类风湿关节炎患者腰椎后路融合术隐性失血的研究

Hidden blood loss in posterior lumbar interbodyfusion in patients with rheumatoid arthritis

中文关键词:  腰椎后路融合术  类风湿关节炎  隐性失血  改良隐性失血

英文关键词:Posterior lumbar interbody fusion  Rheumatoid arthritis  Hidden blood loss  Modified hidden blood loss

中文摘要:

  【摘要】 目的：评估类风湿性关节炎（rheumatoid arthritis，RA）患者行单纯腰椎后路融合术（posterior lumbar interbody fusion，PLIF）或PLIF联合腰椎后外侧融合术（posterior lateral fusion，PLF）的隐性失血（hidden blood loss，HBL）和RA活动性的关系，以及改良HBL（modified HBL，mHBL）相对于HBL，能否提供更加准确的计算失血量的依据。方法：回顾性分析我院2012年1月~2018年4月期间单纯行PLIF或PLIF联合PLF手术的RA患者共61例，男性9例，女性52例，年龄66.0±8.0岁，RA平均病程为16.8±12.7年（0.4～60年）。提取人口统计学信息、RA相关指标（治疗时间、抗RA药物、Steinbrocker分级）、手术节段、手术时间以及出血量相关指标[术前和术后红细胞压积（hematocrit，Hct）和血红蛋白（hemoglobin，Hb）、术中出血、术后引流量]，通过Nadler公式计算血容量（patient volume blood，PVB），通过PVB和Gross公式计算得出TBL。分别通过经典公式[总失血量（total blood loss，TBL）-术中失血量-术后引流量]和改良公式[TBL-术中失血量-引流液中的血液量（drainage blood loss，DBL）]计算HBL和mHBL。采用单因素方差分析，分别对比HBL、mHBL及其TBL在不同手术节段（1节段、2节段和≥3节段）和不同Steinbrocker分级之间的差异，比较术后引流量、HBL和mHBL在是否口服缓解病情的抗风湿药（disease modifying anti-rheumatic drugs，DMARDs）两组中的差异，对比HBL和mHBL两者之间以及两者所占TBL的比例的差异。结果：所有患者Steinbroker分级为Ⅰ级14例、Ⅱ级34例、Ⅲ级13例，在抗RA药物中最常见的为单独应用或联合其他药物一起服用DMARDs（71.4%）。平均手术时间为161.4±52.6min，平均手术节段数为2.9±1.7，平均TBL为907.5±332.4ml，术中失血量平均454.4±386.7ml，平均术后引流量和DBL分别为497.0±273.7ml和300.6±178.3ml，平均HBL和mHBL分别为408.8±288.1ml和612.2±220.8ml。在不同节段术中出血量、术后引流量以及DBL存在统计学差异（P＜0.05），而HBL和mHBL在不同节段均无统计学差异（P＞0.05）；不同RA患者Steinbroker分级之间HBL和mHBL均未见统计学差异（P＞0.05），口服DMARDs组中引流液中失血量小于未服药组（P＜0.05），HBL和mHBL在两组中均无统计学差异（P＞0.05）。对HBL和mHBL之间（P＜0.05）以及两者所占TBL比值对比（P＜0.05）显示存在统计学差异，mHBL要大于HBL。结论：隐性失血与RA活动性无明确相关性，改良mHBL要大于HBL，为评估失血量提供了更准确的依据，提示观察术后引流的重要性。

英文摘要:

  【Abstract】 Objectives: To evaluate the correlation between hidden blood loss(HBL) and the activity of rheumatoid arthritis(RA) in RA patients undergoing posterior lumbar interbody fusion(PLIF) or PLIF combined with posterior lateral fusion(PLF). Methods: This study retrospectively analyzed 61 patients (9 males and 52 females) with RA who underwent PLIF or PLIF plus PLF in our hospital from January 2012 to April 2018. The mean age was 66.0±8.0(y) and the mean duration of RA was 16.8±12.7(y) (0.4~60y). Data extraction include demographic information, RA related factorssuch as RA duration, anti-RA drugs and Steinbrocker classification as well as surgical levels, operation time and hemorrhage-related parameters such as pre- and post-operative hematocrit(Hct) and hemoglobin(Hb), intraoperative blood loss and postoperative drainage. HBL and mHBL were calculated using classical formula [Total blood loss(TBL)-(intraoperative blood loss)-(postoperative drainage)] and modified formula [TBL-(intraoperative blood loss)-drainage blood loss(DBL)] respectively, where TBL was calculated using Gross formula and patient blood volume(PBV) obtained gained using Nadler formula. ANOVA tests were used to compare TBL, HBL and mHBL in various-segment(1 segment, 2 segments and ≥ 3 segments) groups, as well as different grades of Steinbrocker classification, and to compare drainage, HBL and mHBL based on whether taking disease-modifying anti-rheumatic drugs (DMARDs) HBL, mHBL and their proportion in TBL were also compared. Results: There were 14 of grade Ⅰ, 34 of grade Ⅱ and 13 of grade Ⅲ by Steinbroker classification, of whom the most common anti-RA drugs was DMARDs(71.4%). The mean operation time and number of segments was 161.4±52.6min and 2.9±1.7 levels respectively. The mean TBL, intraoperative bleeding, drainage volume and DBL were 907.5±332.4ml, 454.4±386.7ml, 497.0±273.7ml and 300.6±178.3ml, respectively. Among different segments groups, there were statistical differences(P<0.05) in intraoperative blood loss, drainage and DBL but not in HBL and mHBL(P＞0.05). There was no significance in HBL and mHBL among various grades of Steinbroker classification(P＞0.05). DBL was lower in DMARDs group than that of non-drugged group(P<0.05), while HBL and mHBL was not significant different(P＞0.05). The comparison between HBL, mHBL(P<0.05) and their proportion of TBL(P<0.05) showed statistical difference, suggesting that mHBL volume was larger than HBL. Conclusions: There is no significant correlation between HBL and the activity of RA. That mHBL is larger than HBL provides a more accurate basis for measuring factual hidden blood loss and indicates the significance in noticing post-op drainage.