International Center for Health Outcomes and Innovation Research (InCHOIR), Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
International Center for Health Outcomes and Innovation Research (InCHOIR), Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Diabetes Care. 2018 Mar;41(3):469-477. doi: 10.2337/dc17-1554. Epub 2017 Dec 20.
Hyperglycemia and hyperlactatemia are associated with increased morbidity and mortality in critical illness. We evaluated the relationship among hyperlactatemia, glycemic control, and diabetes mellitus (DM) after cardiac surgery.
This was a retrospective cohort study of 4,098 cardiac surgery patients treated between 2011 and 2015. Patients were stratified by DM and glucose-lowering medication history. Hyperglycemia (glucose >180 mg/dL), hypoglycemia (<70 mg/dL), and the hyperglycemic index were assessed postoperatively (48 h). The relationship between lactate and glucose levels was modeled using generalized linear regression. Mortality was analyzed using an extended Cox regression model.
Hyperglycemia occurred in 26.0% of patients without DM (NODM), 46.5% with DM without prior drug treatment (DMNT), 62.8% on oral medication (DMOM), and 73.8% on insulin therapy (DMIT) ( < 0.0001). Hypoglycemia occurred in 6.3%, 9.1%, 8.8%, and 10.8% of NODM, DMNT, DMOM, and DMIT, respectively ( = 0.0012). The lactate levels of all patients were temporarily increased with surgery. This increase was greater in patients who also had hyperglycemia or hypoglycemia and was markedly attenuated in patients with DM. Peak lactate was 5.8 mmol/L (95% CI 5.6, 6.0) in NODM with hyperglycemia vs. 3.3 (95% CI 3.2, 3.4) without hyperglycemia; in DMNT: 4.8 (95% CI 4.4, 5.2) vs. 3.4 (95% CI 3.1, 3.6); in DMOM: 3.8 (95% CI 3.5, 4.1) vs. 2.9 (95% CI 2.7, 3.1); and in DMIT: 3.3 (95% CI 3.0, 3.5) vs. 2.7 (95% CI 2.3, 3.0). Increasing lactate levels were associated with increasing mortality; increasing glucose reduced this effect in DM but not in NODM ( = 0.0069 for three-way interaction).
Stress hyperlactatemia is markedly attenuated in patients with DM. There is a three-way interaction among DM, stress hyperlactatemia, and stress hyperglycemia associated with mortality after cardiac surgery.
高血糖和高乳酸血症与危重病患者的发病率和死亡率增加有关。我们评估了心脏手术后高乳酸血症、血糖控制和糖尿病（DM）之间的关系。
这是一项回顾性队列研究，纳入了 2011 年至 2015 年间接受心脏手术的 4098 例患者。根据 DM 和降糖药物治疗史对患者进行分层。术后（48 小时）评估高血糖（血糖>180mg/dL）、低血糖（<70mg/dL）和高血糖指数。使用广义线性回归模型对乳酸和葡萄糖水平之间的关系进行建模。使用扩展 Cox 回归模型分析死亡率。
无 DM（NODM）患者中 26.0%发生高血糖，DM 无既往药物治疗（DMNT）患者中 46.5%，口服药物（DMOM）治疗患者中 62.8%，胰岛素治疗（DMIT）患者中 73.8%（<0.0001）。分别有 6.3%、9.1%、8.8%和 10.8%的 NODM、DMNT、DMOM 和 DMIT患者发生低血糖（=0.0012）。所有患者的乳酸水平在手术期间暂时升高。高血糖或低血糖患者的升高更为明显，DM 患者的升高明显减弱。NODM 高血糖患者的峰值乳酸为 5.8mmol/L（95%CI 5.6，6.0），无高血糖患者为 3.3mmol/L（95%CI 3.2，3.4）；DMNT：4.8mmol/L（95%CI 4.4，5.2），3.4mmol/L（95%CI 3.1，3.6）；DMOM：3.8mmol/L（95%CI 3.5，4.1），2.9mmol/L（95%CI 2.7，3.1）；DMIT：3.3mmol/L（95%CI 3.0，3.5），2.7mmol/L（95%CI 2.3，3.0）。乳酸水平升高与死亡率增加相关；在 DM 中，增加葡萄糖降低了这种影响，但在 NODM 中没有（DM 与应激性高血糖和应激性高乳酸血症之间的三向相互作用的=0.0069）。
DM 患者应激性高乳酸血症明显减弱。心脏手术后，DM、应激性高乳酸血症和应激性高血糖之间存在三向相互作用，与死亡率相关。
