王 静，高 燕，葛 凤

1.沈阳军区总医院内窥镜科，辽宁 沈阳 110016；2.沈阳军区总医院急诊科，辽宁 沈阳 110016

摘要：目的探求急性心力衰竭患者早期的全心舒张末期容积指数变化与血乳酸及乳酸清除率的相关性。方法回顾性分析2011年7月-2013年6月沈阳军区总医院急诊科收治的急性心力衰竭患者61例，根据患者是否存在肌钙蛋白(TnT>0.16 ng/ml)升高，分为正常组49例和对照组12例。记录患者入院初始及24 h内动脉血乳酸、全心舒张末期容积指数(global end diastolic volume index，GEDI)，8 h及24 h乳酸清除率[(初始乳酸8 h及24 h乳酸)/初始乳酸×100%]。结果入院时两组的乳酸值水平均正常，但二者差异无统计学意义；8 h后对照组的乳酸值出现升高，24 h后正常组的乳酸值显著低于对照组，差异有统计学意义(P<0.05)；治疗后两组的乳酸值均开始下降，乳酸清除率与GEDI变化量呈相关性，但正常组的血乳酸显著低于对照组，差异有统计学意义(P<0.05)。入院后随着治疗的进行，GEDI下降，乳酸明显下降。结论急性心力衰竭患者在早期与血乳酸存在良好的相关性；在脉搏指示持续心排血量监测(pulse induced contour cardiac output，PiCCO)的指导下监控患者的GEDI，使GEDI在正常范围内，可以明确降低血乳酸，提高乳酸清除率，改善预后。

关键词：急性心力衰竭；肌钙蛋白；全心舒张末期容积；乳酸；乳酸清除率；脉搏指示持续心排血量监测(PiCCO)

文章编号：2095-5561(2014)04-0219-04中图分类号：R 541.6+1文献标志码： A

Abstract：ObjectiveTo explore the relationship between global end diastolic volume index(GEDI) and arterial blood lactate of patients with acute heart failure.MethodsRetrospectively analysed 61 cases of acute heart failure patients admitted to Emergency Department of Shenyang Military Command from July 2011 to June 2013.Grouped patients into normal group(n=49) and control group(n=12) according to whether troponin was higher than normal or not.Recorded arterial blood lactic acid and GEDI within 24h from admission to hospotial,lactic acid clearance rate at 8th hour and 24th hour [(incipient lactic acid-lactic acid at 8th hour and 24 th hour)/incipient lactic acid×100%].ResultsThe lactic acid parameters of two groups were normal at the time of admission to hospotial,there was no statistical difference.After 8 hours，the lactic acid parameters of control group began to rise,at the time of 24 hours after admitted,the lactic acid parameters of normal group were obviously inferior to control group.There was statistical significance in the differences(P<0.05).After treating carefully,the blood lactic acid of both groups started dropping.Relativity showed in lactic acid clearance rate and GEDI after treating carefully.However,lactic acid in control group was clearly higher than normal group in each time spot after fluid resuscitation.The differences showed statistical significance(P<0.05).While treatment was given,GEDI declined,lactic acid also dropped.ConclusionThere is a good relationship between global end diastolic volume index and arterial blood lactate of patients with acute heart failure.Supervising GEDI under pulse induced contour cardiac output(PiCCO)′ s guidance to keep patients′ GEDI in a normal range can reduce lactic acid,improve lactate clearance rate,improve prognosis.

KeyWords：acute heart failure；troponin；global end diastolic volume；lactic acid；lactic acid clearance rate；PiCCO

急性心力衰竭(acute heart failure，AHF)病情来势凶猛，常以突发性呼吸困难为表现就诊于急诊科，是心血管疾病院内主要的死亡原因之一。据报道[1]，AHF院内病死率达12%，一年病死率达40%。急诊有效的救治是挽救患者生命、降低病死率的关键[2]。温度稀释法的脉搏指示持续心排血量监测(pulse induced contour cardiac output，PiCCO)技术获得全心舒张末期容积指数(global end diastolic volume index，GEDI)，是心脏容量负荷的灵敏指标[3-5]。AHF患者因为感染、心功能减低、冠状动脉硬化等多种原因诱发，不能保证组织器官的充分氧合和灌注，进而无氧酵解增加，乳酸堆积，动态监测血乳酸，即乳酸清除率可反映患者的病情和疗效。本研究中应用乳酸清除率来分析急性心衰患者的血流动力学，在适时降低前负荷的同时，又可以满足相对的组织灌注，结合乳酸清除率，评价预后。