6小时血乳酸及乳酸清除率对心源性休克早期死亡的预测价值

The predictive value of lactate at 6 hours after admission combined with 6 hours lactate clearance for early death in cardiogenic shock

目的探讨心源性休克患者入科后第6小时血乳酸及乳酸清除率对早期预后的影响。方法收集2020年1月至2022年12月义乌市中心医院收治的88例心源性休克患者临床资料,根据30d转归情况分为存活组(69例)和死亡组(19例),对入科第6小时乳酸(Lac_6h)、乳酸清除率(Δ6Lac)行受试者工作特征(ROC)曲线分析,根据截断值分3个亚组:group A:Lac_6h≤6.1mmol/L且Δ6Lac>18.2%;group B:Lac_6h≤6.1mmol/L且Δ6Lac≤18.2%;group C:Lac_6h>6.1mmol/L且Δ6Lac取任意值,对亚组绘制生存曲线并进行多因素COX分析。结果(1)死亡组入科第6小时乳酸7.9(1.7,11.0)mmol/L,高于存活组1.6(1.2,2.0)mmol/L,而6h乳酸清除率7.9%(30.6%,-17.2%),低于存活组37.5%(20.0%,53.9%),差异均有统计学意义(P<0.001);(2)入科第6小时乳酸预测心源性休克30d死亡的ROC曲线下面积(AUC):0.805,最佳截断值6.1mmol/L,敏感度57.9%,特异度98.6%,而6h乳酸清除率的AUC:0.839,最佳截断值6.1mmol/L,敏感度84.2%,特异度75.4%,配对ROC曲线比较:ΔAUC=0.034,P=0.615,差异无统计学意义;(3)亚组分析:30d生存曲线提示group C组存活率最低8.3%,其次为group B(81%),而group A存活率最高(91%),差异有统计学意义(log rank P<0.001),但group A与group B存活率无统计学意义(P>0.05),多因素COX回归校正Lac_6h>6.1mmol/L是死亡的危险因素HR 24.22,95%CI:4.31-138.52。结论联合入科第6小时乳酸及6h乳酸清除率可作为心源性休克早期监测和评估预后重要指标,临床上可互为参考,入科后第6小时乳酸>6.1mmol/L是心源性休克患者30d死亡的重要危险因素。

Objective To investigate the significance of early lactate clearance rate and blood lactate levels in predicting the early prognosis of patients experiencing cardiogenic shock.Methods An observational study was conducted at Yiwu Central Hospital from January 2020 to December 2022,involving 88 patients diagnosed with cardiogenic shock.The patients were categorized into either a survival group(n=69)or a death group(n=19)based on their 30-day outcomes.Receiver operating characteristic(ROC)curve analysis was carried out on the lactate levels at the 6th hour after admis-sion(Lac_6h)and the 6-hour lactate clearance rate(△6Lac)to assess their predictive value.Subse-quently,the patients were further divided into three subgroups based on predetermined cutoff values:group A(Lac_6h<6.1mmol/L and△6Lac>18.2%),group B(Lac_6h≤6.1mmol/L and△6Lac≤18.2%),and group C(Lac_6h>6.1mmol/L irrespective of△6Lac level).Survival curves were constructed for each subgroup,and multivariate COX analysis was performed to evaluate the results.Results ①The death group exhibited a significantly higher lactate level at the 6th hour post-admission(7.9 mmol/L)compared to the survival group(6.3 mmol/L).Similarly,the lactate clearance rate at 6 hours was significantly lower in the death group(7.9%)compared to the survival group(45.4%).These findings were statistically significant(all P<0.001).②The area under the ROC curve(AUC)for predicting 30-day mortality in cardiogenic shock based on lactate clearance at 6 hours was 0.805 with a best cutoff value of 6.1mmol/L,yielding a sensitivity of 57.9%and specificity of 98.6%.In comparison,the AUC for the 6-hour lactate clearance was 0.839 with a best cutoff value of 6.1mmol/L,sensitivity of 84.2%,and specificity of 75.4%.However,the paired ROC curve comparison revealed a non-significant difference(△AUC=0.034,P=0.615).③Subgroup analysis indicated that group C had the lowest 30-day survival rate(8.3%),followed by group B(81%)and group A(91%).difference statistically(log rank P<0.001),the rates between group A and groupB were not significant(P>0.05),Multiple COX regression identified Lac_6h>6.1mmol/L as significant factor mortality,with HR 24.22,95%CI:4.31~138.52.Conclusions Early combined lactate levels at the 6th hour after admission and the 6-hour lactate clearance rate can be used as important indicators for early monitoring of cardiogenic shock and prognosis assessment,They can serve as references to each other clinically,Lactate level>6.1mmol/L at the 6th hour after admission is an important risk factor for death within 30 days after cardiogenic shock.