乳酸对ECMO支持下急性心肌梗死合并心源性休克患者预后的影响  

Effect of lactate on the prognosis of patients with acute myocardial infarction and cardiogenic shock supported by extracorporeal membrane oxygenation

作　　者：刘亮[1] 肖浩[1] 崔晓磊[1] 吕宝谱 张睿[1] 郑拓康 田英平[1] 高恒波[1] LIU Liang;XIAO Hao;CUI Xiaolei(Department of Emergency Medicine,the Second Hospital of Hebei Medical University,Hebei,Shijiazhuang 050000,China)

机构地区：[1]河北医科大学第二医院急诊医学科,石家庄市050000

出　　处：《河北医药》2024年第11期1632-1635,1641,共5页Hebei Medical Journal

基　　金：河北省医学科学研究课题计划(编号:20221076)。

摘　　要：目的分析血乳酸对体外膜肺氧合(ECMO)支持下治疗急性心肌梗死(AMI)合并心源性休克(CS)患者预后的影响,从而指导临床以期改善预后。方法回顾性分析2018年12月至2021年12月于河北医科大学第二医院急诊医学科就诊的ECMO支持下行冠脉造影及经皮冠状动脉介入(PCI)治疗AMI合并CS患者临床资料。患者均在就诊后经充分评估行VA-ECMO支持治疗,24 h内行冠脉造影及PCI,期间多次测量患者动脉血乳酸值,收集上ECMO前最高血乳酸值、上ECMO后行急诊PCI之前最低血乳酸值、乳酸清除率。根据发病30 d预后情况将患者分为存活组和死亡组。比较ECMO前后血乳酸值的变化,比较存活组、死亡组上ECMO前、后血乳酸值的差异,并绘制ROC曲线评价上机前、后血乳酸对患者预后的预测价值。结果39例患者中30 d存活21例(53.8%),死亡18例(46.2%);上ECMO后最低乳酸值较上ECMO前最高血乳酸值明显下降(均P<0.05);与存活组比较,死亡组上ECMO前最高血乳酸值、上ECMO后最低乳酸值均明显升高,乳酸清除率明显降低(均P<0.05)。ROC曲线分析显示上ECMO前最高血乳酸值、上ECMO后最低乳酸值对ECMO支持下行治疗AMI合并CS患者预后有预测价值,上ECMO前最高血乳酸值对应的ROC曲线下面积(AUC)为0.756,95%CI为0.601~0.911,P值为0.007,当截断值为5 mmol/L时,敏感度为94.1%,特异度为57.1%;上ECMO后最低乳酸值对应的AUC为0.870,95%CI为0.761~0.979,P值为0.000,当截断值为2.45 mmol/L时,敏感度为100%,特异度为61.9%。结论ECMO可以有效降低AMI合并CS患者血乳酸水平;上ECMO前最高血乳酸值、上ECMO后最低血乳酸值对ECMO支持下行治疗AMI合并CS患者预后有预测价值;上ECMO前最高血乳酸值≥5 mmol/L,上ECMO后PCI前最低乳酸值≥2.45 mmol/L提示不良预后;ECMO支持的患者在PCI前降低血乳酸水平可能改善患者预后。Objective To analyze the impact of blood lactate on the prognosis of patients with acute myocardial infarction(AMI)and cardiogenic shock(CS)treated with extracorporeal membrane oxygenation(ECMO),thus guiding clinical practice and improve the prognosis.Methods A retrospective analysis was conducted on the clinical data of AMI patients complicated with CS who were treated with coronary angiography and percutaneous coronary intervention(PCI)undeRthe support of ECMO in the Emergency Medical Department of the Second Hospital of Hebei Medical University from DecembeR2018 to DecembeR2021.All patients underwent the veno-arterial ECMO(VA-ECMO)afteRa thorough evaluation.Coronary angiography and PCI were performed within 24 hours of onset.During this period,arterial blood lactate levels were measured foRmultiple times,and the highest lactate level before applying ECMO,the lowest lactate level before emergency PCI afteRapplying ECMO,and lactate clearance rate were recorded.According to the 30-day prognosis,patients were divided into survival group and death group.Changes in blood lactate levels before and afteRECMO,and differences in blood lactate levels before and afteRECMO between the survival and death groups were compared.The receiveRoperating characteristic(ROC)curves were plotted to evaluate the predictive value of blood lactate levels before and afteRECMO on the prognosis of AMI combined with CS.Results Among the 39 patients,21(53.8%)survived and 18(46.2%)died at 30 days of onset.The lowest lactate value afteRapplying ECMO was significantly loweRthan the highest blood lactate value before applying ECMO(P<0.05).Compared with those of the survival group,the highest blood lactate value before applying ECMO and the lowest lactate value afteRapplying ECMO in the death group were significantly higher,and the lactate clearance rate was significantly loweR(P<0.05).ROC curve showed that the highest blood lactate value before applying ECMO and the lowest lactate value afteRapplying ECMO had a predictive value foRthe prognosis o

关 键 词：血乳酸 体外膜肺氧合 急性心肌梗死 心源性休克 预后 

分 类 号：R542.22[医药卫生—心血管疾病]