非体外循环冠状动脉旁路移植术患者术中红细胞输注的影响因素分析

Influencing factors on intra-operative red blood cell transfusion in off-pump coronary artery bypass grafting

目的探讨影响非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting, OPCABG)患者术中红细胞输注的相关因素,建立红细胞输注的风险评分,为临床科学合理备血提供依据。方法 199例首次行单纯OPCABG的患者,男147例,女52例,中位年龄64岁(39-83岁)。根据患者术中是否输注红细胞,将患者分为未输红细胞组(n=112)和输注红细胞组(n=87),统计患者基本信息、术前检查结果、合并症和用药史、手术情况,对两组患者的相关临床资料进行单因素比较,将P<0.1的指标纳入二元Logistic回归分析,将回归分析中P<0.05的指标用于构建术中输注红细胞的风险评分。根据Logistic回归分析中OR值的大小,赋予各影响因素相应的分值,计算每位患者的总分值作为红细胞输注的风险评分,并采用ROC曲线评价其诊断效能。结果 2组患者临床资料单因素分析,年龄(P<0.05)、血清肌酐(P<0.01)、Hb(P<0.001)、Hct(P<0.001)、血浆Fib(P<0.001)、术中出血量(P<0.001)的差异具有统计学意义。Logistic回归分析显示,术前Fib>4 g/L(OR=3.904,P<0.001)、术前Hct降低(OR=6.241,P<0.001)、术中出血量>400 mL(OR=7.952,P<0.001)是OPCABG患者术中红细胞输注的独立危险因素。设定术前FIB>4 g/L为1分,术前HCT降低为2分,术中出血量>400 mL为3分,计算总分值作为风险评分。风险评分在0-6分范围对应的输血率依次为5.8%、33.3%、43.8%、60.0%、66.7%、90.0%、100%,人均输血量依次为0.1、0.7、0.9、1.4、1.7、2.4、3.4 U。Spearman秩相关分析显示,输血率和人均输血量与风险评分呈正相关,秩相关系数r=1.000,P<0.001。风险评分的ROC曲线下面积(AUC)为0.841,以3分为术中是否输注红细胞的临界值,敏感度为71.4%,特异度为78.7%。结论术前FIB>4 g/L、术前Hct降低、术中出血量>400 mL是OPCABG患者术中红细胞输注的危险因素。基于危险因素建立的风险评分对术中红细胞输注具有较好的预测价值,有助于指导术前安全合理备血。

Objective To explore the factors affecting intraoperative RBC transfusion in patients with off-pump coronary artery bypass grafting(OPCABG) and establish a risk score for RBC transfusion, which provides a reference for safe and reasonable blood preparation before surgery. Methods A total of 199 patients with isolated OPCABG were enrolled, including 147 males and 52 females with a median age of 64 years(ranging from 39 to 83 years). According to whether the patient was transfused with red blood cell(RBC), the patients were divided into the non-RBC transfusion group(n=112) and the RBC transfusion group(n=87). The basic information of the patients, preoperative laboratory test results, comorbidities and medication history, operation information were statistically analyzed. The clinical data of the two groups were analyzed by single factor analysis. The factors of P<0.1 were included in the binary logistic regression analysis. The factors of P<0.05 in the regression analysis were used to establish the risk score of intraoperative RBC transfusion. According to the OR value in the logistic regression analysis, the corresponding score of each influencing factor was assigned, and the total score of each patient was calculated as the risk score of RBC transfusion, and the predictive performance was evaluated by ROC curve. Results The difference between the two groups′ clinical data was statistically significant in age(P<0.05), serum creatinine(P<0.05), Hb(P<0.001), Hct(P<0.001), plasma FIB(P<0.001) and intraoperative blood loss(P<0.001). Logistic regression analysis showed that preoperative FIB>4 g/L(OR=3.904, P<0.001), decreased preoperative HCT(OR=6.241, P<0.001), intraoperative blood loss>400 mL(OR=7.952, P<0.05) were independent risk factors for intraoperative RBC transfusion in OPCABG. Preoperative FIB>4 g/L was set to 1 point, decreased preoperative HCT was set to 2 points, intraoperative blood loss >400 mL was set to 3 points, and the total score was calculated as the risk score. The RBC transfusion rate corresponding to the risk score ranged from 0 to 6 points was 5.8%, 33.3%, 43.8%, 60.0%, 66.7%, 90.0%, and 100%, and the per capita RBC transfusion was 0.1, 0.7, 0.9, 1.4, 1.7, 2.4, and 3.4 U. Spearman rank correlation analysis showed that the RBC transfusion rate and per capita RBC transfusion were positively correlated with the risk score, and the rank correlation coefficient was as follows: r=1.000, P<0.001. The area under the ROC curve(AUC) of the risk score was 0.841, and 3 points was decided as the critical value of intraoperative RBC transfusion with a sensitivity of 71.4% and a specificity of 78.7%. Conclusion Preoperative FIB>4 g/L, decreased preoperative HCT, intraoperative blood loss>400 mL are independent risk factors for intraoperative RBC transfusion in OPCABG. The risk score based on risk factors has a good predictive value for intraoperative RBC transfusion, which is helpful to guide the safe and reasonable blood preparation.