华西综合血液管理策略降低体外循环后急性肾损伤发生风险

Huaxi integrated blood management reduces the risk of acute kidney injury after cardiac surgery

目的本研究旨在评价华西医院体外循环推行综合血液管理(HIBM)策略是否能通过减少输血而降低围术期并发症发生风险。方法回顾分析四川大学华西医院于2019年1月1日至2020年12月31日在体外循环下行成人心血管手术患者。根据策略实施时间,将患者分为实施前(2020.5.31前)、推行期(开始实施HIBM部分策略,2020.6.1~7.31),实施后(2020.8.1后)三组。主要结局指标为急性肾损伤。次要指标为死亡率、应用体外膜氧合或主动脉内球囊反搏、二次开胸止血手术和消化系统并发症。结果3292例患者纳入分析,其中实施前为2265例,推行期318例,实施后709例。与实施前比较,HIBM实施后全主动脉弓置换等大血管手术比例更高(14.7%vs.22.7%,P<0.01);瓣膜置换手术比例减少(76.1%vs.67.0%,P<0.01);输血率(61.1%vs.14.8%)和平均输血量(3.74 U vs.0.8 U)均显著下降(P<0.01)。急性肾损伤发生率在瓣膜置换手术患者(13.3%,vs.9.3%,P=0.006)和全人群(14.2%vs.11.9%,P=0.015)均显著下降。逻辑回归显示,综合血液管理策略能显著降低瓣膜手术患者急性肾损伤发生风险(OR:0.665,95%CI:0.473~0.934,P=0.019),但使用输血指标矫正后,这一显著性消失(OR:0.983,95%CI:0.684~1.413,P=0.927)。HIBM实施前、后患者死亡率、ECMO或IABP、出血和消化系统等并发症发生率无显著性差异。结论HIBM能降低体外循环后瓣膜手术患者的急性肾损伤发生风险,这可能与降低输血有关。

Objective This retrospective study was to evaluate whether Huaxi integrated blood management(HIBM)strategy could reduce the adverse events in patients undergoing cardiac surgery on pump.Methods From Jan.1,2019 to Dec.31,2020,pa⁃tients over 18 years and with cardiovascular surgery on pump in West China Hospital of Sichuan University were included into analysis.Patients were divided into control group(prior to May 31,2020),partial-blood management group(PBM,from June 1,2020 to July 31,2020,started implementing some HIBM strategies),and Huaxi integrated blood management(HIBM,after Aug.1,2020).The primary outcome was acute kidney injury(AKI)after surgery.Secondary outcomes were mortality,the need for ECMO or IABP,bleed⁃ing,and digestive complications.Results There were 3292 cases retrospectively reviewed,in which 2265 in control group,318 in PBM group,and 709 in HIBM group.Compared with control group,blood requirement(3.74 Units/person vs 0.8 Units/person)was significantly lower,while aortic surgery cases(14.7%vs 22.7%)were more in HIBM group(all P<0.01).The incidence of AKI was significantly lower in HIBM group than in control group for patients undergoing valve surgery(13.3%vs.9.3%,P=0.006),and uni⁃variate logistic regression analysis showed that HIBM was associated with lower incidence of AKI(OR 0.665,95%CI:0.473-0.934,P=0.019).However,the significance disappeared after adjusted by blood transfusion(OR:0.983,95%CI:0.684-1.413,P=0.927).There were no significant differences among the groups in mortality,the need for ECMO or IABP,bleeding and digestive complications.Conclusion Huaxi integrated blood management strategy reduces the risk of AKI for patients undergoing valve surgery,which may be via reducing the requirement of allogeneic blood transfusion.