重新审视初次全髋关节置换术出血风险和死亡率的国际标准化比值阈值：一项针对 17567 例患者的国家手术质量改进计划分析。
Revisiting the International Normalized Ratio Threshold for Bleeding Risk and Mortality in Primary Total Hip Arthroplasty: A National Surgical Quality Improvement Program Analysis of 17,567 Patients.
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. 2020 Jan 2;102(1):52-59. doi: 10.2106/JBJS.19.00160.
BACKGROUND
Efforts to identify preoperative risk factors for primary total hip arthroplasty have amplified with its increasing incidence. The international normalized ratio (INR) is 1 measure that may influence postoperative outcomes. This study of a national database assessed whether there exists an association between preoperative INR and postoperative bleeding and mortality among patients who underwent primary total hip arthroplasty.
METHODS
We retrospectively analyzed 17,567 adult patients who underwent primary total hip arthroplasty in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) between 2005 and 2016. Patients were stratified by preoperative INR into 4 groups: INR <1.0, 1.0 to <1.25, 1.25 to <1.5, and ≥1.5. Bleeding necessitating transfusion was the primary outcome, and secondary outcomes included mortality, infection, and readmission. Multivariable logistic regressions controlled for baseline differences.
RESULTS
Among the patients who underwent total hip arthroplasty, 20.5% had INR <1.0, 73.6% had INR 1.0 to <1.25, 4.2% had INR 1.25 to <1.5, and 1.8% had INR ≥1.5. Mortality increased incrementally from 0.3% for INR <1.0 to 4.9% for INR ≥1.5 (p < 0.001), and bleeding risk increased from 13.2% for INR <1.0 to 29.3% for INR ≥1.5 (p < 0.001). After adjustment, bleeding risk was increased for INR 1.25 to <1.5 (odds ratio [OR], 1.55 [95% confidence interval (CI), 1.26 to 1.92]) and INR ≥1.5 (OR, 1.55 [95% CI, 1.15 to 2.08]) compared with INR <1.0. The only group associated with increased mortality was INR ≥1.5 (OR, 2.69 [95% CI, 1.07 to 6.76]). The length of stay significantly increased with increasing INR, from 3.6 to 6.3 days (p < 0.001).
CONCLUSIONS
This study found a significant, independent effect between increased preoperative INR and increased bleeding and mortality. Bleeding risk becomes evident at INR ≥1.25, and those patients with INR ≥1.5 are at significantly increased risk of mortality.
LEVEL OF EVIDENCE
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
背景
随着原发性全髋关节置换术发病率的增加，人们越来越努力地寻找术前风险因素。国际标准化比值（INR）是可能影响术后结果的一个衡量标准。本项针对全国性数据库的研究评估了原发性全髋关节置换术患者的术前 INR 与术后出血和死亡率之间是否存在关联。
方法
我们回顾性分析了 2005 年至 2016 年间在美国外科医师学会国家外科质量改进计划（NSQIP）中接受原发性全髋关节置换术的 17567 名成年患者。根据术前 INR 将患者分为 4 组：INR＜1.0、1.0-＜1.25、1.25-＜1.5 和≥1.5。需要输血的出血是主要结局，次要结局包括死亡率、感染和再入院。多变量逻辑回归控制了基线差异。
结果
在接受全髋关节置换术的患者中，20.5%的 INR＜1.0，73.6%的 INR 为 1.0-＜1.25，4.2%的 INR 为 1.25-＜1.5，1.8%的 INR≥1.5。死亡率从 INR＜1.0 的 0.3%逐渐增加到 INR≥1.5 的 4.9%（p＜0.001），出血风险从 INR＜1.0 的 13.2%增加到 INR≥1.5 的 29.3%（p＜0.001）。调整后，INR 为 1.25-＜1.5（比值比[OR]，1.55[95%置信区间（CI），1.26-1.92]）和 INR≥1.5（OR，1.55[95%CI，1.15-2.08]）与 INR＜1.0 相比，出血风险增加。唯一与死亡率增加相关的组是 INR≥1.5（OR，2.69[95%CI，1.07-6.76]）。随着 INR 的增加，住院时间显著增加，从 3.6 天增加到 6.3 天（p＜0.001）。
结论
本研究发现，术前 INR 升高与出血和死亡率增加之间存在显著的、独立的影响。出血风险在 INR≥1.25 时变得明显，而 INR≥1.5 的患者的死亡率显著增加。
证据水平
预后 IV 级。有关证据水平的完整描述，请参见作者说明。
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