神经外科术后消化道出血高危因素分析

High risk factors of upper gastrointestinal bleeding after neurosurgical procedures

目的分析神经外科手术后发生上消化道出血的危险因子,以指导神经外科临床更好地预防及治疗术后上消化道出血. 方法采用回顾性分析的方法,建立<神经外科术后消化道出血的高危因素调查量表>,采用时间段取样法抽取1500例神经外科手术患者的住院病史,根据量表内容进行多因素分析.结果本研究最后有效病例1430例,术后出现消化道出血的病例数为75例,发生率为5.24%.分析结果表明神经外科术后上消化道出血的发生率男性6.64%(54/813),女性3.40%(21/617);50岁以上患者的发生率达9.88%(41/415),手术前后格拉斯哥昏迷评分<10分的患者,消化道出血的发生率分别达17.5%(14/80,术前GCS 7～10)和20.9%(14/67,术前GCS 3～6),以及20.25%(16/79,术后第1天GCS 7～10)和23.75%(19/80,术后第1天GCS 3～6).择期手术中第四脑室肿瘤术后消化道出血发生率为15.79%(3/19),急诊手术中高血压脑出血术后消化道出血高达46.43%(13/28).随着神经外科手术后并发症数的增加,术后消化道出血的发生率也随之上升. 结论神经外科手术后出现消化道出血临床症状的高危因素包括:年龄>50岁;男性;手术前后格拉斯哥昏迷评分<10分;病变位于脑干及第四脑室;高血压脑出血;脑内及脑室内出血的颅脑外伤;术后出现肺炎、脑水肿、颅高压、颅内感染等各种并发症.

Objective To analyze high risk factors of postoperative upper gastrointestinal （GI） bleeding after neurosurgery so as to give guidance for prevention of GI bleeding. Methods A questionnaire was developed to investigate the medical records of 1500 patients who were hospitalized and underwent neurosurgical operations in 1997. Logistic regression analysis was made. Results 1430 valid questionnaires were obtained. Postoperative upper GI bleeding occurred in 75 patients （ 5.24% ）. The incidence of upper GI bleeding were 6.64% （54/813） in the male patients and 3.40% （21/617） in the female persons （P=0.007）; 9.88% （41/415） in those aged 〉50 and 3.35% in those aged ≤50 （P=0.001）. Glasgow Coma Score less than 10 preand post-operation, the incidence of upper GI bleeding was more than 17. 5% （ 14/80,pre-operation GCS 7-10 ） and 20. 9% （ 14/67, pre-operation GCS 3-6） , and 20. 25% （ 16/79, first day of post-operation GCS 7-10） and 23.75% （ 19/80,first day of post-operation GCS 3-6）. The incidence of upper GI bleeding of the patients with intracerebral hematoma, intraventricular hemorrhage, subdural hematoma, and extradural hematoma were 15.7% , 10.0% , 6.00% , and 2.94% respectively （P=0. 02）. The incidence of upper GI bleeding of the patients with tumors of fourth ventricle of cerebrum, brainstem, cerebral hemisphere, and sellar hypothalamus were 15. 79% （3/19）, 7. 89%, 5. 71%, and 3.74% respectively. In the emergent cases, the incidence of upper GI bleeding was higher in those with hypertension. The incidence of upper GI bleeding was 5.46% in the patients undergoing adrenocortical hormone treatment, significantly higher than that in those who did not receive such treatment （2.13%）. Conclusion Patients who are at high risk of developing postoperative upper GI bleeding including that ： age greater than 50 years; male; Glasgow Coma Score less than 10 pre and post operation; The lesion was located in brain stem and forth ventricle; Hypertensive cerebral hemorrhage; Intracerebral and intraventricular hemorrhagic brain trauma; Postoperative pneumonia, brain edema, encephalic high pressure, pyogenic infection of the central nervous system and other postoperative complications. The mortality of patients with postoperative upper GI bleeding was evidently higher than that of the patients without postoperative upper GI bleeding.