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摘要:目的 调查全膝关节置换术(total knee arthroplasty, TKA)围手术期异体输血率并分析其相关影响因素。方法 回顾性分析北京协和医院骨科2005年1月至2011年12月临床资料完整的初次TKA患者共1165例, 其中男217例, 女948例; 平均年龄62.4岁(16~92岁)。调查患者围手术期异体输血率。对纳入研究的617例单侧TKA病例的自变量(包括34个影响因素)和因变量(住院期间异体输血)进行统计分析, 用多因素Logistic回归分析确定住院期间异体输血的影响因素。结果 1165例TKA手术患者总异体输血率为58.2%(678/1165), 平均异体输血量为2.7 U(1~13 U)。其中695例单侧TKA患者异体输血率为40.0%(278/695);470例一期双侧TKA患者异体输血率为85.1%(400/470)。共617例单侧TKA病例进入统计分析, 单因素分析显示患者年龄(P < 0.0001)、术前血红蛋白水平(P < 0.0001)、术前血细胞比容(P < 0.0001)、美国麻醉医师学会(American Society of Anesthesiologists, ASA)评分≥ 3分(P=0.004)、手术时间(P=0.004)和止血带时间(P=0.050)与异体输血呈显著相关; 多因素Logistic回归分析证实异体输血和年龄(P < 0.0001)、术前血红蛋白水平(P < 0.0001)、手术时间(P < 0.0001)之间呈显著相关。结论 TKA围手术期异体输血率较高。一期双膝同期置换更需注意术后贫血事件的发生。通过评估患者年龄、血红蛋白水平及手术时间, 有利于预测术后异体输血的需求。Abstract:Objective To evaluate the transfusion rates and identify perioperative factors associated with allogeneic blood transfusion (AllTx) after primary total knee arthroplasty (TKA) with routine use of low-molecular-weight heparins.Methods We retrospectively studied the transfusion rate of 1165 consecutive patients who underwent primary TKA between January 2005 and December 2011. Totally 34 independent variables were analyzed in 617 primary unilateral TKAs without autologous blood predonation for requirement of AllTx. Multiple regression analysis model was used to identify risk factors associated with perioperative blood transfusion.Results Overall, 58.2%(678/1165) of patients required AllTx. The median number of units transfused was 2.7 U (range:1 to 13 U). The AllTx rate was 40.0% (278/695) in unilateral TKA procedures and 85.1% (400/470) in one-stage bilateral TKA procedures. Univariate analysis demonstrated the risk of transfusion was independentlypredicted by the patients' age at surgery (P < 0.0001), preoperative hematocrit(P < 0.0001), preoperative hemoglobin concentration (P < 0.0001), American Society of Anesthesiologists (ASA) score ≥ 3 (P=0.004), surgical time (P=0.004), and tourniquet time (P=0.050). Multivariate Logistic regression analysis confirmed significant relationship between allogeneic blood transfusion and age (P < 0.0001), preoperative hemoglobin(P < 0.0001), and surgical time (P < 0.0001).Conclusions AllTx rate is high in TKA procedures, especially in one-stage bilateral TKA procedures. Patient's age, preoperative hemoglobin level, and surgical time are helpful in identifying high-risk patients who require postoperative blood transfusion.
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Keywords:
- knee joint /
- arthroplasty /
- perioperation /
- allogeneic transfusion /
- influencing factor
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主编：Deepak L. Bhatt
出版商：Elsevier
心脏导管和介入术自20世纪上半叶由德国外科医生福斯曼发明以来, 逐步发展和完善, 已经成为当代心脏病学的基石。该领域的技术已从简单的压力测量、描记曲线, 发展为心血管疾病明确诊断、完成治疗不可或缺的手段。很多风险高、创伤大的外科手术已被微创、低风险的介入治疗所取代，医疗经济效益比因此显著提高。如今，心血管介入领域的设备器材、诊疗程序和技术仍在日新月异地发展，如何不断更新和提高介入技术水平，面对不同患者作出最正确的介入临床决策，是心血管医师面临的极大挑战。本书由著名的心血管介入专家Bhatt博士负责组织编写，全面系统地介绍了心血管介入各个领域的最新诊断和治疗策略，以及相关介入技术的原理和要点。
本书分为7部分。第1部分介绍心脏介入治疗的指南、辅助药物和周边技术。第2部分则具体论述冠状动脉介入手术中的难点如无保护左主干病变、慢性完全闭塞病变、分叉病变、桥血管、支架内再狭窄、血栓病变等的处理，以及血管内成像技术的操作、应用和进展。第3部分是外周血管介入，分别阐述上下肢动脉、肾动脉、肠系膜动脉及胸腹主动脉瘤等病变处理技巧，此外还涉及了最新的肾动脉去交感神经术。第4部分脑血管介入术，分为颈、椎动脉和颅内动脉介入两部分。第5部分为静脉系统介入治疗，包括下肢深静脉血栓和肺栓塞的处理，慢性深静脉功能不全及血液透析动静脉瘘通路的处理。第6部分是结构性心脏病的介入诊疗，包括主动脉瓣成型术和经导管主动脉瓣置换术，经导管二尖瓣介入术，肥厚型心肌病、卵圆孔未闭、房间隔缺损及室间隔缺损的封堵，心内膜活检和心包穿刺及介入治疗。最后一部分简要介绍了其他先天性心脏病如主动脉缩窄、动静脉瘘畸形等的介入策略。
心脏介入学是一个操作性、可视性极强的学科，本书充分体现了这一特点。其包含431幅彩图和116个图表，直观、清晰地阐述了诊治流程和介入操作中的关键所在，相应网站上的视频和动画更方便于学习和知识更新。因此，作为Braunwald心脏病学伴侣系列丛书中的一本，本书不仅适用于从事心血管介入或接受心血管介入专科培训的医生，对放射科介入医生、心血管外科医生和经常与介入医生密切合作的其他心血管医生都有很好的参考作用，是一本不可多得的实用性极强的心血管介入参考书。
(北京协和医院心内科 郭潇潇)
(中国医学科学院图书馆 供 稿)
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表 1 全膝关节置换术异体输血各相关参数的单因素方差分析结果[( $ \overline x \pm s $)/例(%)]
变量 非异体输血(n=374) 异体输血(n=243) P值 年龄(岁) 67.01±9.95 (16~92) 72.46±10.13(35~90) < 0.0001 性别 0.745 女 293(78.5%) 184(76.1%) 男 81(21.5%) 59(23.9%) BMI(kg/m2) 31.95±6.49(16.5~62.6) 30.42±6.81(16.5~50.6) 0.062 身高(cm) 163.10±10.05(131.6~198.1) 164.90±11.82(134.0~218.4) 0.200 体重(kg) 85.10±18.93(40.8~156.5) 82.68±19.70(42.2~149.7) 0.312 诊断 0.389 OA 328(87.7%) 203(83.5%) RA 32(18.5%) 27(11.1%) 其他 14(6.4%) 13(5.3%) 合并症 高血压 257(68.6%) 174(73.2%) 0.507 冠心病 42(11.3%) 28(11.7%) 0.066 糖尿病 71(19.0%) 68(28.2%) 0.097 出血性疾病 4(1.0%) 8(2.3%) 0.721 贫血 8(2.1%) 5(2.0%) 0.006 慢性阻塞性肺疾病 18(4.8%) 10(4.2%) 0.896 术前用药 肝素 2(0.5%) 0(0) 1.000 华法林 27(7.2%) 17(7.0%) 0.574 阿司匹林 104(28.4%) 68(28.2%) 1.000 氯吡格雷 14(3.8%) 7(2.8%) 0.923 NSAIDs 88(23.6%) 47(19.7%) 0.565 糖皮质激素 35(9.4%) 27(11.3%) 0.777 利尿剂 32(8.7%) 23(9.4%) 1.000 铁剂 19(5.1%) 15(6.3%) 0.164 ASA评分 2~3 278(74.3%) 145(59.5%) 0.622 ≥3 96(25.7%) 98(40.5%) 0.004 术前化验 PT(s) 13.74±1.85(9.9~30.7) 14.23±2.90(9.7~32.9) 0.177 INR 1.07±0.59(0.9~10.7) 1.08±0.30(0.8~ 3.2) 0.913 APTT(s) 29.44±4.15(20 ~52.2) 29.74±4.34(21.9~43.9) 0.569 Hgb(g/L) 127.10±14.00(87 ~187) 115.00±15.20(76~142) < 0.0001 Hct(%) 38.80±3.89(26.8~56.1) 35.57±1.52(24.5~43.7) < 0.0001 Plt(×109/L) 248.00±71.32(65 ~623) 243.50±77.76(90~517) 0.616 主刀医生 0.730 A 122(32.6%) 78(32.3%) B 48(12.8%) 32(13.5%) C 93(24.8%) 42(16.9%) D 111(29.0%) 91(37.3%) 麻醉方式 0.969 CEA 319(85.5%) 205(84.5%) GA 26(7.2%) 21(8.5%) RB 25(6.8%) 17(7.0%) 联合 1(0.2%) 0(0) 手术时间(min) 109.10±25.70(65~315) 123.60±40.51(76~270) 0.004 止血带时间(min) 79.58±25.19(17~125) 95.89±28.13(65~180) 0.050 引流放置 0.441 有 246(66.0%) 207(60.6%) 无 127(34.0%) 95(39.4%) BMI:体重指数；OA：骨关节炎；RA：类风湿关节炎；NSAIDs：非甾体抗炎药；ASA：美国麻醉医师学会；PT：凝血酶原时间；INR：国际标准化比值；APTT：活化部分凝血活酶时间；Hgb：血红蛋白；Hct：血细胞比容；Plt：血小板计数；CEA：连续硬膜外麻醉；GA：全身麻醉；RB：区域阻滞麻醉；联合：全身麻醉联合区域阻滞麻醉 
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表 2 全膝关节置换术患者住院期间异体输血率和影响因素的Logistic回归分析结果
影响因素 Bi SE Wald P OR 95%可信区间 年龄 0.017 0.0008 3.993 < 0.0001 1.06 1.03 ~1.09 术前血红
蛋白-0.801 1.429 0.314 < 0.0001 0.565 0.027~2.380 手术时间 0.010 0.004 5.314 < 0.0001 1.015 1.0152~1.0153
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