高危心脏手术中，使用趋势互换法评价血管内微透析技术评估乳酸浓度的变化
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Assessment of changes in lactate concentration with intravascular microdialysis during high-risk cardiac surgery using thetrend interchangeability method
背景与目的
血乳酸水平是很强的死亡预测因子并且在高危患者手术中推荐反复进行血乳酸的检测。我们假定经中心静脉导管血管内微透析技术可代替血气分析技术监测血乳酸的变化。
方 法
同时记录高危心脏外科患者微透析和中心静脉测定的血乳酸水平。用线性回归法确定绝对值之间的相关性。使用重复测量试验的Bland-Alman 检验比较偏差、准确性和一致性限度。用四象限图和趋势互换性法(TIM)评估测定乳酸变化。
结 果
23例患者中，中心静脉导管作为标准护理的一部分，无并发症发生。绝对值相关系数为0.96(P<0.0001)，偏差、准确性和一致性限度分别为-0.19、0.51和-1.20-0.82 mmol/L。血乳酸变化的测定值(n=80)与四象限图的一致性率为94%。相比之下，TIM显示测量的23次(29)乳酸变化不可解释的，在其余57(71)次可解释性变化中，18(32)次可互换，8(14)次处于灰色地带，31(54)次不可互换。
结 论
经中心静脉导管微透析可提供可靠的血乳酸值，尽管血乳酸含量的变化显示出很好的一致性，这两种手段测定的乳酸的变化很难与TIM法互换。
原始文献摘要
C. Gouëzel, E. Lorne, V. Bonnet, et al. Assessment of changes in lactate concentration with intravascular microdialysis during high-risk cardiac surgery using the trend interchangeability method[J]. British Journal of Anaesthesia, 2017, 119(6):1110-1117.
Background：Blood lactate is a strong predictor of mortality, and repeated blood lactate assays are recommended during surgery in high-risk patients. We hypothesized that the use of intravascular microdialysis incorporated in a central venous catheter would be interchangeable with the reference blood gas technique to monitor changes in blood lactate.
Methods：Microdialysis and central venous blood lactate measurements were recorded simultaneously in high-risk cardiac surgical patients. The correlation between absolute values was determined by linear regression, and the Bland–Altman test for repeated measurements was used to compare bias, precision, and limits of agreement. Changes in lactate measurements were evaluated with a four-quadrant plot and trend interchangeability method (TIM).
Results： In the 23 patients analysed, the central venous catheter was used as part of standard care, with no complications. The correlation coefficient for absolute values (n=104) was 0.96 (P<0.0001). The bias, precision, and limits of agreement were −0.19, 0.51, and −1.20 to 0.82 mmol litre−1, respectively. The concordance rate for changes in blood lactate measurements (n=80) was 94% with the four-quadrant plot. In contrast, the TIM showed that 23 (29) changes in lactate measurements were not interpretable, and among the remaining 57 (71) interpretable changes, 18 (32) were interchangeable, 8 (14) were in the grey zone, and 31 (54) were not interchangeable.
Conclusions： Microdialysis with a central venous catheter appears to provide reliable absolute blood lactate values. Although changes in blood lactate measurements showed an excellent concordance rate, changes between the two methods were poorly interchangeable with the TIM.
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