OBJECTIVE 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.

RESEARCH DESIGN AND METHODS 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.

RESULTS 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) (P < 0.0001). Hypoglycemia occurred in 6.3%, 9.1%, 8.8%, and 10.8% of NODM, DMNT, DMOM, and DMIT, respectively (P = 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 (P = 0.0069 for three-way interaction).

CONCLUSIONS 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.

目的高血糖和高乳酸血症与危重疾病的发病率和死亡率增加相关。我们评估了心脏手术后高脂血症，血糖控制和糖尿病（DM）之间的关系。

研究设计与方法这是一项回顾性队列研究，研究对象为2011年至2015年期间接受治疗的4,098例心脏外科手术患者。根据DM和降糖药物史对患者进行分层。术后（48 h）评估高血糖（葡萄糖> 180 mg / dL），低血糖（<70 mg / dL）和高血糖指数。乳酸和葡萄糖水平之间的关系使用广义线性回归建模。使用扩展的Cox回归模型分析死亡率。

结果高血糖发生在26.0％的无DM（NODM）的患者中，有46.5％的未经DMNT的药物治疗，口服药物（DMOM）的62.8％和胰岛素治疗（DMIT）的73.8％（P <0.0001）。低血糖分别发生在NODM，DMNT，DMOM和DMIT的6.3％，9.1％，8.8％和10.8％（P= 0.0012）。所有患者的乳酸水平随手术时间暂时升高。在患有高血糖症或低血糖症的患者中，这种增加更大，而在DM患者中则明显减弱。患有高血糖症的NODM的乳酸峰值峰值为5.8 mmol / L（95％CI 5.6，6.0），而没有高血糖症的乳酸峰值为3.3（95％CI 3.2，3.4）；在DMNT中：4.8（95％CI 4.4、5.2）与3.4（95％CI 3.1、3.6）；在DMOM中：3.8（95％CI 3.5，4.1）与2.9（95％CI 2.7，3.1）；在DMIT中：3.3（95％CI 3.0，3.5）与2.7（95％CI 2.3，3.0）。乳酸水平的增加与死亡率的增加有关。增加葡萄糖会降低DM中的这种作用，但不会降低NODM中的作用（三效相互作用P = 0.0069）。

结论DM患者的应激性高脂血症明显减弱。DM，应激性高脂血症和应激性高血糖症之间存在三方面的相互作用，与心脏手术后的死亡率相关。