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体外循环是心脏外科发展的基石,为目前呼吸及心脏循环衰竭的主要机械支持[1-2],但体外循环会导致血管收缩及血流减少,低体温会使这种情况进一步加剧,而当机体与体外循环分离时若体温不能完全恢复到常温,则会使病人乳酸水平升高[3-4]。儿童体外循环后高乳酸血症是目前临床常见表现,被认为是术后早期不良事件的重要预测因素,而患儿体内升高的乳酸水平通常被视为低心排血量的替代标志物,系由组织灌注不足所致。高乳酸血症也可发生于组织灌注正常的病人,此时高乳酸血症可能与高血糖等因素相关[5-7]。低体质量、低月龄的婴幼儿受其血容量较小等特点影响,在体外循环过程中,患儿全身组织经历低温、缺氧及低灌注等过程,更容易出现高乳酸血症[8]。本研究分析低月龄、低体质量患儿体外循环后乳酸水平相关影响因素,并分析患儿乳酸与血糖及氧合指标间的相关性。现作报道。
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术后1例患儿死亡,最终纳入病例128例,其中高乳酸组43例,正常乳酸组85例。高乳酸组患儿年龄-ASA分级IV~V级比例均高于正常乳酸组(P < 0.05),2组患儿性别、体质量差异均无统计学意义(P>0.05)(见表 1)。
分组 n 年龄/月 男 女 体质量/kg ASA分级 先心病类型 Ⅱ~Ⅲ级 IV~V级 房间隔缺损 室间隔缺损 动脉导管未闭 高乳酸组 43 4.73±0.32 9 34 3.97±0.46 18 25 5 31 7 正常乳酸组 85 4.87±0.29 23 62 4.09±0.38 20 65 8 72 5 χ2 — 2.49△ 0.57 1.57△ 4.60 4.00 P — < 0.05 > 0.05 > 0.05 < 0.05 > 0.05 △示t值 表 1 2组患儿一般资料比较(n)
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高乳酸组患儿体外循环时间、主动脉阻断时间、葡萄糖及乳酸水平均高于正常乳酸组(P < 0.05~P < 0.01),2组SaO2-SvO2水平、酮症发生率差异均无统计学意义(P>0.05)(见表 2)。
分组 n 体外循环时间/min 主动脉阻断时间/min 葡萄糖/ (mmol/L) 乳酸/ (mmol/L) SaO 2-SvO 2/% 酮症 高乳酸组 43 59.83±12.93 38.93±11.27 11.07±1.12 2.85±0.23 29.76±1.98 9(20.93%) 正常乳酸组 85 54.24±12.71 34.21±11.34 10.23±0.97 1.51±0.19 30.29±2.15 21(24.71%) t — 2.34 2.23 4.39 35.07 1.35 0.23△ P — < 0.05 < 0.05 < 0.01 < 0.01 > 0.05 > 0.05 △示χ 2值 表 2 2组患儿手术及实验室相关指标比较(x±s)
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多因素logistic回归分析显示,月龄较大是体外循环术后防止乳酸水平升高的保护因素(P < 0.05),体外循环时间、主动脉阻断时间较长及体内高葡萄糖水平是体外循环术后乳酸水平升高的独立危险因素(P < 0.05~P < 0.01)(见表 3)。
因素 B SE Waldχ2 P OR(95% CI) 月龄 -1.682 0.649 6.707 < 0.05 0.186(0.052~0.664) 体外循环时间 0.049 0.020 6.185 < 0.05 1.050(1.010~1.091) 主动脉阻断时间 0.067 0.024 7.908 < 0.01 1.069(1.020~1.120) 葡萄糖 0.848 0.224 14.400 < 0.01 2.335(1.507~3.619) SaO 2-SvO 2 -0.030 0.120 0.062 > 0.05 0.971(0.767~1.228) ASA分级 0.397 0.500 0.631 > 0.05 1.488(0.558~3.966) 表 3 影响患儿术后乳酸水平的多因素logistic回归分析
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Pearson相关分析显示,患儿体内乳酸水平与葡萄糖呈明显正相关关系(r=0.509,P < 0.01),与SaO2-SvO2水平无明显相关性(r=-0.047,P>0.05)。
低月龄、低体质量体外循环患儿乳酸水平与血糖及氧合指标的相关性
Analysis of correlation between lactate level and blood glucose, oxygenation indexes in low-month-old and low-weight children treated with cardiopulmonary bypass
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摘要:
目的分析因先天性心脏病行体外循环治疗的低月龄、低体质量患儿其体内乳酸水平与血糖及氧合指标的相关性。 方法选择在体外循环下行手术治疗的小儿先天性心脏病病人129例,根据术后6 h乳酸水平,将患儿分为高乳酸组(n=43)和正常乳酸组(n=85)。比较2组患儿手术相关指标及体内葡萄糖、乳酸和氧合指标水平。采用多因素logistic回归模型分析影响患儿术后体内乳酸水平的因素,应用Pearson相关模型对术后6 h患儿体内乳酸水平与葡萄糖及氧合指标的相关性进行分析。 结果高乳酸组患儿体外循环时间、主动脉阻断时间、葡萄糖及乳酸水平均高于正常乳酸组(P < 0.05~P < 0.01),2组动脉血氧饱和度(SaO2)与静脉血氧饱和度(SvO2)差值(SaO2-SvO2)水平、酮症发生率差异均无统计学意义(P>0.05)。多因素logistic回归分析显示,月龄较大是体外循环术后防止乳酸水平升高的保护因素(P < 0.05),体外循环时间、主动脉阻断时间较长及体内高葡萄糖水平是体外循环术后乳酸水平升高的独立危险因素(P < 0.05~P < 0.01)。Pearson相关分析显示,患儿体内乳酸水平与葡萄糖呈明显正相关关系(P < 0.01),与SaO2-SvO2水平无明显相关性(P>0.05)。 结论低体质量婴儿体外循环术后6 h的乳酸水平与葡萄糖水平有关,与氧摄入无关。 Abstract:ObjectiveTo analyze the correlation between lactate level and blood glucose, oxygenation index in low-month-old and low-weight congenital heart disease children treated with cardiopulmonary bypass. MethodsOne hundred and twenty-nine congenital heart disease children treated with cardiopulmonary bypass were divided into the high lactate group(n=43) and normal lactate group(n=85) according to the lactate level after 6 h of surgery.The operation-related indexes, and levels of glucose, and oxygenation indexes were compared between two groups.The multivariate logistic regression model was used to analyze the influencing factors of lactate level in children after operation.The Pearson correlation model was used to analyze the correlation between lactate level and glucose, oxygenation index in children after 6 hours of operation. ResultsThe extracorporeal circulation time, aortic occlusion time, glucose and lactate levels in high lactate group were higher than those in normal lactate group(P < 0.05 to P < 0.01).The differences of arterial oxygen saturation(SaO2) and venous oxygen saturation(SvO2) (SaO2-SvO2) levels and incidence rate of ketosis were not statistically significant between two groups(P>0.05).The results of multivariate logistic regression analysis showed that the older age was a protective factor to prevent the increasing of lactate level after cardiopulmonary bypass(P < 0.05), the extracorporeal circulation time, aortic occlusion time and high glucose level were the independent risk factors of the increasing of lactate level after cardiopulmonary bypass(P < 0.05 to P < 0.01).The results of Pearson correlation analysis showed that the lactate level was significantly positively correlated with glucose(P < 0.01), but had no significant correlation with(SaO2-SvO2) level(P>0.05). ConclusionsThe lactate level in low-month-old and low-weight children after 6 h of cardiopulmonary bypass is correlated with the glucose level, but not with oxygen intake. -
Key words:
- low-weight infant /
- cardiopulmonary bypass /
- lactate /
- glucose /
- oxygenation index
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表 1 2组患儿一般资料比较(n)
分组 n 年龄/月 男 女 体质量/kg ASA分级 先心病类型 Ⅱ~Ⅲ级 IV~V级 房间隔缺损 室间隔缺损 动脉导管未闭 高乳酸组 43 4.73±0.32 9 34 3.97±0.46 18 25 5 31 7 正常乳酸组 85 4.87±0.29 23 62 4.09±0.38 20 65 8 72 5 χ2 — 2.49△ 0.57 1.57△ 4.60 4.00 P — < 0.05 > 0.05 > 0.05 < 0.05 > 0.05 △示t值 表 2 2组患儿手术及实验室相关指标比较(x±s)
分组 n 体外循环时间/min 主动脉阻断时间/min 葡萄糖/ (mmol/L) 乳酸/ (mmol/L) SaO 2-SvO 2/% 酮症 高乳酸组 43 59.83±12.93 38.93±11.27 11.07±1.12 2.85±0.23 29.76±1.98 9(20.93%) 正常乳酸组 85 54.24±12.71 34.21±11.34 10.23±0.97 1.51±0.19 30.29±2.15 21(24.71%) t — 2.34 2.23 4.39 35.07 1.35 0.23△ P — < 0.05 < 0.05 < 0.01 < 0.01 > 0.05 > 0.05 △示χ 2值 表 3 影响患儿术后乳酸水平的多因素logistic回归分析
因素 B SE Waldχ2 P OR(95% CI) 月龄 -1.682 0.649 6.707 < 0.05 0.186(0.052~0.664) 体外循环时间 0.049 0.020 6.185 < 0.05 1.050(1.010~1.091) 主动脉阻断时间 0.067 0.024 7.908 < 0.01 1.069(1.020~1.120) 葡萄糖 0.848 0.224 14.400 < 0.01 2.335(1.507~3.619) SaO 2-SvO 2 -0.030 0.120 0.062 > 0.05 0.971(0.767~1.228) ASA分级 0.397 0.500 0.631 > 0.05 1.488(0.558~3.966) -
[1] FUJII Y. Evaluation of inflammation caused by cardiopulmonary bypass in a small animal model[J]. Biology(Basel), 2020, 9(4): 81. [2] DAVIDSON JA, KHAILOVA L, TREECE A, et al. Alkaline phosphatase treatment of acute kidney injury in an infant piglet model of cardiopulmonary bypass with deep hypothermic circulatory arrest[J]. Sci Rep, 2019, 9(1): 1. [3] MULLANE D, LENIHAN M, HANLEY C, et al. Efficacy of glyceryl trinitrate(GTN) to facilitate the rewarming process during cardiopulmonary bypass[J]. J Cardiothorac Surg, 2020, 15(1): 214. doi: 10.1186/s13019-020-01258-0 [4] LUKASZEWSKI M, LUKASZEWSKI R, KOSIOROWSKA K, et al. The use of data science to analyse physiology of oxygen delivery in the extracorporeal circulation[J]. BMC Cardiovasc Disord, 2019, 19(1): 292. doi: 10.1186/s12872-019-01301-6 [5] KLEE P, RIMENSBERGER PC, KARAM O. Association between lactates, blood glucose, and systemic oxygen delivery in children after cardiopulmonary bypass[J]. Front Pediatr, 2020, 8: 332. doi: 10.3389/fped.2020.00332 [6] PENDINO JC, HESS L, BELTRAME S, et al. Oxygen saturation and lactate concentration gradient from the right atrium to the pulmonary artery in the immediate postoperative following cardiac surgery with extracorporeal circulation[J]. Rev Bras Ter Intensiva, 2017, 29(3): 287. [7] DESPLANQUE L, HAMAIDE-DEFROCOURT F, BERKIA I, et al. Lactate clearance in infants undergoing surgery for congenital heart disease[J]. Artif Organs, 2019, 43(1): 54. doi: 10.1111/aor.13402 [8] 武婷, 史国宁, 陈彭, 等. 婴幼儿体外循环心脏术中不同胶体渗透压水平影响末梢循环及氧合功能的研究[J]. 中华胸心血管外科杂志, 2017, 33(2): 98. doi: 10.3760/cma.j.issn.1001-4497.2017.02.008 [9] 周智恩, 严善秀, 何伦德, 等. 血乳酸水平及清除率与体外循环术后患儿预后的关系[J]. 中国体外循环杂志, 2010, 8(3): 170. doi: 10.3969/j.issn.1672-1403.2010.03.012 [10] 章晓华, 熊卫萍, 庄建. 血浆乳酸水平与成人心脏手术预后关系[J]. 中国体外循环杂志, 2018, 16(6): 351. [11] MEJAK BL, ING RJ, MCROBB C, et al. Cryoprecipitate and platelet administration during modified ultrafiltration in children less than 10 kg undergoing cardiac surgery[J]. J Extra Corpor Technol, 2013, 45(2): 107. [12] WOLFSDORF JI, NICOLE G, MICHAEL A, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar state: a consensus statement from the international society for pediatric and adolescent diabetes[J]. Pediatr Diabetes, 2018, 19(27): 155. [13] SINGH SP, CHAUHAN S, BISOI AK, et al. Lactate clearance for initiating and weaning off extracorporeal membrane oxygenation in a child with regressed left ventricle after arterial switch operation[J]. Ann Card Anaesth, 2016, 19(1): 188. doi: 10.4103/0971-9784.173046 [14] BOJAN M, DESPLANQUE L, ALBINNI S. Increased lactate load of older red blood cell preparations increases blood lactate concentrations in infants during cardiac surgery[J]. Paediatr Anaesth, 2018, 28(2): 185. doi: 10.1111/pan.13310 [15] 刘梅, 肖颖彬, 陈林, 等. 7262例体外循环管理经验总结[J]. 中国胸心血管外科临床杂志, 2006, 13(1): 61. doi: 10.3969/j.issn.1007-4848.2006.01.020 [16] 曹辛, 陈健, 洪伟, 等. 监测动脉血乳酸对评估婴幼儿先天性心脏病手术预后的临床意义[J]. 云南医药, 2019, 40(5): 396. [17] 张小贞, 王树伟, 余鹏飞, 等. 成人心脏瓣膜术后高乳酸血症的体外循环相关因素[J]. 中国体外循环杂志, 2019, 17(6): 349. [18] LADHA S, KAPOOR P, SINGH S, et al. The role of blood lactate clearance as a predictor of mortality in children undergoing surgery for tetralogy of Fallot[J]. Ann Card Anaesth, 2016, 19(2): 217. doi: 10.4103/0971-9784.179589