单病种患者血液管理对二尖瓣手术患者输血和转归的影响

Effects on patient blood management with single disease on blood transfusion and outcomes of patients undergoing mitral valve surgery

目的探讨单病种患者血液管理(PBM)对二尖瓣手术患者输血和转归的影响。方法选择2015年1月1日至2016年5月31日和2018年1月1日至2019年6月30日于大连市中心医院、大连医科大学附属第一医院、大连医科大学附属第二医院接受二尖瓣手术的411例患者为研究对象。患者中位年龄为62.0岁(18.0~83.0岁);男性患者为217例,女性为194例。根据是否按照2017年12月实施的《大连市医疗机构单病种临床用血评价和考核方案(试行)》推行PBM,将患者分为研究组(n=227,实施PBM,入院时间为2018年1月1日至2019年6月30日)和对照组(n=184,未实施PBM,入院时间为2015年1月1日至2016年5月31日)。采用回顾性研究方法,收集2组患者的一般临床资料,如年龄、性别、术前血红蛋白(Hb)值、术前活化部分凝血活酶时间(APTT);围手术期输血(异体红细胞输注率和输注量、自体血回输率和回输量)和转归(术后住院时间、抗菌药物使用时间)情况等。2组患者的年龄、术前Hb值、术前APTT等计量资料的比较,采用Mann-Whitney U秩和检验;性别构成比、异体红细胞输注率、自体血回输率等计数资料的比较,采用χ^(2)检验。本研究遵循的程序符合大连市临床用血质控中心伦理委员会制定的标准,并获得该伦理委员会批准(批准文号:LL-2016-02)。结果①研究组男性患者比例[57.7%(131/227)比46.7%(86/184)]和年龄[63.0岁(57.0,69.0岁)比60.0(53.0,66.0岁)]均高于对照组,并且差异均有统计学意义(χ^(2)=4.907,P=0.027;Z=3.157,P=0.002);而2组患者的术前Hb值和APTT分别比较,差异均无统计学意义(Z=0.892、-0.491,P=0.373、0.623)。②研究组患者的异体红细胞输注率[44.9%(102/227)比58.2%(107/184)]、人均异体红细胞输注量[4.0 U(2.0,7.1 U)比6.0 U(3.0,10.0 U)]、人均自体血回输量[750.0 mL(517.3,1000.0 mL)比1000.0 mL(750.0,1250.0 mL)]均低于对照组,而自体血回输率高于对照组[65.2%(148/227)比35.3%(65/184)],并且差异均有统计学意义(χ^(2)/Z=7.105、-2.207、-4.076、36.322,P=0.008、0.027、<0.001、<0.001)。③2组患者的术后住院时间和抗菌药物使用时间分别比较,差异均无统计学意义(Z=-1.079、-1.705,P=0.280、0.088)。2组患者的抗菌药物构成比比较,差异有统计学意义(χ^(2)=46.173,P<0.001),研究组以使用1种抗菌药物为主(73.6%,22/167),对照组以使用2种抗菌药物为主(50.5%,93/184)。结论单病种PBM的实施可有效提高二尖瓣手术自体输血比例、降低异体红细胞输注率和输注量,节约血液资源,并且降低患者术后感染风险和抗菌药物使用种类。

Objective To explore implementation effect of single disease patients blood management(PBM)on blood transfusion and outcomes of patients undergoing mitral valve surgery.Methods From January 1,2015 to May 31,2016 and January 1,2018 to June 30,2019,a total of 411 patients undergoing mitral valve surgery in Dalian Central Hospital,the First and Second Affiliated Hospital of Dalian Medical University,were selected as research subjects.There were 217 male and 194 female patients whose median age was 62.0 years(18.0-83.0 years).According to whether patients received PBM in terms of the Evaluation and assessment scheme for clinical blood use of single disease in medical institutions in Dalian issued in December 2017,they were divided into study group(n=227,PBM was implemented,and the admission time was from January 1,2018 to June 30,2019)and control group(n=184,PBM was not implemented,and the admission time was from January 1,2015 to May 31,2016).Using retrospective research method,the data were collected including patients′general clinical information such as age,gender,preoperative hemoglobin(Hb)value and activited partial thomboplastin time(APTT);perioperative blood transfusion information,such as proportion and volume of red blood cell allogeneic transfusion and autologous blood transfusion;and outcomes,such as postoperative hospitalization time,application time and types of antimicrobial agents.The measurement data,including age,preoperative Hb value and APTT,etc.were statistically analyzed with Mann-Whitney U rank sum test for comparison between groups.The enumeration data,including composition ratio of gender,proportion of red blood cell allogeneic transfusion and autologous blood transfusion were analyzed with chi-square test for comparison between groups.The procedures followed in this study were in accordance with the standards established by the Committee of Dalian Clinical Blood Quality Control Center,and this study was approved by the committee(Approval No.LL-2016-02).Results①The male proportion[57.7%(131/227)vs 46.7%(86/184)]and age[63.0 years(57.0,69.0 years)vs 60.0 years(53.0,66.0 years)]of patients in study group were both higher than those of control group,and the differences were all statistically significant(χ^(2)=4.907,P=0.027;Z=3.157,P=0.002).There were no significant differences in preoperative Hb value and APTT between two groups(Z=0.892,-0.491;P=0.373,0.623).②The proportion of red blood cell allogeneic transfusion[44.9%(102/227)vs 58.2%(107/184)],per capita volume of red blood cell allogeneic transfusion[4.0 U(2.0,7.1 U)vs 6.0 U(3.0,10.0 U)],and per capita volume of autologous blood transfusion[750.0 mL(517.3,1000.0 mL)vs 1000.0 mL(750.0,1250.0 mL)]of patients in study group were lower than those of control group,the proportion of autologous blood transfusion[65.2%(148/227)vs 35.3%(65/184)]of study group was higher than that of control group,and the differences were all statistically significant(χ^(2)/Z=7.105,-2.207,-4.076,36.322;P=0.008,0.027,<0.001,<0.001).③There were no statistically significant difference in postoperative hospitalization time and antimicrobial agents application time between two groups(Z=-1.079,-1.705;P=0.280,0.088).There was statistically significant difference in composition ratio of antibacterial agents between two groups(χ^(2)=46.173,P<0.001).And the study group patients mainly used one type of antimicrobial agent(73.6%,167/227),while the control group mainly used 2 types(50.5%,93/184).Conclusions The implementation of single disease PBM increased the proportion autologous blood transfusion,reduced the proportion and volume of red blood cell allogeneic transfusion,and saved the blood resources.And it decreased the risk of postoperative infection and types of antimicrobial agents.