 d乳酸清除率预测aSAH转归不良临床价值高于术后1 d和术后2 d乳酸水平(Z=3.254,P=0.015;Z=4.201,P=0.008)。结论术后1 d乳酸水平、术后2 d乳酸水平和术后3 d乳酸清除率均为影响aSAH转归不良的独立危险因素,但术后3 d乳酸清除率对aSAH转归不良的临床预测价值最高,有望成为aSAH转归不良的预测指标。

Objective To detect the lactic acid level and lactic acid clearance rate of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage(aSAH),and evaluate its predictive value for the poor clinical outcome of aSAH.Methods A total of 125 patients with aSAH who underwent surgical treatment in our hospital from January 2018 to December 2020 were collected,and the patients were divided into good outcome group(90 cases) and poor outcome group(35 cases),according to the modified Rankin Scale(mRS) score at 3 months after operation.The general clinical data,cerebrospinal fluid lactic acid level and lactic acid clearance rate of 1 day,2 days and 3 days after operation were compared between the two groups.Logistic multivariate regression analysis of the risk factors affecting the poor outcome of aSAH,receiver operating curve(ROC) to evaluate the predictive value of the cerebrospinal fluid lactate level and lactate clearance rate of 1 day and 2 days postoperatively on the clinical outcome of aSAH.Results The proportion of age,GCS score(3-8 points),Hunt-Hess grade≥ 3,modified Fisher grade≥3,postoperative cerebral hemorrhage and postoperative delayed cerebral ischemia in the poor outcome group was higher than the good outcome group,there were statistical differences between the two groups(P<0.05).The cerebrospinal fluid lactic acid level in the poor outcome group was higher than that in the good outcome group at 1 day and 2 days after the operation(P<0.05),and the lactate clearance rate within 3 days after the operation in the poor outcome group was higher than that in the good outcome group(P<0.05).GCS score,Hunt-Hess grading,modified Fisher grading,postoperative cerebral hemorrhage,postoperative delayed cerebral ischemia,postoperative 1 day lactic acid level,postoperative 2 days lactic acid level and postoperative 3 days lactic acid clearance rate were independent risk factor which affected the poor outcome of aSAH.Lactic acid levels at 1 day and 2 days after operation had clinical value in predicting poor outcome of aSAH,but there was no statistical difference between groups(Z=0.856,P=0.547).The clinical value of lactate clearance rate at 3 days after operation in predicting poor outcome of aSAH was higher than 1 day and 2 days after operation(Z=3.254,P=0.015;Z=4.201,P=0.008).Conclusion Lactic acid level at 1 day after operation,lactate level at 2 days after operation,and lactate clearance rate at 3 days after operation are all independent risk factors that affect the poor outcome of aSAH,but the postoperative 3-day lactate clearance rate has the highest clinical predictive value for the poor outcome of aSAH,and it is expected become a predictor of poor outcome of aSAH.