下肢关节手术后静脉血栓风险因素及评估体系分析

Risk Factors and Assessment System Analysis of Venous Thromboembolism in Joint Surgery Patients

目的:在规范化治疗的前提下:(1)分析关节术后静脉血栓发生的影响因素;(2)评估各量表对血栓发生的指示作用,并试图给出新的识别高危人群的临界分值,为进一步个体化给药方案的制定奠定基础。方法:对2015年1月至3月骨科收治的下肢关节病、需行手术的87例患者术后静脉血栓发生情况进行分析。考察因素:性别、年龄、BMI、手术、骨折、活动能力、下肢水肿、静脉曲张、恶性肿瘤、肺疾病、脑梗史、脑梗家族史及输血。患者术后1、3、7天及出院后6周行双下肢静脉彩超检查静脉血栓。单因素分析采用卡方检验,多因素分析采用logistic回归分析。采用ROC曲线分析,以Caprini、Autar和Wells量表指征血栓发生的敏感性和特异性。结果:87名患者术后血栓发生例数为7例,发生在下肢远端静脉,发生率约为8%。卡方检验及logistic回归分析结果显示,手术、股骨颈骨折、活动能力、静脉曲张、恶性肿瘤是显著影响规范化治疗后血栓发生的因素,其中活动能力与股骨颈骨折为重要因素。血栓风险的Caprini、Autar和Wells评分ROC曲线下面积分别为0.84(Caprini)、0.78(Autar)和0.56(Wells),Caprini评分的最佳临界值点为8.5,对应的敏感性和特异性分别为0.86和0.74。结论:活动能力与股骨颈骨折是规范化下肢关节手术治疗后血栓发生的重要影响因素。Caprini评分对静脉血栓高危人群有一定的识别能力,当临界分值定为8.5时,对血栓发生的识别有最好的敏感性和特异性。该结果提示,在目前规范化治疗体系下,Caprini评分高于8.5的下肢关节手术患者可能需要进一步的个体化治疗。如考察患者对抗凝药物的敏感性,以调整用法用量,并定时监测效应指标等。

Objective: Under the premise of standardized treatment,(1) to analyze risk factors of venous thromboembolism(VTE) after joint surgery;(2) to analyze the effectiveness of different VTE assessment scales and to provide a new cut-off value for further individualized medicine. Methods: We evaluated 87 patients performed lower limb joint surgery at our center. The risk factors for analysis were: gender, age,BMI, operation, fracture, mobile ability, edema of lower extremity, varicose veins, malignancy, severe lung disease, history of cerebral infarction, family history of cerebral infarction and blood transfusion. Doppler ultrasound was used to detect lower limb VTE after 1, 3, 7 days and 6 weeks postoperatively. Data analysis was conducted with SPSS 13.0. Results: There were 7 patients(8%) who developed VTE. Single factor Chi square analysis and logistic regression analysis demonstrated risk factors of VTE as operation, mobile ability, fracture, varicose veins and malignancy, and definite association of mobile ability and operation with VTE. ROC curve areas were 0.84, 0.78 and 0.56 calculated respectively by Caprini, Autar and Wells scale. The cutoff value of Caprini scale was 8.5 and the corresponding sensitivity and specificity were 0.86 and 0.74, respectively. Conclusions: Mobile ability and fracture were the significant risk factors for VTE under standard medication for lower extremity joint surgery. Caprini scale can well identify patients with high risk of VTE. The cutoff value is 8.5 which indicated that individualized medicine might be more useful for patients with the VTE risk score higher than 8.5.