中心静脉氧饱和度/乳酸比值在心脏外科手术后的应用意义  

Significance of the ratio of central venous oxygen saturation to lactate after cardiac surgery

作　　者：李俊[1] 杨敏[1] 张伸[1] 张海[1] 吴乾[1] 

机构地区：[1]上海交通大学附属胸科医院重症监护科,上海200031

出　　处：《上海医学》2014年第9期783-787,共5页Shanghai Medical Journal

基　　金：上海市胸科医院科技发展基金资助项目(YZ12-13)

摘　　要：目的监测患者术后早期中心静脉氧饱和度(ScvO2)与乳酸的比值,判断其是否为成为预测心脏外科术后病死率的可靠方法。方法随机选取2012年10月—2013年3月行心脏外科手术的患者149例,术中均行体外循环。分别于术后3、6、9、12和24h监测ScvO2/乳酸比值,并记录患者术后3d生命体征的各项参数取最差值进行序贯器官衰竭估计(SOFA)评分。以术后28d为观察终点,通过结合SOFA评分来比对ScvO2/乳酸比值预测患者病死率的灵敏度和特异度。结果 149例患者中存活142例;死亡7例,存活时间3~26d,平均存活时间为(14.0±2.6)d。回归分析结果显示,SOFA评分为17分和ScvO2/乳酸比值为8与患者预后不良具有独立相关性,以此两个数值节点可预测患者术后早期病死率。149例患者中,SOFA评分<17分且ScvO2/乳酸比值≤8的患者的病死率(8.7%)显著高于SOFA评分<17分且ScvO2/乳酸比值>8的患者(1.3%,P<0.01),SOFA评分≥17分且ScvO2/乳酸比值≤8的患者的病死率(18.8%)显著高于SOFA评分≥17分且ScvO2/乳酸比值>8的患者(2.6%,P<0.01)。瓣膜置换组、先天性心脏病纠治组、夹层动脉瘤升主动脉置换组、冠状动脉旁路移植组的病死率分别为2.9%(3/103)、8.0%(2/25)、1/8、1/13,4组间差异均无统计学意义(P值均>0.05)。瓣膜置换组和先天性心脏病纠治组中,SOFA评分<17分且ScvO2/乳酸比值>8者的病死率分别为1.8%(1/53)和0,均显著低于同组SOFA评分<17分且ScvO2/乳酸比值≤8者的1/15和1/4(P值均<0.01);SOFA评分≥17分且ScvO2/乳酸比值>8者的病死率均为0,均显著低于同组SOFA评分≥17分且ScvO2/乳酸比值≤8者的1/10和2/3(P值均<0.01)。夹层动脉瘤升主动脉置换组和冠状动脉旁路移植组中,SOFA评分≥17分且ScvO2/乳酸比值>8者的病死率分别为1/3和1/4,均显著高于同组SOFA评分≥17分且ScvO2/乳酸比值≤8者的0和0(P值均<0.01)。ScvO2/乳酸比值≤8时预测患者病死率的灵敏度为98.1%,特Objective To monitor central venous oxygen saturation （S^O2） and lactate early after cardiac surgery so as to develop a reliable predictor of mortality. Methods A total of 149 patients undergoing open heart surgery and extracorporeal circulation between October 2012 and March 2013 were enrolled in this prospective study. The ratios of ScvO2 to lactate （ScvO2/lactate） were measured at 3, 6, 9, 12, and 24 hours after surgery. The worst parameters of vital signs were collected to conduct sequence organ failure assessment （SOFA） on day 3 after surgery. The end point of observation was day 28 after surgery. Results Of the patients, 142 patients survived, 7 patients died and the survival time ranged from 3 to 26 days with an average duration of （14.0＋ 2.6） d. Regression analysis showed that SOFA = 17 and Scv,O2/lactate = 8 were independently associated with unfavorable outcome. The mortality rates of SOFA〈17 and ScvO2/lactate≤8 were significantly higher than SOFA〈17 and ScvO2/lactate〉8 （8.7% vs. 1.3%, P〈0.01）. The mortality rates of SOFA≥17 and ScvO2/ lactate≤8 was significantly higher than SOFA〈17 and ScvO2/lactate〉8 （18.8% vs. 2.6%, P〈0.01）. The mortality rates were 2.9% （3/103）, 8.0 % （2/25）, 12. 5% （1/8） and 7.7% （1/13） in the patients undergoing valve replacement, congenital heart disease treatment, aneurysm treatment and coronary bypass grafting, respectively, and there was no significant difference in mortality rates between different treatments （all P〉0. 05）. The mortality rates of SOFA〈 17 and ScvO2/lactate〉8 was 1.8 % （1/53） in valve replacement group and zero in congenital heart disease group, which were significantly lower than that of SOFA〈 17 and ScvO2/lactate≤8 in the corresponding group （ 1/15, 1/4, both P〈0. 01 ）. No patient died in valve replacement group and congenital heart disease group when SOFA≥ 17 and ScvO2/lactate〉8, which were significantly lower than that of SOFA≥ 17 and ScvO2/lactate≤8 in the corres

关 键 词：心脏外科术后 中心静脉氧饱和度 乳酸 病死率 

分 类 号：R654.2[医药卫生—外科学]