婴幼儿法洛四联症围手术期血糖与动脉血乳酸变化的相关性

Correlation between perioperative blood glucose and changes of arterial blood lactate in infants with tetralogy of Fallot

目的研究婴幼儿法洛四联症围手术期血糖与动脉血乳酸变化的相关性及干预血糖对预后的影响。方法收集2014年1月至2020年12月在山西省儿童医院行法洛四联症根治手术的127例患儿的临床资料,其中男73例,女54例;年龄为(6.1±4.5)个月,范围在2~12个月,体重为(7.4±2.9)kg,范围在4~10.5 kg,术前经皮血氧饱和度为80.2%±10.3%,范围在69%~91%,血红蛋白为(155.2±30.5)g/L,范围在118~212 g/L,MaGoon指数为1.30±0.34(1.10~1.70)。记录围手术期9个时间点的血糖及动脉血乳酸值,按术后2 h血糖值分为3组:高血糖组(血糖值≥11.1 mmol/L)61例,可接受血糖组(4.5 mmol/L≤血糖值<11.1 mmol/L)63例,低血糖组(血糖值<4.5 mmol/L)3例,其中高血糖组按照控制目标血糖分为两小组:常规控制血糖组(8.0~11.1 mmol/L)35例,严控血糖组(4.5 mmol/L≤血糖值<8.0 mmol/L)26例。比较各组间动脉血乳酸值变化、主动脉阻断时间、体外循环时间、呼吸机辅助时间、ICU滞留时间、并发症发生率。结果全组无死亡,18例出现并发症。手术开始后即导致血糖及乳酸的增高,血糖在术后2 h达到(10.30±2.01)mmol/L,此时乳酸达到(4.19±1.75)mmol/L,均为录得的最高值;术后48 h血糖[(4.91±0.25)mmol/L]及动脉血乳酸[(0.97±0.31)mmol/L]恢复至正常范围。血糖与动脉血乳酸变化有相关性(r=0.9691,P<0.001。高血糖严控血糖组中乳酸在术后12 h[(3.10±0.85)mmol/L]、术后24 h[(2.62±0.41)mmol/L]、术后48 h[(2.02±0.27)mmol/L]以及呼吸机辅助时间(32.1±10.65)h和ICU滞留时间(4.15±1.39)d明显高于可接受血糖组(P=0.048、P=0.031、P=0.016、P=0.006、P=0.042);上述指标高血糖严控血糖组同样明显高于常规控制血糖组(P=0.050、P=0.046、P=0.022、P=0.007、P=0.003);在并发症发生率方面,高血糖严控血糖组(23.1%)高于可接受血糖组(9.5%)及常规控制血糖组(11.4%)。低血糖组中只收集到3例,未予统计学分析。结论法洛四联症围手术期乳酸与血糖密切相关,对于婴幼儿术后高血糖患儿,有效控制血糖可产生良好效果,但不宜过度严控,保持适当程度的偏高血糖对术后恢复更加有利。

Objective To explore the correlation between perioperative blood glucose(BG)and changes of arterial blood lactate in infants with tetralogy of Fallot(TOF)and to examine the prognostic effect of BG intervention.Methods Clinical data were retrospectively reviewed for 127 children undergoing radical surgery for TOF from January 2014 to December 2020.There were 73 boys and 54 girls.Average age was(6.1±4.5)(2-12)month,average body weight(7.4±2.9)(4-10.5)kg,preoperative percutaneous oxygen saturation(80.2%±10.3%)(69%-91%),hemoglobin(155.2±30.5)(118-212)g/L and McGoon index(MI)(1.30±0.34)(1.10-1.70).The levels of BG and arterial blood lactate were recorded at 9 timepoints during perioperative period.According to the value of BG at 2 h postoperatively,they were divided into 3 groups of hyperglycemia(≥11.1 mmol/L,n=61),acceptable BG(4.5 mmol/L≤blood glucose concentration<11.1 mmol/L,n=63)and hypoglycemia(<4.5 mmol/L,n=3).In accordance with the target BG value,hyperglycemia group was further divided into 2 groups of routine control of BG(8.0~11.1 mmol/L,n=35)and strict control of BG(4.5 mmol/L≤blood glucose concentration<8 mmol/L,n=26).Arterial blood lactate,aortic occlusion time,cardiopulmonary bypass time,mechanical assisted ventilation time,stay in intensive care unit(ICU)and complication rates were compared among the groups.Results There was no death in the whole group and 18 cases were complicated.After a start of operation,BG value and arterial blood lactate level spiked immediately.BG peaked at(10.30±2.01)mmol/L and lactate(4.19±1.75)mmol/L at 2h postoperatively.In most cases,BG(4.91±0.25 mmol/L)and arterial lactate level(0.97±0.31 mmol/L)normalized in 48h postoperatively.Pearson's correlation analysis indicated that BG and changes of arterial blood were correlated(r=0.9691,P<0.0001).In hyperglycemia group of strict control,arterial blood lactate at 12h(3.10±0.85 mmol/L,P=0.048),24h(2.62±0.41 mmol/L,P=0.031)and 48h(2.02±0.27 mmol/L,P=0.016)postoperatively were significantly higher than those of acceptable BG group.Time of mechanical assisted ventilation(32.1±10.65 hours,P=0.006)and ICU stay(4.15±1.39 day,P=0.042)were significantly longer than those of acceptable BG group.The above parameters were also significantly higher in hyperglycemia group of strict control than those of routine control of BG group(P=0.050,0.046,0.022,0.007,0.003).Additionally,the incidence of complications was higher in hyperglycemia group(23.1%)than that of acceptable BG group(9.5%)and routine control of BG group(11.4%).In hypoglycemic group,there were only 3 cases and no statistical analysis was noted.Conclusions Lactic acid is correlated closely with BG during perioperative period of TOF.For infants with postoperative hyperglycemia,effective control of BG may be achieved with better outcomes.However,it is inappropriate to over-control and maintaining an appropriate degree of hyperglycemia may benefit postoperative recovery of TOF.