深低温停循环下肺动脉内膜剥脱术中患者血乳酸升高的相关因素及其对预后的影响  

Risk factors of hyperlactatemia during pulmonary endarterectomy under deep hypothermic circulatory arrest and its influence on prognosis

作　　者：方颖慧 张亚军[1] 甄雅南[2] 刘晓鹏 孙光[2] 韩永新 Fang Yinghui;Zhang Yajun;Zhen Yanan;Liu Xiaopeng;Sun Guang;Han Yongxin(Department of Anesthesiology,China‑Japan Friendship Hospital,Beijing 100029,China;Department of Cardiovascular Surgery,China‑Japan Friendship Hospital,Beijing 100029,China)

机构地区：[1]中日友好医院手术麻醉科,北京100029 [2]中日友好医院心脏血管外科,北京100029

出　　处：《中华医学杂志》2023年第2期125-131,共7页National Medical Journal of China

摘　　要：目的探讨深低温停循环(DHCA)下肺动脉内膜剥脱(PEA)术中患者血乳酸升高的相关因素及其对预后的影响。方法回顾性分析2016年12月至2022年1月在中日友好医院接受PEA的患者资料。通过受试者工作特征曲线分析血乳酸峰值水平对术后主要并发症的预测能力,并通过最大约登指数确定cut-off值。采用多因素logistic回归分析术中血乳酸水平升高的相关因素及临床结局的影响因素。结果共纳入110例患者,男69例,女41例,年龄(50.6±12.8)岁。受试者工作特征曲线分析结果提示,预测主要术后并发症(术后48 h再手术、再次气管插管、需要肾替代治疗的急性肾损伤、伤口感染、脑卒中、心房颤动、体外膜肺氧合)的血乳酸水平cut-off值为7 mmol/L。39例患者(35.5%)术中血乳酸峰值≥7 mmol/L。根据术中血乳酸峰值≥7 mmol/L与<7 mmol/L分为两组,两组患者年龄、性别及体质指数差异均无统计学意义(均P>0.05)。术中血乳酸峰值与机械通气时间(r=0.262,P=0.008)、重症监护病房停留时间(r=0.304,P=0.002)呈正相关。多因素logistic回归分析结果显示,DHCA持续时间长(OR=1.186,95%CI:1.027~1.370,P=0.020)、最低红细胞比容(HCT)低(OR=0.580,95%CI:0.341~0.988,P=0.045)和术前肺血管阻力(PVR)高(OR=1.096,95%CI:1.020~1.177,P=0.012)是术中血乳酸峰值≥7 mmol/L的相关因素。术中血乳酸峰值≥7 mmol/L和<7 mmol/L的患者中分别有41.0%(16/39)和14.1%(10/71)出现主要并发症,差异有统计学意义(P=0.001)。此外,多因素logistic回归分析结果显示,术中血乳酸峰值是术后主要并发症发生的影响因素(OR=1.625,95%CI:1.176~2.245,P=0.003)。术中血乳酸峰值<7 mmol/L和≥7 mmol/L的患者院内死亡发生率差异无统计学意义(8.5%比10.3%,P=0.753)。结论术前PVR高、术中HCT低、停循环时间长是术中血乳酸升高的相关因素,术中血乳酸水平高的患者术后并发症发生风险升高。Objective To investigate the incidence,risk factors,and outcomes of hyperlactatemia after pulmonary endarterectomy(PEA)under deep hypothermic circulatory arrest(DHCA).Methods From December 2016 to January 2022,patients receiving PEA in China-Japan Friendship Hospital were enrolled in the study.Arterial blood samples were analyzed intraoperatively.Multivariate logistic regression analysis was performed to identify the predictors of intraoperative lactate elevation as well as major factors influencing the clinical outcome of the surgery.Results A total of 110 patients(69 males and 41 females)were enrolled,aged(50.6±12.8)years.Receiver operating characteristic curve yielded an optimal cut-off lactate level of 7 mmol/L for predicting major postoperative complications(re-operation,re-intubation,postoperative renal failure requiring renal replacement therapy,wound infection,stroke,atrial fibrillation,and perioperative extracorporeal membrane oxygenation usage within 48 hours after surgery).Thirty-nine patients(35.5%)had an intraoperative peak arterial lactate level of≥7 mmol/L.According to intraoperative peak arterial lactate level,the patients were divided into two groups(<7 mmol/L and≥7 mmol/L).There were no statistically significant differences in age,sex and body mass index between the two groups(all P>0.05).Intraoperative peak lactate level was associated with prolonged mechanical ventilation time(r=0.262,P=0.008)and intensive care unit length of stay(r=0.304,P=0.002).Multivariate logistic regression analysis identified three key variables associated with lactate level≥7 mmol/L:DHCA duration(OR=1.186,95%CI:1.027-1.370,P=0.020),nadir hematocrit(HCT)(OR=0.580,95%CI:0.341-0.988,P=0.045)and preoperative pulmonary vascular resistance(PVR)(OR=1.096,95%CI:1.020-1.177,P=0.012).Patients with lactate≥7 mmol/L carried a higher rate of major complications(P=0.001).For patients with lactate≥7 mmol/L,41.0%(16 out of 39 cases)had major complications,while for patients with lactate<7 mmol/L,only 14.1%(10 out of 71)had

关 键 词：动脉内膜切除术 深低温停循环 高乳酸血症 

分 类 号：R614[医药卫生—麻醉学]