Liu Y, Sun Y, Fan L, Hao J
Department of Orthopedics, Capital Medical University Teaching Hospital, Beijing Electric Power Hospital of State Grade, Beijing, 100073, China.
Musculoskelet Surg. 2017 Aug;101(2):139-144. doi: 10.1007/s12306-016-0447-7. Epub 2017 Jan 7.
The actual total blood loss after a hip fracture has been found to be considerably larger than that observed during surgery and collected in drainage postoperatively. However, no previous studies have offered reasonable explanations for the deficit between a large hemoglobin drop and a small intraoperative blood loss. The aim was to quantify blood loss associated with hip injuries and surgery, and to identify the relative risk factors for perioperative hidden blood loss.
Eighty-nine patients with a femoral intertrochanteric fracture were operated on between August 2012 and October 2013. The patients were accepted to undergo DHS (AO/ASIF) surgery or PFN-a (AO/ASIF) surgery and were randomly assigned to one of the two groups according to whether they had a wound drain or not. Admission information collected included: age, gender, body mass index (BMI), the American Society of Anesthetists system (ASA grading), plasma albumin (ALB), specific gravity of urine (SGU), fracture type (FT), surgery type (ST), and time from admission to surgery in hours (TAS). Blood samples for HB (hemoglobin) analysis were obtained upon admission, at 1 h preoperatively, and at successive postoperation days. The hidden blood loss was calculated by deducting the observed perioperative blood loss from the calculated total blood loss based on the hematocrit changes.
A total of 82 patients with a mean admission lapse time of 4 h after injury remained for the final analysis. One-way analysis of variance (ANOVA) of HBL shows the significant difference was observed in BMI subgroups, ALB subgroups, SGU subgroups, and ST subgroups, but no difference was observed in other subgroups. A multivariate linear regression investigating the relationship between HBL and all factors show that decreased albumin at admission and PFN-a surgery were variables associated with increased HBL.
Several readily available preoperative factors in the form of non-drainage, BMI < 25 kg/m, admission specific gravity of urine >1.020, surgery type PFN-a, and admission albumin <30 g/L were associated with a greater likelihood of more HBL. In addition, the latter two are independent risk factors for greater HBL in patients with intertrochanteric fractures.
研究发现髋部骨折后的实际总失血量远大于手术中观察到的失血量以及术后引流收集到的失血量。然而，以往尚无研究对血红蛋白大幅下降与术中少量失血之间的差异给出合理的解释。本研究旨在量化髋部损伤及手术相关的失血量，并确定围手术期隐性失血的相关危险因素。
2012年8月至2013年10月期间，对89例股骨粗隆间骨折患者进行了手术。这些患者接受动力髋螺钉（DHS，AO/ASIF）手术或股骨近端防旋髓内钉-a（PFN-a，AO/ASIF）手术，并根据是否留置伤口引流管随机分为两组。收集的入院信息包括：年龄、性别、体重指数（BMI）、美国麻醉医师协会分级系统（ASA分级）、血浆白蛋白（ALB）、尿比重（SGU）、骨折类型（FT）、手术类型（ST）以及入院至手术的时间（小时，TAS）。入院时、术前1小时以及术后连续几天采集血样进行血红蛋白（HB）分析。隐性失血量通过根据血细胞比容变化计算出的总失血量减去观察到的围手术期失血量得出。
最终纳入82例患者进行分析，平均受伤至入院间隔时间为4小时。对隐性失血量（HBL）进行单因素方差分析显示，在BMI亚组、ALB亚组、SGU亚组和ST亚组中存在显著差异，而在其他亚组中未观察到差异。对HBL与所有因素之间关系进行多因素线性回归分析显示，入院时白蛋白降低和PFN-a手术是与HBL增加相关的变量。
术前几个易于获取的因素，如未留置引流管、BMI<25kg/m²、入院时尿比重>1.020、手术类型为PFN-a以及入院时白蛋白<30g/L，与更高的隐性失血量可能性相关。此外，后两者是粗隆间骨折患者隐性失血量增加的独立危险因素。
