重新审视原发性全膝关节置换术并发症的国际标准化比值（INR）阈值：21239 例分析。

Revisiting the International Normalized Ratio (INR) Threshold for Complications in Primary Total Knee Arthroplasty: An Analysis of 21,239 Cases.

机构信息

David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

Department of Anesthesiology, Hospital for Special Surgery, New York, NY.

出版信息

J Bone Joint Surg Am. 2019 Mar 20;101(6):514-522. doi: 10.2106/JBJS.18.00771.

DOI:10.2106/JBJS.18.00771

PMID:30893232

Abstract

BACKGROUND

Consensus guidelines recommend use of the international normalized ratio (INR) to predict the risk of perioperative bleeding in orthopaedic surgery. However, current recommendations for targeting an INR of <1.5 are based on studies across all surgical disciplines. This study examined the impact of the INR on perioperative bleeding, mortality, postoperative infections, length of hospital stay (LOS), and readmissions following primary total knee arthroplasty (TKA).

METHODS

We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for adult patients who underwent primary TKA from 2010 to 2016. Patients for whom an INR had been recorded within 1 day before the surgery were stratified and analyzed for perioperative bleeding, mortality within 30 days, deep wound and superficial infections, LOS, and readmissions. Multivariable regressions were utilized to adjust for differences in demographics and comorbidities among INR groups.

RESULTS

Of 21,239 patients, 57.2% had an INR of ≤1.0; 38.1% had an INR of >1.0 to 1.25, 3.9% had an INR of >1.25 to 1.5, and 0.8% had an INR of >1.5. After adjustment, a progressively increased bleeding risk was found with an INR of >1.0 to 1.25 (odds ratio [OR] = 1.19, 95% confidence interval [CI] = 1.07 to 1.31, p = 0.001), an INR of >1.25 to 1.5 (OR = 1.29, 95% CI = 1.02 to 1.63, p = 0.033), and an INR of >1.5 (OR = 2.02, 95% CI = 1.29 to 3.14, p = 0.002) relative to an INR of ≤1.0. Patients with an INR of >1.5 were at increased risk for infection (OR = 5.34, 95% CI = 2.45 to 11.68, p < 0.001), but only patients with an INR of >1.25 to 1.5 were at increased risk for mortality (OR = 3.37, 95% CI = 1.31 to 8.63, p = 0.011) relative to those with an INR of ≤1.0. Overall and TKA-related readmission rates and LOS were significantly increased for patients with an INR of >1.25 to 1.5 or an INR of >1.5.

CONCLUSIONS

An INR of >1.25 to 1.5 was associated with increased bleeding, infection, and mortality rates following TKA, and an INR of >1.5 was associated with increased bleeding and infection rates. Current INR target recommendations in consensus guidelines should be reconsidered.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

摘要

背景

共识指南建议使用国际标准化比值（INR）来预测矫形外科手术围手术期出血的风险。然而，目前推荐将 INR 目标值设定为 <1.5 的建议是基于所有外科学科的研究。本研究检查了 INR 对围手术期出血、死亡率、术后感染、住院时间（LOS）和初次全膝关节置换术（TKA）后再入院的影响。

方法

我们回顾性分析了美国外科医师学会国家手术质量改进计划（NSQIP）数据库中 2010 年至 2016 年期间接受初次 TKA 的成年患者。记录了手术前 1 天内 INR 的患者进行分层分析，以评估围手术期出血、30 天内死亡率、深部伤口和浅表感染、LOS 和再入院情况。利用多变量回归来调整 INR 组之间的人口统计学和合并症差异。

结果

在 21239 名患者中，57.2%的患者 INR 值≤1.0；38.1%的患者 INR 值为>1.0 至 1.25，3.9%的患者 INR 值为>1.25 至 1.5，0.8%的患者 INR 值为>1.5。调整后，发现 INR 值>1.0 至 1.25（比值比[OR] = 1.19，95%置信区间[CI] = 1.07 至 1.31，p = 0.001）、INR 值>1.25 至 1.5（OR = 1.29，95%CI = 1.02 至 1.63，p = 0.033）和 INR 值>1.5（OR = 2.02，95%CI = 1.29 至 3.14，p = 0.002）与 INR 值≤1.0 相比，出血风险逐渐增加。INR 值>1.5 的患者感染风险增加（OR = 5.34，95%CI = 2.45 至 11.68，p<0.001），但只有 INR 值>1.25 至 1.5 的患者死亡率风险增加（OR = 3.37，95%CI = 1.31 至 8.63，p = 0.011）与 INR 值≤1.0 的患者相比。INR 值>1.25 至 1.5 或 INR 值>1.5 的患者总体和 TKA 相关再入院率和 LOS 显著增加。