贫血患者冠状动脉旁路移植术前血红蛋白纠正目标值的探讨

Discussion on the target value of preoperative hemoglobin correction in anemia patients with CABG

目的探讨贫血患者行冠状动脉旁路移植(CABG)手术前血红蛋白(Hb)目标值的提升。方法回顾性分析我院2016年1月至2018年12月择期行CABG的患者,收集符合入选标准患者术前的基础资料以及术后的输血量、输血率、肝功能损害、肾功能损害、住ICU时间、住院时间及住院病死率。通过受试者工作特征曲线(ROC)和约登指数(Youden index,YI)找到术后输血率达到最低时所对应的Hb水平,依据Hb值将患者分为三组,对比分析三组的临床结局。结果最终符合入选标准的患者共计2313例,ROC分析显示男性术前Hb为119 g/L、女性Hb为109 g/L约登指数达到最大值,男性患者按照Hb<119 g/L、119~130 g/L、≥130 g/L分为三组,分别为M1组(351例,22.23%)、M2组(442例,27.99%)、M3组(786例,49.78%);女性按照Hb<109 g/L、109~120 g/L、≥120 g/L分为三组,分别为F1组(187例,25.55%)、F2组(253例,34.47%)、F3组(294例,40.05%)。基线资料除Hb存在显著差异外,组间比较,男性年龄三组之间均存在差异,年龄越大贫血越严重,体重指数(BMI)和术前血小板计数三组之间均存在显著差异[M1(23.95±3.91)kg/m^(2)、M2(24.36±3.23)kg/m^(2)、M3(24.93±3.68)kg/m^(2),P<0.05],术前慢性肾脏病(CKD)病史三组之间存在显著差异(72例、37例、47例,P<0.05),慢性肝病和左心室射血分数(left ventricular ejection fraction,LVEF)M1和M3组之间存在显著差异;三组之间的女性在年龄和BMI方面均存在显著差异,术前血小板计数F1和F2之间有差异。在术后临床结局方面,M1[(2.13±5.27)ml,46.72%,(5.62±20.85)IU]和F1[(1.74±2.31)ml,51.3%,(4.11±9.56)IU]组在输注红细胞量、输血率、输血总量方面均比M2[(0.90±2.46)ml,22.17%,(2.81±12.15)IU]、M3[(0.58±3.52)ml,13.28%,(1.99±15.09)IU]组和F2[(1.09±1.96)ml,34.40%,(2.23±6.71)IU]、F3[(1.16±2.79)ml,37.5%,(3.16±11.07)IU]组多,存在显著差异(P<0.05);而M2和M3、F2和F3在所有临床观察结局方面均无差异;男性M1[(23.97±8.19)d,7例]组在住院时间(d)、住院死亡人数两方面比M2[(21.68±6.92)d,1例)]、M3[(21.00±5.74)d,2例]组高,存在显著差异(P<0.05),且M1组住ICU时间比M3组显著延长;女性仅F1组在住院时间方面长于F2、F3组,F1组术后肝功能损害例数高于F2组。结论术前贫血程度影响CABG患者术后的输血量,并导致术后肝肾功能损害并延长ICU停留时间及住院时间,CABG术前将男性Hb纠正至119 g/L、女性纠正至109 g/L可减少围术期输血量和输血率。

Objective To investigate the target value of the increasing amount of hemoglobin(Hb) level in patients with anemia before coronary artery bypass grafting(CABG). Methods The retrospective analysis was performed on the patients with selective CABG surgery in our hospital from January 2016 to December 2018.Basic preoperative data and postoperative blood transfusion volume, blood transfusion rate, liver function impairment, renal function impairment, length of stay in ICU, length of stay and in-hospital mortality of the patients meeting the inclusion criteria were collected. The receiver operating characteristic curve(ROC) and Youden Index(YI) were firstly used to find the Hb level corresponding to the lowest postoperative blood transfusion rate. The patients were divided into three groups according to the Hb value. The clinical outcomes of the three groups were compared and analyzed. Results A total of 2313 patients met the inclusion criteria. ROC analysis showed that when preoperative Hb for males was 119 g/L and 109 g/L for female respectively, Youden index reached the maximum. The male patients were then divided into three groups with Hb<119 g/L, 119~130 g/L,and ≥130 g/L, i.e., M1 group(351 cases, 22.23%), M2 group(442 cases, respectively 27.99%) and M3 group(786 cases, 49.78%);likewise, the female patients were then divided into three groups with Hb<109 g/L, 109~120 g/L and ≥120 g/L, same as above, F1 group(187 cases, 25.55%), F2 group(253 cases, 34.47%), and F3 group(294 cases, 40.05%). In addition to significant differences in hemoglobin in baseline data, there were differences among the three groups in age in males: the older the males, the more serious the anemia. Significant differences were found in BMI and preoperative platelet count between the male three groups [M1(23.95±3.91) kg/m^(2), M2(24.36±3.23) kg/m^(2) and M3(24.93±3.68) kg/m^(2), as well as in preoperative CKD history between the three groups [M1(72 cases), M2(37 cases) and M3(47 cases)]. There were significant differences in chronic liver disease and left ventricular ejection fraction(LVEF%) between the male M1 and M3 groups. As for the female groups, the differences in age and BMI between F1 and F2 and F3 were significant, and the differences in preoperative platelet count between F1 and F2 were statistically significant. In terms of postoperative clinical outcomes of male and female patients, M1[(2.13±5.27) ml,46.72%,(5.62±20.85) IU], F1[(1.74±2.31) ml,51.3%,(4.11±9.56) IU] and M2[(0.90 ± 2.46) ml, 22.17%,(2.81 ± 12.15) IU], M3[(0.58 ± 3.52) ml, 13.28%,(1.99 ± 15.09) IU], F2[(1.09 ± 1.96) ml,34.40%,(2.23±6.71) IU], F3[(1.16±2.79) ml,37.5%,(3.16±11.07) IU] in red blood cell volume, blood transfusion rate and total blood transfusion, showed significant differences(All P<0.05). There were no differences in all clinical outcomes between M2 and M3 and so between F2 and F3.The length of hospital stay and in-hospital death(cases) in male M1(23.97±8.19 days,1 cases) group were significantly higher than those in M2(21.68±6.92 days,7 cases) and M3(21.00 ± 5.74 days,3 cases) group, and the duration of stay in ICU in M1 group was significantly longer than that in M3 group too. In females, F1 group had longer hospital stay than F2 and F3 group, and the number of postoperative liver function impairment in F1 group was more than that in F2 group. Conclusions The extent of preoperative anemia could affect the amount of postoperative blood transfusion in CABG patients, which leads to postoperative liver and kidney function impairment and prolongs the duration of ICU stay and hospitalization. Improving preoperative hemoglobin to 119 g/L in males and 109 g/L in females could reduce the perioperative blood transfusion amount and transfusion rate.