早期液体平衡和乳酸清除率对体外膜肺氧合辅助治疗急性心肌梗死合并心源性休克患者的短期预后价值研究

Short-term Prognostic Value of Early Fluid Balance and Lactate Clearance in Patients with Acute Myocardial Infarction Combined with Cardiogenic Shock Treated with Extracorporeal Membrane Oxygenation

背景心源性休克(CS)是急性心肌梗死(AMI)患者的主要死亡原因,研究体外膜肺氧合(ECMO对AMI合并CS患者的疗效具有重要意义。目的探究早期液体平衡和乳酸清除率对接受ECMO辅助治疗AMI合并CS患者的短期预后价值。方法回顾性分析2017年4月—2022年12月在郑州大学第一附属医院接受ECMO治疗的49例AMI合并CS患者的临床资料,根据ECMO上机后30 d结局将患者分为生存组(n=27)和死亡组(n=22)。采用单因素及多因素Logistic回归分析评估AMI合并CS患者ECMO上机后30 d死亡的影响因素。使用受试者工作特征曲线(ROC曲线)评估24 h液体平衡、24 h乳酸清除率及联合指标在预测AMI合并CS患者ECMO上机后30 d预后的价值,采用Delong检验比较ROC曲线下面积(AUC)。结果死亡组患者年龄、肌酐、罪犯血管左主干或左前降支、急性肾损伤、连续性肾脏替代治疗比例、24 h液体平衡、上机24 h乳酸高于生存组,24 h乳酸清除率低于生存组(P<0.05)。多因素Logistic回归分析结果显示,年龄[OR=1.102,95%CI(1.008,1.205)]、急性肾损伤[OR=15.888,95%CI(1.299,194.388)]、24 h液体平衡[OR=1.085,95%CI(1.003,1.174)]、24 h乳酸清除率[OR=0.001,95%CI(0,0.096)]是AMI合并CS患者上机后30 d结局的影响因素(P<0.05)。ROC曲线分析结果显示,24 h液体平衡、24 h乳酸清除率及联合指标预测AMI合并CS患者上机后30 d死亡的AUC分别为0.688[95%CI(0.539,0.812),P=0.015]、0.707[95%CI(0.560,0.828),P=0.006]、0.847[95%CI(0.715,0.934),P<0.001],联合指标预测的AUC分别高于24 h液体平衡(Z=2.05,P<0.05)、24 h乳酸清除率(Z=2.30,P<0.05)。结论24 h液体平衡和24 h乳酸清除率均与AMI合并CS患者上机后30 d结局有关,同时24 h液体平衡联合24 h乳酸清除率对患者ECMO上机后30 d死亡具有更高的预测效能。

Background Cardiogenic shock(CS)is the leading cause of death in patients with acute myocardial infarction(AMI),and it is important to explore the efficacy of extracorporeal membrane oxygenation(ECMO)in AMI patients combined with CS.Objective To investigate the short-term prognostic value of early fluid balance and lactate clearance in AMI patients combined with CS treated with ECMO.Methods The clinical data of 49 hospitalized AMI patients combined with CS treated with ECMO from April 2017 to December 2022 in the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed.The included patients were divided into the survival group(n=27)and death group(n=22)according to 30-day post-ECMO outcomes.Univariate and Multivariable Logistic regression analyses were used to evaluate the influencing factors of 30-day post-ECMO death.Receiver operating characteristic(ROC)curve was plotted to evaluate the predictive value of 24-h fluid balance,24-h lactate clearance and their combination for 30-day post-ECMO outcomes.Delong test was used to compare the area under the ROC curve(AUC).Results Age,creatinine level,the proportion of offender vessel as left main or left anterior descending branch,acute kidney injury and continuous renal replacement therapy,24-h fluid balance,24-h lactate with ECMO in the death group were higher than the survival group,and 24-h lactate clearance was lower than the survival group(P<0.05).Multivariate Logistic regression analysis showed that age〔OR=1.102,95%CI(1.008,1.205)〕,acute kidney injury〔OR=15.888,95%CI(1.299,194.388)〕,24-h fluid balance〔OR=1.085,95%CI(1.003,1.174)〕and 24-h lactate clearance〔OR=0.001,95%CI(0,0.096)〕were independent influencing factors of 30-d post-ECMO outcomes in AMI patients combined with CS.The ROC analysis showed that the AUCs for 24-h fluid balance,24-h lactate clearance and their combination in the prediction of 30-d post-ECMO outcomes in AMI patients combined with CS were 0.68〔895%C(I 0.539,0.812),P=0.015〕,0.707〔95%CI(0.560,0.828),P=0.006〕,0.847〔95%CI(0.715,0.934),P<0.001〕,respectively.The AUC of their combination was higher than 24-h fluid balance(Z=2.05,P<0.05)and 24-h lactate clearance(Z=2.30,P<0.05),respectively.Conclusion Both 24-h fluid balance and 24-h lactate clearance were associated with 30-d post-ECMO outcomes,and their combination was more effective in predicting 30-d post-ECMO death.