摘要目的 探讨血乳酸清除率(LCR)与急性一氧化碳中毒迟发性脑病(DEACMP)患者预后的关系.方法 回顾性分析354例急性重度一氧化碳中毒(ASCOP)患者的临床资料,根据患者入院时初始血乳酸水平分为高乳酸血症组(动脉血乳酸＞2 mmol/L,263例)和低乳酸血症组(动脉血乳酸≤2mmol/L,91例);所有入选者分别于治疗前及治疗6、24、72 h在不吸氧条件下取1 mL动脉血,检测动脉血乳酸,同时计算LCR.比较两组患者的初始血乳酸水平及6、24、72 h LCR.同时高乳酸血症组以6 h LCR分为高LCR组(LCR＞10％,101例)和低LCR组(LCR≤10％,162例),比较两组患者DEACMP发生率.用Spearman线性相关分析对血LCR水平与DEACMP发生率进行相关分析.采用多个自变量的逐步logistic回归分析观察DEACMP的危险因素.结果 高乳酸血症组初始血乳酸水平(mmol/L:2.73±0.57比1.69±0.20,t=5.327,P=0.001)及6、24、72 h LCR[6 h:(9.0±2.4)％比(1.2±0.6)％,t=9.468,P=0.001;24 h:(8.6±3.7)％比(1.2±0.4)％,t=4.889,P=0.001;72 h:(14.0±3.9)％比(1.7±1.0)％,t=5.211,P=0.001]明显高于低乳酸血症组.高LCR组初始血乳酸水平明显低于低LCR组(mmol/L:2.41±0.23比2.92±0.63,t=2.429,P=0.023),6h及24 h LCR则明显高于低LCR组[6 h:(11.0±1.2)％比(8.0±2.1)％,t=4.487,P=0.001;24 h:(12.2±3.0)％比(6.3±1.8)％,t=6.264,P=0.001],72 h LCR则与低LCR组无明显差异[(14.1±3.6)％比(13.9±4.1)％,t=0.182,P=0.857].高LCR组DEACMP发生率明显低于低LCR组[15.8％(16/101)比61.1％(99/162),x2=51.814,P=0.001].ASCOP高乳酸血症患者治疗6、24、72 h LCR水平与DEACMP发生率均呈负相关(r1=-0.493,P1=0.011;r2=-0.408,P2=0.038;r3=-0.428,P3=0.029).Logistic回归分析显示,6h和24 h LCR降低[优势比(OR)分别为2.701、1.070,P值分别为0.035、0.001]、昏迷时间长(OR=1.537,P=0.068)、接触CO时间长(OR=2.686,P=0.014)、年龄大(OR=1.464,P=0.017)、急性一氧化碳中毒并发症多(OR=1.363,P=0.072)的ASCOP患者出现DEACMP的危险性增加.结论 LCR有助于DEACMP患者严重程度的评估、指导治疗和判断预后.

abstractsObjective To study the relationship between lactate clearance rate(LCR)and prognosis after acute carbon monoxide poisoning in patients with delayed encephalopathy(DEACMP).Methods Data from 354 patients with acute severe carbon monoxide poisoning(ASCOP)were retrospectively analyzed.The patients were divided into hyperlactacidemia group(arterial lactic acid ＞ 2 mmol/L,n=263)and low lactic acidosis group(arterial lactate ≤2 mmol/L,n=91)according to the blood lactic acid level at admission.Arterial blood(1 mL)was collected from all patients before and 6,24,72 hours after treatment at ambient air,and arterial blood lactic acid was determined,and LCR was calculated.The initial level of blood lactic acid and LCR at 6,24,72 hours were compared between two groups.At the same time,the patients with hyperlactacidemia were divided into high LCR group(LCR more than 10％,n=101)and low LCR group(LCR less than or equal to 10％,n=162)according to 6-hour LCR,and the incidence of DEACMP was compared between two groups.The relationship between LCR and the incidence of DEACMP was analyzed with Spearman linear correlation analysis.The risk factors associated with DEACMP were analyzed with logistic regression analysis.Results The initial level of blood lactic acid(mmol/L:2.73±0.57 vs.1.69±0.20,t=5.327,P=0.001)and LCR at 6,24,72 hours[6 hours:(9.0±2.4)％ vs.(1.2±0.6)％,t=9.468,P=0.001;24 hours:(8.6±3.7)％ vs.(1.2±0.4)％,t=4.889,P=0.001;72hours:(14.0±3.9)％vs.(1.7±1.0)％,t=5.211,P=0.001]in hyperlactacidemia group were significantly higher than those in low lactic acidosis group.The initial level of blood lactic acid in high LCR group was significantly lower than that in low LCR group(mmol/L:2.41±0.23 vs.2.92±0.63,t=2.429,P=0.023),and LCR at 6 hours and 24 hours were significantly higher than those in low LCR group [6 hours:(11.0±1.2)％vs.(8.0±2.1)％,t=4.487,P=0.001;24hours:(12.2±3.0)％vs.(6.3±1.8)％,t=6.264,P=0.001].But there was no difference in 72-hour LCR between high LCR group and low LCR group[(14.1±3.6)％ vs.(13.9±4.1)％,t=0.182,P=0.857].The incidence of DEACMP in high LCR group was significantly lower than that in low LCR group[15.8％(16/101)vs.61.1％(99/162),x2=51.814,P=0.001].The blood LCR at early period(6,24,72 hours)in ASCOP patients with hyperlactacidemia was negatively correlated with the incidence of DEACMP(r1=-0.493,P1=0.011;r2=-0.408,P2=0.038;r3=-0.428,P3=0.029).Logistic regression analysis showed that LRC at 6 hours and 24 hours[odds ratio(OR)was 2.701,1.070,Pvalue was 0.035,0.001],long-time coma(OR=1.537,P=0.068),contact carbon monoxide(CO)long time(OR=2.686,P=0.014),age(OR=1.464,P=0.017),acute carbon monoxide complications(OR=1.363,P=0.072)patients with ASCOP had an increased risk of DEACMP.Conclusion LCR is helpful for the assess of DEACMP patients severity,for the treatment guide and for prognosis judgement.