腰椎后路融合内固定术围手术期输注悬浮红细胞的危险因素分析
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摘要
目的探讨行腰椎后路融合内固定术病人围手术期输注悬浮红细胞的危险因素。方法回顾性分析2016年1月至2018年6月在广州市番禺区中医院骨伤科施行腰椎后路融合手术的468例病人的临床资料,选取性别、年龄、身体质量指数(body mass index,BMI)、吸烟史、饮酒史、糖尿病、高血压、肺部疾病、心脏疾病、肾脏疾病、骨质疏松症、低蛋白血症、美国麻醉师协会(American Society of Anesthe-siologists,ASA)评分、术前血红蛋白(hemoglobin,Hb)、抗凝药物使用史、手术时间、融合节段、椎管减压方式等可能影响围手术期输血的危险因素,先后应用单因素分析和多元Logistic回归分析围手术期输血的独立危险因素。结果 468例病人中有61例(13%)发生输注红细胞事件。单因素分析显示年龄、性别、BMI、术前Hb水平、术前合并心脏疾病、低蛋白血症、骨质疏松症、术前使用抗凝药、ASA评分、融合节段、手术时间、术中出血量、术后引流量及术后并发症是输血事件发生的危险因素。多元Logistic回归分析结果提示,年龄≥66岁(OR=2.3,95%CI为1.2～4.7)、术前Hb≤125 g/L(OR=2.6,95%CI为1.3～5.1)、融合节段≥3个(OR=3.0,95%CI为1.4～6.3)、手术时间≥215 min(OR=4.0,95%CI为2.1～7.6)是增加围手术期输血事件发生的独立危险因素。结论高龄、术前Hb偏低、多节段融合、手术时间过长的病人行腰椎后路融合内固定术围手术期输血风险较高,故在术前准备中应考虑上述预期输血的因素。
Objective To explore the risk factors of the perioperative infusion of red blood cells(RBC) in patients undergoing posterior lumbar fusion and internal fixation(PLIF/TLIF).Methods The clinical data of 468 patients undergoing PLIF/TLIF surgery between January 2016 and 30 June 2018 in Panyu Hospital of Chinese Medicine were reviewed. The characteristics of patients, perioperative factors(ASA score, major medical comorbidities including diabetes, hypertension, pulmonary disease, heart disease, renal insufficiency,osteoporosis, hypoproteinemia, chronic use of anticoagulant/antiplatelet drugs, preoperative hemoglobin(Hb),estimated blood loss in operation, blood transfusion, operative time, the methods of decompression, number of levels fused, blood transfusion, postoperative drainage volume and complications) were collected. Univariate analysis and multivariate logistic analysis were used to identify the factors which played the most important roles in blood transfusion.Results Out of 468 cases, 61 cases(13%) had a blood transfusion. The results of univariate analysis showed that female gender, older age, BMI, higher ASA grade, presence of diabetes, heart disease and osteoporosis, use of anticoagulant/platelet drugs prior to the surgery, longer operative time, and lower pre-surgery Hb and albumin levels were associated with the need for RBC transfusion. Multivariate logistic analysis revealed that the occurrence of blood transfusion was significantly influenced by age ≥66 years old(OR=2.3,95%CI:1.2-4.7), preoperative Hb≤125 g/L(OR=2.6,95%CI:1.3-5.1), multi-level fusion(OR=3.0,95%CI:1.4-6.3), extended operative time(OR=4.0,95%CI:2.1-7.6).Conclusion Older age, low preoperative Hb, multi-level fusion, and longer operative time are independent factors, which may increased the rate of blood transfusion. Factors anticipating transfusion should be taken into consideration in the patient's preoperative preparation.
Objective To explore the risk factors of the perioperative infusion of red blood cells(RBC) in patients undergoing posterior lumbar fusion and internal fixation(PLIF/TLIF).Methods The clinical data of 468 patients undergoing PLIF/TLIF surgery between January 2016 and 30 June 2018 in Panyu Hospital of Chinese Medicine were reviewed. The characteristics of patients, perioperative factors(ASA score, major medical comorbidities including diabetes, hypertension, pulmonary disease, heart disease, renal insufficiency,osteoporosis, hypoproteinemia, chronic use of anticoagulant/antiplatelet drugs, preoperative hemoglobin(Hb),estimated blood loss in operation, blood transfusion, operative time, the methods of decompression, number of levels fused, blood transfusion, postoperative drainage volume and complications) were collected. Univariate analysis and multivariate logistic analysis were used to identify the factors which played the most important roles in blood transfusion.Results Out of 468 cases, 61 cases(13%) had a blood transfusion. The results of univariate analysis showed that female gender, older age, BMI, higher ASA grade, presence of diabetes, heart disease and osteoporosis, use of anticoagulant/platelet drugs prior to the surgery, longer operative time, and lower pre-surgery Hb and albumin levels were associated with the need for RBC transfusion. Multivariate logistic analysis revealed that the occurrence of blood transfusion was significantly influenced by age ≥66 years old(OR=2.3,95%CI:1.2-4.7), preoperative Hb≤125 g/L(OR=2.6,95%CI:1.3-5.1), multi-level fusion(OR=3.0,95%CI:1.4-6.3), extended operative time(OR=4.0,95%CI:2.1-7.6).Conclusion Older age, low preoperative Hb, multi-level fusion, and longer operative time are independent factors, which may increased the rate of blood transfusion. Factors anticipating transfusion should be taken into consideration in the patient's preoperative preparation.
引文
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[16]Goz V,Weinreb JH,Schwab F,et al.Comparison of complications,costs,and length of stay of three different lumbar interbody fusion techniques:an analysis of the nationwide inpatient sample database[J].Spine J,2014,14(9):2019-2027.
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[18]Parker SL,Mendenhall SK,Shau DN,et al.Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis:comparative effectiveness and cost-utility analysis[J].World Neurosurg,2014,82(1-2):230-238.
[19]Li JX,Phan K,Mobbs R.Oblique lumbar interbody fusion:technical aspects,operative outcomes,and complications[J].World Neurosurg,2017,98:113-123.
[20]Bowen RE,Gardner S,Scaduto AA,et al.Efficacy of intraoperative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation[J].Spine(Phila Pa 1976),2010,35(2):246-251.
[21]Stone N,Sardana V,Missiuna P.Indications and outcomes of cell saver in adolescent scoliosis correction surgery:a systematic review[J].Spine(Phila Pa 1976),2017,42(6):E363-E370.
[22]Auerbach AD,Vittinghoff E,Maselli J,et al.Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery[J].JAMA Intern Med,2013,173(12):1075-1081.
[23]Kushioka J,Yamashita T,Okuda S,et al.High-dose tranexamic acid reduces intraoperative and postoperative blood loss in posterior lumbar interbody fusion[J].J Neurosurg Spine,2017,26(3):363-367.
[24]Kim KT,Kim CK,Kim YC,et al.The effectiveness of low-dose and high-dose tranexamic acid in posterior lumbar interbody fusion:a double-blinded,placebo-controlled randomized study[J].Eur Spine J,2017,26(11):2851-2857.
[25]廖刃,刘进.围手术期血液管理:由限制性输血走向个体化输血[J].中华医学杂志,2014,94(7):481-482.2018-07-15
[2]Nuttall GA,Horlocker TT,Santrach PJ,et al.Predictors of blood transfusions in spinal instrumentation and fusion surgery[J].Spine(Phila Pa 1976),2000,25(5):596-601.
[3]Aoude A,Nooh A,Fortin M,et al.Incidence,predictors,and postoperative complications of blood transfusion in thoracic and lumbar fusion surgery:an analysis of 13,695 patients from the American college of surgeons national surgical quality improvement program database[J].Global Spine J,2016,6(8):756-764.
[4]Shander A,Hofmann A,Ozawa S,et al.Activity-based costs of blood transfusions in surgical patients at four hospitals[J].Transfusion,2010,50(4):753-765.
[5]Carabini LM,Zeeni C,Moreland NC,et al.Development and validation of a generalizable model for predicting major transfusion during spine fusion surgery[J].J Neurosurg Anesthesiol,2014,26(3):205-215.
[6]Basques BA,Anandasivam NS,Webb ML,et al.Risk factors for blood transfusion with primary posterior lumbar fusion[J].Spine(Phila Pa 1976),2015,40(22):1792-1797.
[7]中华人民共和国卫生部.临床输血技术规范[J].临床输血与检验,2000,2(3):1-11.
[8]中华人民共和国国家卫生和计划生育委员会.成人体重判定[S].2013.
[9]陈龙,张冯江,胡双飞,等.同种异体输血及自体血回输在脊柱手术围术期的预测因素[J].中国老年学杂志,2014(6):1476-1479.
[10]Morcos MW,Jiang F,McIntosh G,et al.Predictors of blood transfusion in posterior lumbar spinal fusion:a canadian spine outcome and research network study[J].Spine(Phila Pa 1976),2018,43(1):E35-E39.
[11]Yoshihara H,Yoneoka D.Predictors of allogeneic blood transfusion in spinal fusion in the United States,2004-2009[J].Spine(Phila Pa 1976),2014,39(4):304-310.
[12]董碧蓉.老年衰弱综合征的研究进展[J].中华保健医学杂志,2014,16(6):417-420.
[13]Zheng F,Cammisa FP Jr,Sandhu HS,et al.Factors predicting hospital stay,operative time,blood loss,and transfusion in patients undergoing revision posterior lumbar spine decompression,fusion,and segmental instrumentation[J].Spine(Phila Pa 1976),2002,27(8):818-824.
[14]McCunniff PT,Young ES,Ahmadinia K,et al.Smoking is associated with increased blood loss and transfusion use after lumbar spinal surgery[J].Clin Orthop Relat Res,2016,474(4):1019-1025.
[15]Lenoir B,Merckx P,Paugam-Burtz C,et al.Individual probability of allogeneic erythrocyte transfusion in elective spine surgery:the predictive model of transfusion in spine surgery[J].Anesthesiology,2009,110(5):1050-1060.
[16]Goz V,Weinreb JH,Schwab F,et al.Comparison of complications,costs,and length of stay of three different lumbar interbody fusion techniques:an analysis of the nationwide inpatient sample database[J].Spine J,2014,14(9):2019-2027.
[17]de Kunder SL,van Kuijk S,Rijkers K,et al.Transforaminal lumbar interbody fusion(TLIF)versus posterior lumbar interbody fusion(PLIF)in lumbar spondylolisthesis:a systematic review and meta-analysis[J].Spine J,2017,17(11):1712-1721.
[18]Parker SL,Mendenhall SK,Shau DN,et al.Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis:comparative effectiveness and cost-utility analysis[J].World Neurosurg,2014,82(1-2):230-238.
[19]Li JX,Phan K,Mobbs R.Oblique lumbar interbody fusion:technical aspects,operative outcomes,and complications[J].World Neurosurg,2017,98:113-123.
[20]Bowen RE,Gardner S,Scaduto AA,et al.Efficacy of intraoperative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation[J].Spine(Phila Pa 1976),2010,35(2):246-251.
[21]Stone N,Sardana V,Missiuna P.Indications and outcomes of cell saver in adolescent scoliosis correction surgery:a systematic review[J].Spine(Phila Pa 1976),2017,42(6):E363-E370.
[22]Auerbach AD,Vittinghoff E,Maselli J,et al.Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery[J].JAMA Intern Med,2013,173(12):1075-1081.
[23]Kushioka J,Yamashita T,Okuda S,et al.High-dose tranexamic acid reduces intraoperative and postoperative blood loss in posterior lumbar interbody fusion[J].J Neurosurg Spine,2017,26(3):363-367.
[24]Kim KT,Kim CK,Kim YC,et al.The effectiveness of low-dose and high-dose tranexamic acid in posterior lumbar interbody fusion:a double-blinded,placebo-controlled randomized study[J].Eur Spine J,2017,26(11):2851-2857.
[25]廖刃,刘进.围手术期血液管理:由限制性输血走向个体化输血[J].中华医学杂志,2014,94(7):481-482.2018-07-15