加速康复外科理念下肝切除术后水电解质紊乱的倾向性匹配回顾性分析

Propensity score matching and retrospective analysis of postoperative fluid management and electrolyte disorders after hepatectomy under the concept of enhanced recovery after surgery

目的研究加速康复外科(ERAS)与肝切除术后水电解质紊乱的相关性并探讨防治策略。方法回顾性病例对照研究方法分析2019年1月至2020年12月南方医科大学南方医院152例ERAS管理和233例传统管理的肝切除术后患者临床资料,然后进行倾向性匹配后分析液体及主要电解质补充量与血清电解质紊乱情况,Logistic回归综合分析术后低钾的风险因素;ROC曲线分析术后低钾的预测指标。结果倾向性匹配后,纳入107例ERAS组和135例传统组。ERAS组术后第1、2、4天的静脉补液、补钾量显著低于传统组(P<0.05);ERAS术后第4天补钾患者占比显著低于传统组(17.76%vs 94.81%,P<0.05);ERAS组术后第5天低钾血症发生率高于传统组(33.64%vs 22.22%,P<0.05)。回归分析显示ERAS是肝切除术后低钾血症的危险因素(OR 3.234,95%CI 2.021~5.176,P<0.05),年龄及术后第1天血清钾水平是低钾血症发生的独立危险因素(OR 1.033,95%CI 1.008~1.058,P<0.05;OR 3.073,95%CI 1.335~7.072,P<0.05),术后第3天血清钾水平及术后第4天静脉补钾量是低钾血症的独立保护因素(OR 0.009,95%CI 0.003~0.032,P<0.05;OR 0.582,95%CI 0.468~0.723,P<0.05)。ROC曲线分析得出术后第3天血钾≤3.86 mmol/L为预测术后第5天出现低钾血症的最佳诊断截点。结论ERAS管理与肝切除术后低钾血症的发生有一定相关性,血清钾监测及维持补钾是预防ERAS相关低钾血症的有效措施。

Objective To investigate the relevance between enhanced recovery after surgery(ERAS)and postoperative fluid management and electrolyte disorders after hepatectomy,of which prevention and management strategies is discussed as well.Methods Retrospective case-control study was to analyze the data of 152 patients with ERAS management and 233 patients with conventional management after hepatectomy in Nanfan Hosiptal,Southern Medical University from Jan.2019 to Dec.2020.The difference of fluid and main electrolyte supplementation,serum electrolyte concentration and electrolyte disorder were analyzed after propensity score matching(PSM).Logistic regression was used to comprehensively analyze the risk factors of postoperative hypokalemia.ROC curve was conducted to analyze the predictors of postoperative hypokalemia.Results After PSM,107 ERAS and 135 conventionally managed cases were included.The amount of intravenous fluid and potassium supplementation on the 1st,2nd and 4th postoperative day(POD1,POD2,POD4)in ERAS group was significantly lower than that in the traditional group.The proportion of patients with potassium supplementation on POD4 after ERAS surgery was significantly lower than that in the traditional group(17.76%vs 94.81%,P<0.05).The incidence of hypokalemia on POD5 in ERAS group was significantly higher than that in the traditional group(33.64%vs 22.22%,P<0.05).Regression analysis showed that ERAS was a risk factor for hypokalemia after hepatectomy(OR 3.234,95%CI 2.021-5.176,P<0.05).Age and serum potassium level on POD1 were independent risk factors for hypokalemia(OR 1.033,95%CI 1.008-1.058,P<0.05;OR 3.073,95%CI 1.335-7.072,P<0.05),and serum potassium level on POD3 and intravenous potassium supplementation on POD4 were independent protective factors(OR 0.009,95%CI 0.003-0.032,P<0.05;OR 0.582,95%CI 0.468-0.723,P<0.05).ROC curve analysis showed that serum potassium≤3.86 mmol/L on POD3 was the best cut-off value for predicting the occurrence of hypokalemia on POD5.Conclusion ERAS management is correlated with the occurrence of hypokalemia after hepatectomy,and serum potassium monitoring and maintenance of potassium supplement are effective measures to prevent ERAS associated hypokalemia.