Lopez-Delgado Juan C, Esteve Francisco, Javierre Casimiro, Torrado Herminia, Rodriguez-Castro David, Carrio Maria L, Farrero Elisabet, Skaltsa Konstantina, Mañez Rafael, Ventura Josep L
Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain.
Intensive Care Department, Bellvitge University Hospital, IDIBELL (Institut d'Investigació Biomèdica Bellvitge), Barcelona, Spain.
J Cardiothorac Vasc Anesth. 2015 Dec;29(6):1441-53. doi: 10.1053/j.jvca.2015.04.024. Epub 2015 Apr 29.
Although hyperlactatemia is common after cardiac surgery, its value as a prognostic marker is unclear. The aim of the present study was to determine whether postoperative serial arterial lactate (AL) measurements after cardiac surgery could predict outcome.
Prospective, observational study.
Surgical intensive care unit in a tertiary-level university hospital.
Participants included 2,935 consecutive patients.
AL was measured on admission to the intensive care unit and 6, 12, and 24 hours after surgery, and evaluated together with clinical data and outcomes including in-hospital and long-term mortality.
In-hospital and long-term mortality (mean follow-up 6.3±1.7 years) were 5.9% and 8.7%, respectively. Compared with survivors, nonsurvivors showed higher mean AL values in all measurements (p<0.001). Hyperlactatemia (AL>3.0 mmol/L) was a predictor for in-hospital mortality (odds ratio = 1.468; 95% confidence interval = 1.239-1.739; p<0.001) and long-term mortality (hazard ratio = 1.511; 95% confidence interval = 1.251-1.825; p<0.001). Recent myocardial infarction and longer cardiopulmonary bypass time were predictors of hyperlactatemia. The pattern of AL dynamics was similar in both groups, but nonsurvivors showed higher AL values, as confirmed by repeated measures analysis of variance (p<0.001). The area under the curve also showed higher levels of AL in nonsurvivors (80.9±68.2 v 49.71±25.8 mmol/L/h; p = 0.038). Patients with hyperlactatemia were divided according to their timing of peak AL, with higher mortality and worse survival in patients in whom AL peaked at 24 hours compared with other groups (79.1% v 86.7%-89.2%; p = 0.03).
The dynamics of the postoperative AL curve in patients undergoing cardiac surgery suggests a similar mechanism of hyperlactatemia in survivors and nonsurvivors, albeit with a higher production or lower clearance of AL in nonsurvivors. The presence of a peak of hyperlactatemia at 24 hours is associated with higher in-hospital and long-term mortality.
尽管心脏手术后高乳酸血症很常见，但其作为预后标志物的价值尚不清楚。本研究的目的是确定心脏手术后连续的动脉血乳酸（AL）测量是否可以预测预后。
前瞻性观察性研究。
一所三级大学医院的外科重症监护病房。
参与者包括2935例连续患者。
在重症监护病房入院时以及术后6、12和24小时测量AL，并与临床数据和包括院内及长期死亡率在内的预后进行评估。
院内死亡率和长期死亡率（平均随访6.3±1.7年）分别为5.9%和8.7%。与幸存者相比，非幸存者在所有测量中的平均AL值更高（p<0.001）。高乳酸血症（AL>3.0 mmol/L）是院内死亡率（比值比=1.468；95%置信区间=1.239-1.739；p<0.001）和长期死亡率（风险比=1.511；95%置信区间=1.251-1.825；p<0.001）的预测因素。近期心肌梗死和较长的体外循环时间是高乳酸血症的预测因素。两组的AL动态模式相似，但通过重复测量方差分析证实，非幸存者的AL值更高（p<0.001）。曲线下面积也显示非幸存者的AL水平更高（80.9±68.2对49.71±25.8 mmol/L/h；p = 0.038）。高乳酸血症患者根据其AL峰值出现的时间进行分组，与其他组相比，AL在24小时达到峰值的患者死亡率更高，生存率更差（79.1%对86.7%-89.2%；p = 0.）。
心脏手术患者术后AL曲线的动态变化表明，幸存者和非幸存者的高乳酸血症机制相似，尽管非幸存者的AL产生更高或清除更低。24小时出现高乳酸血症峰值与更高的院内及长期死亡率相关。
