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目的 比较心脏术后与非心脏术后患者乳酸平均值和乳酸变异度对预后的影响,并探讨入重症医学科(ICU)乳酸首值和首个24 h乳酸最高值对预后的预测价值.方法 采用回顾性研究方法,选择2014年9月至2016年9月郑州大学第一附属manbet官网登录 ICU收治的心脏术后和非心脏术后患者(术后立即转入ICU、年龄≥18岁、ICU住院时间≥1 d).根据乳酸平均值将两组患者再分为正常乳酸组(0~2 mmol/L)、相对高乳酸组(2~4 mmol/L)、绝对高乳酸血组(>4 mmol/L),分析乳酸平均值与患者预后的关系.根据乳酸变异度四分位数将两组患者再分为4组,采用多因素回归模型评估不同乳酸变异度3组的死亡风险.根据入ICU乳酸首值、首个24 h乳酸最高值绘制受试者工作特征曲线(ROC),评价两项指标对预后的预测价值.结果 纳入268例心脏术后和281例非心脏术后患者,两组患者基线资料均衡.① 乳酸平均值与ICU病死率:在正常乳酸水平(0~2 mmol/L)时,心脏术后和非心脏术后患者病死率差异无统计学意义〔7.9%(14/177)比6.5%(14/217),优势比(OR)=1.245,1=0.694〕;在相对高乳酸水平(2~4 mmol/L)时,两组差异也无统计学意义〔33.3%(12/36)比23.7%(9/38),OR=1.611,1=0.442〕;在绝对高乳酸水平(>4 mmol/L)时,非心脏术后患者病死率明显高于心脏术后患者〔69.2%(18/26)比43.6%(24/55),OR=0.344,1=0.036〕.② 乳酸变异度(mmol·L-1·d-1)四分位数与ICU死亡风险:非心脏术后组乳酸变异度与ICU病死率呈线性关系,<0.50(参照),0.50~0.85(OR=1.17, 1=0.87),0.85~1.44(OR=4.86,1=0.04),>1.44(OR=22.66,1<0.01),且在较高变异度(0.85~1.44和>1.44)两组差异有统计学意义;心脏术后组死亡风险呈逐渐升高的趋势,为<0.55(参照),0.55~1.25(OR=0.61,1=0.61),1.25~2.43(OR=3.46,1=0.10),>2.43(OR=12.14,1<0.01),死亡风险只在最高变异度(>2.43)组出现差异.③ ROC曲线分析显示:两组患者入ICU首个24 h乳酸最高值预测预后的ROC曲线下面积(AUC)均大于入ICU乳酸首值,对预后评价的敏感度及特异度也较高.心脏术后和非心脏术后患者首个24 h乳酸最高值预测预后的AUC分别为0.877、0.875,截断值分别为5.35 mmol/L、5.65 mmol/L,敏感度为81.6%、67.9%,特异度为93.8%、96.1%.结论 非心脏术后患者应更积极控制高乳酸血症和乳酸波动.用24 h乳酸最高值评价术后患者预后的预测价值更大.

Objective To compare the impact of mean lactate concentration and lactate variability on postoperative outcome after cardiac surgery and non-cardiac surgery in critical patients, and to explore the prognostic value of the first lactate and the highest lactate during the first 24 hours in intensive care unit (ICU). Methods A retrospective study was conducted. The postoperative patients of cardiac surgery and non-cardiac surgery who were transferred to ICU immediately, and who were at least 18 years old and whose ICU lengths of stay were at least 1 day, and who were admitted to ICU of the First Affiliated Hospital of Zhengzhou University from September 2014 to September 2016 were enrolled. According to the mean lactate concentration, the patients were divided into normal lactate group (0-2 mmol/L), relatively high lactate group (2-4 mmol/L), and absolute high lactate group (> 4 mmol/L), and the relationship between the mean lactate concentration and the prognosis of patients was analyzed. According to the degree of lactate variability, the patients were divided into four groups, and multivariate regression models were used to assess the risk of death in three different lactate variability groups. The value of the first lactate value and the highest lactate value during the first 24 hours in ICU were evaluated to predict the prognosis by the receiver operating characteristic (ROC) curve. Results 268 postoperative patients of cardiac surgery and 281 cases of non-cardiac surgery were selected, and the characteristic of the baseline data in the two groups was balanced. ① Mean lactate concentration and mortality in ICU: in the normal lactate group (0-2 mmol/L), there was no significant difference in mortality between the post-cardiac operative group and post-non-cardiac operative group [7.9% (14/177) vs. 6.5% (14/217), odds ratio (OR) = 1.245, 1 = 0.694]. In the relatively high lactate group (2-4 mmol/L), there was no significant difference between the two groups, either [33.3% (12/36) vs. 23.7% (9/38), OR = 1.611, 1 = 0.442]. In the absolute high lactate group (> 4 mmol/L), ICU mortality in post-non-cardiac operative group was obviously higher than that of post-cardiac operative group [69.2% (18/26) vs. 43.6% (24/55), OR = 0.344, 1 = 0.036]. ② The ranges of lactate variability per quartile (mmol·L-1·d-1) and ICU mortality risk: there was a linear relationship between lactate variability and ICU mortality in post-non-cardiac operative group, < 0.50 (reference), 0.50-0.85 (OR = 1.17, 1 = 0.87), 0.85-1.44 (OR =4.86, 1 = 0.04), > 1.44 (OR = 22.66, 1 < 0.01) , and there was a significant difference between the two groups in the high degree of variability (0.85-1.44 and > 1.44). The risk of death after cardiac surgery tended to increase, < 0.55 (reference), 0.55-1.25 (OR = 0.61, 1 = 0.61), 1.25-2.43 (OR = 3.46, 1 = 0.10), > 2.43 (OR = 12.14, 1 < 0.01), and the risk of death only showed difference in the highest degree of variation (> 2.43). ③ ROC curve showed that the area under ROC curves (AUC) of the highest lactate in 24 hours were larger than that of the first lactate in both groups, with higher sensitivity and specificity. In the post-cardiac operative group and post-non-cardiac operative group, the AUC of the highest lactate in the first 24 hours were 0.877 and 0.875, the cut-off values were 5.35 mmol/L and 5.65 mmol/L, the sensitivity were 81.4% and 67.9%, and the specificity were 93.8% and 96.1%, respectively. Conclusions Patients with post-non-cardiac operation should be more active in controlling hyperlactatemia and lactate variability. The highest lactate in the first 24 hours maybe one of the indicator for the assessment of the prognosis of the postoperative patients.