目的 探讨引起胃肠道手术患者术后动脉血乳酸(Lac)升高的危险因素.方法 回顾性分析宁夏医科大学总医院2013年11月至2014年11月实施胃肠道手术后转入重症加强治疗病房(ICU)的216例患者的临床资料,依据术后初始Lac水平分为Lac升高组(Lac ＞2 mmol/L,100例)和Lac正常组(Lac≤2 mmol/L,1 16例).记录两组患者的相关资料:①基线资料:性别、年龄、术前急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、基础疾病、术后初始Lac;②术前危险因素:24h补液总量、24 h补胶体量;③术中危险因素:是否行急诊手术、手术时间、手术部位、抗菌药物使用、平均动脉压最高值、最低值及其差值(MAPmax、MAPmin、△MAP)、补液总量、补胶体量.采用多元线性回归分析筛选出影响胃肠道手术患者术后Lac水平的危险因素.结果 ①两组患者性别、年龄、术前APACHEⅡ评分以及基础疾病等基线资料比较差异均无统计学意义(均P＞0.05);Lac升高组初始Lac水平明显高于Lac正常组(mmol/L:5.1±3.6比1.3±0.4,t=10.584,P=0.000).②两组患者术前24 h补液总量、补胶体量和术中MAPmax均无明显差异.与Lac正常组比较,Lac升高组术中△MAP[mmHg(1 mmHg=0.133 kPa):35.8±14.4比28.7±13.7,t=3.727,P=0.000]、急诊手术比例(19.0％比9.5％,x 2=9.869,P=0.007)、术中补液总量[mL:4 500(3 500,5 800)比3 700(2 812,5 075),Z=-3.244,P=0.001]、术中补胶体量[mL:1 000(1 000,1 900)比1 000(1 000,1 787),Z=-2.347,P=0.019]均明显升高,手术时间明显延长(min:222.0±91.5比187.0±75.9,t=3.026,P=0.003);而术中MAPmin(mmHg:68.7±11.6比75.9±10.6,t=-4.716, P=0.000)和抗菌药物使用率(62.0％比86.2％,x2=18.318,P=0.000)均明显降低.③食管、胃、十二指肠及小肠、大肠手术患者分别占6.9％、22.7％、16.7％、53.7％,术后Lac分别为2.8(1.6,5.4)、2.3(1.2,5.8)、2.5(1.5,5.2)、1.7 (1.1,2.9) mmol/L,说明手术部位影响术后高乳酸血症的发生(x2=11.032,P=0.012),其中大肠手术后不易发生高乳酸血症(均P＜ 0.05).④多元线性回归分析显示:手术部位(t=-2.725,P=0.007)、术中MAPmin(t=-4.533,P=0.000)、术中未使用抗菌药物(t=2.441,P=0.016)是胃肠道术后患者Lac升高的危险因素.⑤术中使用抗菌药物组术后初始降钙素原(PCT)升高(PCT＞0.5 μg/L)的发生率明显低于术中未使用抗菌药物组[17.89％ (17/95)比67.74％(21/31),x 2=27.572,P=0.000].结论 手术部位影响胃肠道手术患者术后高乳酸血症的发生,其中大肠手术后发生高乳酸血症的可能性最低;胃肠道手术患者术中应常规应用抗菌药物并提高MAP水平;术前及术中过多补液无法减少术后高乳酸血症的发生.
目的 探討引起胃腸道手術患者術後動脈血乳痠(Lac)升高的危險因素.方法 迴顧性分析寧夏醫科大學總醫院2013年11月至2014年11月實施胃腸道手術後轉入重癥加彊治療病房(ICU)的216例患者的臨床資料,依據術後初始Lac水平分為Lac升高組(Lac ＞2 mmol/L,100例)和Lac正常組(Lac≤2 mmol/L,1 16例).記錄兩組患者的相關資料:①基線資料:性彆、年齡、術前急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分、基礎疾病、術後初始Lac;②術前危險因素:24h補液總量、24 h補膠體量;③術中危險因素:是否行急診手術、手術時間、手術部位、抗菌藥物使用、平均動脈壓最高值、最低值及其差值(MAPmax、MAPmin、△MAP)、補液總量、補膠體量.採用多元線性迴歸分析篩選齣影響胃腸道手術患者術後Lac水平的危險因素.結果 ①兩組患者性彆、年齡、術前APACHEⅡ評分以及基礎疾病等基線資料比較差異均無統計學意義(均P＞0.05);Lac升高組初始Lac水平明顯高于Lac正常組(mmol/L:5.1±3.6比1.3±0.4,t=10.584,P=0.000).②兩組患者術前24 h補液總量、補膠體量和術中MAPmax均無明顯差異.與Lac正常組比較,Lac升高組術中△MAP[mmHg(1 mmHg=0.133 kPa):35.8±14.4比28.7±13.7,t=3.727,P=0.000]、急診手術比例(19.0％比9.5％,x 2=9.869,P=0.007)、術中補液總量[mL:4 500(3 500,5 800)比3 700(2 812,5 075),Z=-3.244,P=0.001]、術中補膠體量[mL:1 000(1 000,1 900)比1 000(1 000,1 787),Z=-2.347,P=0.019]均明顯升高,手術時間明顯延長(min:222.0±91.5比187.0±75.9,t=3.026,P=0.003);而術中MAPmin(mmHg:68.7±11.6比75.9±10.6,t=-4.716, P=0.000)和抗菌藥物使用率(62.0％比86.2％,x2=18.318,P=0.000)均明顯降低.③食管、胃、十二指腸及小腸、大腸手術患者分彆佔6.9％、22.7％、16.7％、53.7％,術後Lac分彆為2.8(1.6,5.4)、2.3(1.2,5.8)、2.5(1.5,5.2)、1.7 (1.1,2.9) mmol/L,說明手術部位影響術後高乳痠血癥的髮生(x2=11.032,P=0.012),其中大腸手術後不易髮生高乳痠血癥(均P＜ 0.05).④多元線性迴歸分析顯示:手術部位(t=-2.725,P=0.007)、術中MAPmin(t=-4.533,P=0.000)、術中未使用抗菌藥物(t=2.441,P=0.016)是胃腸道術後患者Lac升高的危險因素.⑤術中使用抗菌藥物組術後初始降鈣素原(PCT)升高(PCT＞0.5 μg/L)的髮生率明顯低于術中未使用抗菌藥物組[17.89％ (17/95)比67.74％(21/31),x 2=27.572,P=0.000].結論 手術部位影響胃腸道手術患者術後高乳痠血癥的髮生,其中大腸手術後髮生高乳痠血癥的可能性最低;胃腸道手術患者術中應常規應用抗菌藥物併提高MAP水平;術前及術中過多補液無法減少術後高乳痠血癥的髮生.
목적 탐토인기위장도수술환자술후동맥혈유산(Lac)승고적위험인소.방법 회고성분석저하의과대학총의원2013년11월지2014년11월실시위장도수술후전입중증가강치료병방(ICU)적216례환자적림상자료,의거술후초시Lac수평분위Lac승고조(Lac ＞2 mmol/L,100례)화Lac정상조(Lac≤2 mmol/L,1 16례).기록량조환자적상관자료:①기선자료:성별、년령、술전급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분、기출질병、술후초시Lac;②술전위험인소:24h보액총량、24 h보효체량;③술중위험인소:시부행급진수술、수술시간、수술부위、항균약물사용、평균동맥압최고치、최저치급기차치(MAPmax、MAPmin、△MAP)、보액총량、보효체량.채용다원선성회귀분석사선출영향위장도수술환자술후Lac수평적위험인소.결과 ①량조환자성별、년령、술전APACHEⅡ평분이급기출질병등기선자료비교차이균무통계학의의(균P＞0.05);Lac승고조초시Lac수평명현고우Lac정상조(mmol/L:5.1±3.6비1.3±0.4,t=10.584,P=0.000).②량조환자술전24 h보액총량、보효체량화술중MAPmax균무명현차이.여Lac정상조비교,Lac승고조술중△MAP[mmHg(1 mmHg=0.133 kPa):35.8±14.4비28.7±13.7,t=3.727,P=0.000]、급진수술비례(19.0％비9.5％,x 2=9.869,P=0.007)、술중보액총량[mL:4 500(3 500,5 800)비3 700(2 812,5 075),Z=-3.244,P=0.001]、술중보효체량[mL:1 000(1 000,1 900)비1 000(1 000,1 787),Z=-2.347,P=0.019]균명현승고,수술시간명현연장(min:222.0±91.5비187.0±75.9,t=3.026,P=0.003);이술중MAPmin(mmHg:68.7±11.6비75.9±10.6,t=-4.716, P=0.000)화항균약물사용솔(62.0％비86.2％,x2=18.318,P=0.000)균명현강저.③식관、위、십이지장급소장、대장수술환자분별점6.9％、22.7％、16.7％、53.7％,술후Lac분별위2.8(1.6,5.4)、2.3(1.2,5.8)、2.5(1.5,5.2)、1.7 (1.1,2.9) mmol/L,설명수술부위영향술후고유산혈증적발생(x2=11.032,P=0.012),기중대장수술후불역발생고유산혈증(균P＜ 0.05).④다원선성회귀분석현시:수술부위(t=-2.725,P=0.007)、술중MAPmin(t=-4.533,P=0.000)、술중미사용항균약물(t=2.441,P=0.016)시위장도술후환자Lac승고적위험인소.⑤술중사용항균약물조술후초시강개소원(PCT)승고(PCT＞0.5 μg/L)적발생솔명현저우술중미사용항균약물조[17.89％ (17/95)비67.74％(21/31),x 2=27.572,P=0.000].결론 수술부위영향위장도수술환자술후고유산혈증적발생,기중대장수술후발생고유산혈증적가능성최저;위장도수술환자술중응상규응용항균약물병제고MAP수평;술전급술중과다보액무법감소술후고유산혈증적발생.
Objective To investigate the risk factors that cause arterial blood lactate (Lac) elevation in patients after gastrointestinal operation.Methods The data of 216 patients who had undergone gastrointestinal operation, and transferred to intensive care unit (ICU) of Ningxia Medical University General Hospital from November 2013 to November 2014 were retrospectively analyzed.According to the initial level of blood Lac after operation,the patients were divided into two groups: high Lac group (Lac ＞ 2 mmol/L, n =100) and normal Lac group (Lac ≤ 2 mmol/L, n =116).The baseline data of two groups were recorded as follows: ① baseline data: gender, age, preoperative acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, previous diseases, initial Lac level after operation;② preoperative risk factors: 24-hour total amount of fluid, and the amount of colloid for resuscitation;③ intraoperative risk factors: the proportion of emergency operation, operation time, site of operation, usage of antibacterial drug, the highest and lowest mean arterial pressure and its difference (MAPmax, MAPmin, A MAP),total amount of fluid and colloid for resuscitation.The risk factors of increasing Lac post gastrointestinal operation was evaluated using multiple linear regression analysis.Results ① There were no significant differences in baseline data such as gender, age, preoperative APACHE Ⅱ score and previous diseases between the two groups (all P ＞ 0.05).Initial Lac level in high Lac group was significantly higher than that of normal Lac group (mmol/L: 5.1 ± 3.6 vs.1.3 ±0.4,t =10.584,/P =0.000).② There were no significant differences in 24-hour amount of fluid and colloid for resuscitation before operation, and intraoperative MAPmax between two groups.Compared with normal Lac group, intraoperative A MAP [mmHg (1 mmHg =0.133 kPa): 35.8 ± 14.4 vs.28.7 ± 13.7, t =3.727, P =0.000], the proportion of emergency operations (19.0％ vs.9.5％, x 2 =9.869, P =0.007), intraoperative transfusion volume [mL: 4 500 (3 500, 5 800) vs.3 700 (2 812, 5 075), Z =-3.244, P =0.001], intraoperative colloid volume [mL: 1 000 (1 000, 1 900) vs.1 000 (1 000, 1 787), Z =-2.347, P =0.019], and operation time (minutes: 222.0±91.5 vs.187.0±75.9, t =3.026,P =0.003) in high Lac group were significantly increased, and the levels of intraoperative MAPmin (mmHg: 68.7 ± 11.6 vs.75.9± 10.6, t =-4.716, P =0.000) and intraoperative antibiotics usage (62.0％ vs.86.2％, x 2 =18.318, P =0.000)were significantly decreased.③The patients undergoing operation of esophagus, stomach, duodenal and intestine,and colon accounted for 6.9％, 22.7％, 16.7％, and 53.7％, respectively, their Lac was 2.8 (1.6, 5.4), 2.3 (1.2, 5.8),2.5 (1.5, 5.2), 1.7 (1.1, 2.9) mmol/L, respectively, indicating that surgical site had an influence on the occurrence of postoperative hyperlactacidemia (x 2 =11.032, P =0.012).④ It was showed by multiple linear regression analysis that the operation site (t =-2.725, P =0.007), MAPmin (t =-4.533, P =0.000), non-antibiotics usage during operation (t =2.441, P =0.016) were the risk factors of Lac increase in patients after gastrointestinal operation.⑤ The incidence of postoperative incipient procalcitonin (PCT) increase (PCT ＞ 0.5 μg/L) in patients and usage of antibiotics was significantly lower than that in patients who did not receive antibiotics during operation [17.89％ (17/95) vs.67.74％ (21/31), x 2 =27.572, P =0.000].Conclusions The surgical site showed an influence on the occurrence of hyperlactacidemia in patients after gastrointestinal operation, and the lowest occurrence rate was found in the colonic operation.In patients suffering from gastrointestinal operation, antibiotics should be routinely used to improve MAP.Excessive preoperative and intraoperative fluid infusion cannot reduce the occurrence of hyperlactacidemia.
