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Correlation Between Initial Postoperative Hemoglobin Value and Prognosis in Non-Cardiac Surgery Patients Receiving Intraoperative Blood Transfusion
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摘要:
目的 分析术中输血的非心脏手术患者其术后初始（术后24 h）血红蛋白（hemoglobin, Hb）值与预后之间的关系，为手术合理用血提供参考。 方法 回顾性分析四川大学华西医院2012–2018年所有非心脏手术、术中输血且年龄≥18岁的患者。以术后初始Hb分组，共划分为6组：Hb<75 g/L，75 g/L≤Hb<85 g/L，85 g/L≤Hb<95 g/L，95 g/L≤Hb<105 g/L，105 g/L≤Hb<115 g/L和Hb≥115 g/L。采用多元线性回归分析比较各组患者住院时间的差异，二元logistic回归分析比较其住院死亡率、自动出院率、急性缺血性损伤（包括急性肾损伤、心肌梗死和脑梗死）发生率、住院时间>28 d患者比例的差异，同时分析术后初始Hb与手术类型、术中红细胞输注量（输注量<8 U vs. 输注量≥8 U）和术前是否贫血（术前Hb<100 g/L vs. 术前Hb≥100 g/L）的多重交互作用对术后住院时间的影响。 结果 本研究共纳入7528例患者，以95 g/L≤Hb<105 g/L组患者为参照组，Hb<75 g/L组患者的住院时间增加，死亡率〔比值比（odds ratio, OR）=2.562〕和自动离院率（OR=1.681）增加；75 g/L≤Hb<85 g/L组患者住院时间增加，急性缺血性损伤发生率增高（OR=1.778）。交互项分析结果显示，术后初始Hb与手术类型之间存在显著交互作用且影响术后住院时间。 结论 非心脏手术的输血患者，术后初始Hb<85 g/L与较差的预后相关，然而更高的术后初始Hb并未带来更好的获益，提示85 g/L≤Hb<95 g/L可能是合理的术中用血的靶血红蛋白值。 Abstract:Objective To analyze the relationship between initial (within 24 hours) postoperative hemoglobin (Hb) value and prognosis in non-cardiac surgery patients receiving intraoperative blood transfusion, and to provide support for sensible blood use in surgery. Methods A retrospective analysis was performed on all patients aged 18 or older who underwent non-cardiac surgeries and who received intraoperative blood transfusion at West China Hospital, Sichuan University from 2012 to 2018. According to their initial postoperative Hb levels, the patients were divided into 6 groups, including Hb<75 g/L, 75 g/L≤Hb<85 g/L, 85 g/L≤Hb<95 g/L, 95 g/L≤Hb<105 g/L, 105 g/L≤Hb<115 g/L, and Hb≥115 g/L goups. Multivariate linear regression was performed to examine the differences in the length-of-stay between the groups and binary logistic regression analysis was conducted to examine the differences between the groups in inpatient mortality, the rate of patient voluntary discharge against medical advice, incidence of acute ischemic injury, including acute kidney injury, myocardial infarction, and cerebral infarction, and length-of-stay longer than 28 days. In addition, the effects of multiple interactions between initial postoperative Hb and the types of surgery, the amount of intraoperative red blood cell infusion (red blood cell<8 U vs. red blood cell≥8 U), and preoperative anemia status (Hb<100 g/L vs. Hb≥100 g/L) on postoperative length-of-stay were analyzed. Results A total of 7528 patients were included in this study. Compared to those of the reference group, the 95 g/L≤Hb<105 g/L group, the length-of-stay of patients with initial postoperative Hb<75 g/L increased and the mortality (odds ratio [OR]=2.562) and the rate of voluntary discharge against medical advice (OR=1.681) increased significantly. Patients in the 75 g/L≤Hb<85 g/L group had increased length-of-stay and increased incidence of acute ischemic injury (OR=1.778) relative to the reference group. The interaction analysis showed that there was significant interaction between initial postoperative Hb and the types of surgery, which influenced the postoperative length-of-stay. Conclusion In non-cardiac surgery patients who have receive blood transfusion, initial postoperative Hb<85 g/L is associated with poorer prognosis. However, those patients with higher initial postoperative Hb did not gain more benefits, suggesting that 85 g/L≤Hb<95 g/L may be the target Hb value for sensible intraoperative transfusion. -
Key words:
- Blood transfusion /
- Surgery /
- Rational use of blood /
- Hemoglobin
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图 2 纳入患者手术类型分布
Figure 2. Distribution of the types of surgeries among the patients included
Hd/Nck: head and neck; Ortho: orthopedic.
图 3 不同手术类型的患者术后初始Hb值分布
Figure 3. Distribution of initial postoperative hemoglobin (Hb) values by surgical types
Hd/Nck: head and neck; Ortho: orthopedic.
图 4 不同手术类型的患者术后红细胞输注情况
Figure 4. Percentage of patients who received postoperative RBC transfusion by surgical types
Hd/Nck: head and neck; Ortho: orthopedic; RBC: red blood cell.
表 1 不同术后初始Hb患者的基本特征
Table 1. Baseline and clinical data of the study cohort
Factor Total
(n=7528)Initial postoperative hemoglobin/(g/L) P <75
(n=1149)75-84
(n=1423)85-94
(n=1688)95-104
(n=1398)105-114
(n=867)≥115
(n=1003)Demographics Male/case (%) 4237 (56.3) 707 (61.5) 817 (57.4) 915 (54.2) 721 (51.6) 453 (52.2) 624 (62.2) <0.001 Age/yr.* 52 (42, 65) 50 (40, 63) 51 (41, 64) 53 (42, 66) 53 (43, 65) 54 (43, 66) 53 (43, 65) 0.001 Body mass/kg* 59.0 (50.1, 66.0) 59.0 (50.0, 67.1) 59.0 (50.0, 66.0) 58.0 (50.0, 65.0) 58.0 (50.0, 65.0) 59.0 (51.0, 65.0) 60.0 (53.0, 68.0) <0.001 Intraoperative transfusions RBC/U* 3.0 (2.0, 6.0) 3.5 (2.0, 7.0) 3.0 (2.0, 6.0) 3.0 (2.0, 5.5) 3.0 (2.0, 5.5) 3.0 (2.0, 4.5) 3.0 (2.0, 4.5) <0.001 Plasma/mL* 300 (0, 600) 200 (0, 700) 200 (0, 600) 200 (0, 550) 250 (0, 550) 300 (0, 450) 350 (0, 600) <0.05 PLT/case (%) 169 (2.2) 50 (4.4) 39 (2.7) 32 (1.9) 25 (1.8) 12 (1.4) 11 (1.1) <0.001 Cryoprecipitate/case (%) 256 (3.4) 74 (6.4) 57 (4.0) 56 (3.3) 37 (2.6) 16 (1.8) 16 (1.6) <0.001 Cell salvage/case (%) 795 (10.6) 87 (7.6) 137 (9.6) 187 (11.1) 162 (11.6) 98 (11.3) 124 (12.4) <0.001 Emergency admission/case (%) 2669 (35.5) 579 (50.4) 612 (43.0) 599 (35.5) 447 (32.0) 232 (26.8) 200 (19.9) <0.001 Surgical type/case (%) Ortho 1976 (26.2) 342 (29.8) 495 (34.8) 483 (28.6) 335 (24.0) 177 (20.4) 144 (14.4) <0.001 General 3057 (40.6) 411 (35.8) 548 (38.5) 692 (41.0) 591 (42.3) 386 (44.5) 429 (42.8) <0.001 Neuro 602 (8.0) 83 (7.2) 90 (6.3) 134 (7.9) 134 (9.6) 81 (9.3) 80 (8.0) <0.05 Urology 693 (9.2) 102 (8.9) 119 (8.4) 152 (9.0) 136 (9.7) 90 (10.4) 94 (9.4) 0.644 Vascular 596 (7.9) 154 (13.4) 110 (7.7) 106 (6.3) 92 (6.6) 52 (6.0) 82 (8.2) <0.001 Thoracic 437 (5.8) 33 (2.9) 32 (2.2) 76 (4.5) 78 (5.6) 62 (7.2) 156 (15.6) <0.001 Hd/Nck 90 (1.2) 14 (1.2) 18 (1.3) 23 (1.4) 16 (1.1) 11 (1.3) 8 (0.8) 0.866 Plastic 77 (1.0) 10 (0.9) 11 (0.8) 22 (1.3) 16 (1.1) 8 (0.9) 10 (1.0) 0.739 Pre-op Hb/(g/L)* 107 (86, 129) 90 (74, 109) 95 (80, 117) 101 (84, 120) 108 (89, 127) 120 (102, 135) 133 (118, 147) <0.001 Pre-op PLT/(×109 L－1)* 107 (86, 129) 90 (74, 109) 95 (80, 117) 101 (84, 120) 108 (89, 127) 120 (102, 135) 133 (118, 147) <0.001 Discharge Hb/(g/L)* 94 (84, 105) 85 (74, 98) 87 (79, 98) 91 (84, 100) 96 (88, 103) 100 (90, 109) 108 (98, 119) Pre-op: pre-operation; Hd/Nck: head and neck; Ortho: orthopedic. * Numbers indicate median (Q1, Q3) for continuous data elements. 
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表 2 不同术后初始Hb组住院时间的差异
Table 2. Differences in length-of-stay of patients with different initial postoperative hemoglobin
Hb/(g/L) n Length-of-stay/d, median (Q1, Q3) <75 1149 12 (7, 22)a 75-84 1423 10 (7, 18.25)a 85-94 1688 10 (7, 17)a 95-104 1398 10 (7, 15) 105-114 867 10 (7, 14) ≥115 1003 10 (7, 14) a P<0.05, vs. 95-104 g/L Hb.
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表 3 不同术后初始Hb组死亡率及自动离院率的差异
Table 3. Differences in inpatient mortality and the rate of voluntary discharge against medical advice of patients with different initial postoperative hemoglobin
Hb/(g/L) Mortality Voluntary discharge against medical advice Case (%) OR P 95% CI Case (%) OR P 95% CI <75 65 (5.66) 2.562 <0.001 1.514, 4.337 107 (9.31) 1.681 0.004 1.183, 2.389 75-84 38 (2.67) 1.463 0.178 0.841, 2.544 91 (6.39) 1.313 0.129 0.924, 1.865 85-94 41 (2.43) 1.529 0.121 0.894, 2.617 108 (6.40) 1.408 0.044 1.009, 1.966 95-104 24 (1.72) 1 1 1 65 (4.65) 1 1 1 105-114 11 (1.27) 0.779 0.512 0.368, 1.647 38 (4.38) 1.032 0.887 0.671, 1.586 ≥115 15 (1.50) 1.015 0.965 0.510, 2.019 42 (4.19) 1.103 0.652 0.720, 1.691 OR: odds ratio; CI: confidence interval.
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表 4 不同术后初始Hb组急性缺血性损伤发生率和住院天数超过28 d患者比例的差异
Table 4. Differences in the incidence of acute ischemic injury and the proportion of patients with length-of-stay exceeding 28 days in groups with different initial postoperative Hb
Hb/(g/L) Acute ischemic injury Acute kidney injury Cerebral ischemia Length-of-stay>28 d Case (%) OR (95% CI) Case (%) OR (95% CI) Case (%) OR (95% CI) Case (%) OR (95% CI) <75 30 (2.61) 1.707 (0.926, 3.146) 20 (1.74) 1.297 (0.600, 2.802) 9 (0.78) 2.242 (0.793, 6.341) 161 (14.01) 2.108 (1.568, 2.833)a 75-84 35 (2.46) 1.778 (1.002, 3.155)b 19 (1.33) 1.356 (0.643, 2.858) 16 (1.12) 2.549 (1.018, 6.383)b 157 (11.03) 1.585 (1.188, 2.116)b 85-94 29 (1.72) 1.275 (0.710, 2.287) 14 (0.83) 0.933 (0.428, 2.030) 15 (0.89) 1.921 (0.769, 4.797) 152 (9.00) 1.383 (1.040, 1.838)b 95-104 20 (1.43) 1 13 (0.93) 1 7 (0.50) 1 90 (6.44) 1 105-114 14 (1.61) 1.094 (0.541, 2.210) 5 (0.58) 0.629 (0.217, 1.826) 6 (0.69) 1.213 (0.401, 3.673) 46 (5.31) 0.930 (0.636, 1.359) ≥115 17 (1.69) 1.165 (0.589, 2.306) 7 (0.70) 0.684 (0.261, 1.794) 10 (1.00) 2.117 (0.772, 5.806) 49 (4.89) 0.963 (0.658, 1.408) a P<0.001，b P<0.05. OR: odds ratio; CI: confidence interval.
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表 5 不同手术类型术后初始Hb与住院时间的关系
Table 5. Association between initial postoperative Hb and length-of-stay by surgery types
Hb/(g/L) Ortho
(n=1976)General
(n=3057)Neuro
(n=602)Urology
(n=693)Vascular
(n=596)Thoracic
(n=437)Hd/Nck
(n=90)Plastic
(n=77)<75 16 (8, 26)a 10 (7, 19)a 15.5 (7.5, 32) 15 (7, 26)a 8 (5, 14) 11 (8, 18) 10 (6, 16.75) 45 (11, 85)a 75-84 11 (7, 21)a 10 (7, 17)a 11 (6.75, 26.25) 11.5 (7, 22)a 8 (5, 12.75) 10 (8, 15.5) 11 (7.5, 16.5) 29 (7, 36) 85-94 11 (7, 19) 10 (7, 15) 11 (6, 17.75) 11 (7, 21) 8 (5, 13) 11 (9, 16.25)a 13 (7.5, 14) 26 (12.5, 47.5) 95-104 10 (7, 15) 10 (7, 14) 8 (6, 14.75) 9 (7, 14.5) 9 (7, 15.25) 12 (9, 20) 11.5 (8.25, 14) 20 (12, 56) 105-114 9 (7, 13) 9.5 (7, 14) 9 (6.75, 16.25) 10 (8, 16.25)a 8 (6.25, 12) 11 (9, 15) 9 (6, 14) 15 (10.5, 29) ≥115 9 (7, 13) 9 (7, 13) 11.5 (7, 15) 8.5 (7, 12) 9 (7, 13) 11 (8, 15.25) 14 (11.5, 29.75)a 23.5 (6.5, 49.75) Median (Q1, Q3) for hospital days. a P<0.05, vs. 95-104 g/L Hb. Hd/Nck: head and neck; Ortho: orthopedic.
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