【作者】 李响；

【导师】 王月兰；

【作者基本信息】 山东大学 ， 麻醉学（专业学位）， 2025， 硕士

【摘要】 研究背景:术前贫血作为围手术期最常见的合并症之一,全球非心脏手术患者中患病率高达30%-50%。大量临床研究表明,术前贫血与术后感染、器官功能障碍以及死亡发生率显著增加密切相关,并被美国麻醉医师学会(American Society of Anesthesiologists,ASA)列为术后不良事件的重要预测指标。值得注意的是,现有循证医学证据多聚焦于心外科、普外科及骨科领域,针对神经外科患者的研究相对匮乏。作为神经外科最主要的手术方式,开颅手术常伴随围术期应激反应强、机械通气时间长及术后恢复延迟等特点,对患者器官功能储备构成严峻挑战。这些因素通过增加组织氧耗、降低全身氧输送及诱发全身炎症反应,严重干扰患者的氧供-氧耗平衡与免疫稳态,并导致肺泡-毛细血管屏障受损,从而显著增加术后肺部并发症(Postoperative pulmonary complications,PPCs)发生风险。已有研究证实术前贫血可通过降低组织氧供及激活全身性炎症反应影响术后恢复,但迄今为止,术前贫血与开颅手术患者术后肺部并发症及其他不良事件之间的关联尚未得到明确验证,相关机制亦缺乏系统性探讨。研究目的:1.明确术前贫血与开颅手术患者术后肺部并发症之间的临床关联;2.明确术前贫血对开颅手术患者术后其他不良事件的影响;3.探究开颅手术患者围术期管理,为临床实践提供证据支持。研究方法:1 研究设计本研究为回顾性队列研究,纳入山东第一医科大学第一附属医院(山东省千佛山医院)2017年1月1日至2023年12月31日期间接受开颅手术且符合纳入及排除标准的患者;严格遵循世界卫生组织(World Health Organization,WHO)2011年发布的贫血诊断标准,依据术前静脉血常规中血红蛋白水平,将非妊娠女性患者血红蛋白水平低于120 g/L或男性患者血红蛋白水平低于130 g/L纳入术前贫血组,其余患者纳入非贫血组。2 数据收集2.1 基线特征及围术期变量年龄、性别、体重、吸烟史、过敏史、基础疾病史(高血压、冠心病、糖尿病、肝硬化等)、ASA分级、手术类型、手术体位、手术名称、手术及麻醉时长、术中输血情况、拔管时机及术后转归。2.2 实验室及影像学指标术前及术后血红蛋白水平、白细胞水平、中性粒细胞水平、淋巴细胞水平以及术后胸部影像学检查:X线或CT。3 结局指标3.1 术后肺部并发症研究采用Canet等人提出并广泛使用的术后肺部并发症定义,将其诊断标准设定为术后出现以下任意一种或多种事件:肺炎、胸腔积液、气胸、肺不张、急性呼吸窘迫综合征(Acute respiratory distress syndrome,ARDS)或呼吸衰竭。所有并发症的诊断均遵循标准化流程。3.2 术后不良事件术后不良事件包括死亡、颅内感染、心律失常、急性心肌梗死、急性心力衰竭、非计划二次插管及休克。所有不良事件的判定均基于电子病历系统客观记录。4 统计分析4.1 数据描述连续变量依据是否符合正态分布分别以均值±标准差(Mean±SD)或中位数(四分位距,IQR)表示,分类变量以频数(n,%)呈现。4.2 组间比较连续变量根据是否符合正态分布分别采用独立样本t检验或Mann-Whitney U检验,分类变量行Pearson χ2检验(显著性水平α=0.05)。4.3 倾向性评分匹配构建逻辑回归模型计算倾向性评分,并采用1:1最近邻匹配法,控制混杂因素。在倾向性评分匹配(Propensity score matching,PSM)基础上使用逆概率加权(Inverse probability weighting,IPW)校正残余混杂。4.4 单因素及多因素分析对逆概率加权后的数据进行单因素及多因素Logistic回归分析,调整年龄、合并症等潜在混杂因素,计算比值比(Oddsratio,OR)及其95%置信区间(95%CI)以量化术前贫血对术后肺部并发症及其他不良事件的独立影响。所有统计分析均采用统计计算R 软件(Rversion 4.1.2)处理。研究结果:1 基线特征术前贫血发生率为20.19%,其中男性占比38.44%,女性61.56%。倾向性评分匹配前,两组患者在性别构成、住院时长、体重、手术及麻醉时长和术中是否输血上存在显著组间差异(P<0.05)。2主要结局和次要结局倾向性评分匹配前,术前贫血组患者术后肺部并发症发生率(48.57%vs 42.51%,P=0.037)及住院期间死亡率(2.86%vs0.99%,P=0.010)显著高于非贫血组患者,术后肺部并发症中仅胸腔积液发病率差异具有统计学意义(P=0.027)。倾向性评分匹配后单因素及多因素分析证实术前贫血是术后肺部并发症发生率(OR=1.33,95%CI 1.06-1.68,P=0.014)及住院期间死亡率(OR=2.88,95%CI 1.04-7.96,P=0.042)增加的独立危险因素。研究结论:1.术前贫血是开颅手术患者住院期间术后肺部并发症发生率及死亡率增加的独立危险因素;2.建议通过术前贫血筛查及多学科管理优化血红蛋白水平,改善患者预后。更多还原

【Abstract】 BackgroundPreoperative anemia,as one of the most common comorbidities in the perioperative period,has a prevalence rate of up to 30%to 50%among non-cardiac surgical patients worldwide.A substantial body of clinical research has demonstrated a significant correlation between preoperative anemia and increased incidence of postoperative infection,organ dysfunction,and mortality.The American Society of Anesthesiologists(ASA)has identified preoperative anemia as an important predictor of adverse postoperative events.It is worth noting that the existing evidence-based medical research predominantly focuses on the fields of cardiac surgery,general surgery,and orthopedics,with a relative scarcity of studies targeting neurosurgical patients.As one of the most common approaches in neurosurgery,craniotomy is characterized by intense perioperative stress responses,prolonged mechanical ventilation,and delayed postoperative recovery,which critically challenge patients’ organ functional reserve.These factors collectively exacerbate tissue oxygen consumption,compromise systemic oxygen delivery,and trigger inflammatory cascades,thereby severely disrupting the oxygen deliveryconsumption balance and immune homeostasis.Such pathophysiological disturbances ultimately lead to alveolar-capillary barrier dysfunction,significantly elevating the risk of postoperative pulmonary complications.While numerous studies have confirmed that preoperative anemia can affect postoperative recovery by reducing tissue oxygen supply and activating systemic inflammatory responses,the association between preoperative anemia and postoperative pulmonary complications and other adverse events in craniotomy patients has not yet been clearly established.The underlying mechanisms also lack systematic exploration.Objectives1.To clarify the clinical association between preoperative anemia and postoperative pulmonary complications in craniotomy patients.2.To evaluate the impact of preoperative anemia on other adverse postoperative events in craniotomy patients.3.To explore evidence-based perioperative management strategies for craniotomy patients to inform clinical practice.Methods1 Study DesignThis study is a retrospective cohort study that includes patients who underwent craniotomy at Shandong First Medical University Affiliated Hospital(Qianfoshan Hospital,Shandong Province)from January 1,2017,to December 31,2023,and meet the inclusion and exclusion criteria;it strictly follows the anemia diagnostic criteria released by the World Health Organization(WHO)in 2011.Based on preoperative venous blood routine hemoglobin levels,non-pregnant female patients with hemoglobin levels below 120 g/L or male patients with hemoglobin levels below 130 g/L are included in the preoperative anemia group,while the remaining patients are included in the non-anemia group.2 Data Collection2.1 Baseline Characteristics and Perioperative VariablesBaseline characteristics and perioperative variables were collected,including age,sex,weight,smoking history,allergy history,medical history(e.g.,hypertension,coronary heart disease,diabetes,cirrhosis),American Society of Anesthesiologists classification,type of surgery,surgical position,surgical name,duration of surgery and anesthesia,intraoperative transfusion status,timing of extubation,and postoperative outcomes.2.2 Laboratory and Imaging IndicatorsPreoperative and postoperative hemoglobin levels,white blood cell counts,neutrophil counts,lymphocyte counts,as well as chest imaging examinations(X-ray or CT)were recorded and analyzed.3 Outcome Measures3.1 Postoperative Pulmonary ComplicationsIn accordance with the definition of postoperative pulmonary complications proposed by Canet et al.and widely adopted in clinical research,the diagnostic criteria for PPCs in this study were set as the occurrence of any one or more of the following events after surgery:pneumonia,pleural effusion,pneumothorax,atelectasis,acute respiratory distress syndrome,or respiratory failure.The diagnosis of all complications strictly followed standardized procedures.3.2 Postoperative Adverse EventsPostoperative adverse events included in-hospital mortality,intracranial infection,arrhythmia,acute myocardial infarction,acute heart failure,unplanned reintubation,and shock.All adverse events were determined based on objective records in the electronic medical record system.4 Statistical Analysis4.1 Data DescriptionContinuous variables were described as mean±standard deviation(Mean±SD)or median(interquartile range,IQR)based on normal distribution characteristics,while categorical variables were presented as frequencies(n,%).4.2 Group ComparisonsContinuous variables were compared using independent samples t-tests or Mann-Whitney U tests,and categorical variables were compared using Pearson χ2 tests(significance level α=0.05).4.3 Propensity Score MatchingA logistic regression model was constructed to calculate propensity scores,and a 1:1 nearest neighbor matching method was used to control for confounding factors.After propensity score matching,inverse probability weighting was applied to adjust for residual confounding.4.4 Univariate and Multivariate AnalysisInverse probability weighting was applied to the data,followed by univariate and multivariate logistic regression analyses.Potential confounding factors such as age and comorbidities were adjusted for.Odds ratios(OR)and their 95%confidence intervals(95%CI)were calculated to quantify the independent effects of preoperative anemia on postoperative pulmonary complications and other adverse events.All statistical analyses were conducted using the R software(version 4.1.2).Results1 Baseline CharacteristicsThe incidence of preoperative anemia was 20.19%,with 38.44%being male and 61.56%being female.Before propensity score matching,there were significant differences between the two groups in terms of gender composition,length of hospital stay,weight,duration of surgery and anesthesia,and whether blood was transfused during the operation(P<0.05).2 Primary and Secondary OutcomesPrior to propensity score matching,the incidence of postoperative pulmonary complications(48.57%vs 42.51%,P=0.037)and in-hospital mortality(2.86%vs 0.99%,P=0.010)were significantly higher in patients with preoperative anemia compared to those without.Among postoperative pulmonary complications,only pleural effusion showed a statistically significant difference in incidence(P=0.027).After propensity score matching,both univariate and multivariate analyses showed that preoperative anemia is an independent risk factor for the incidence of postoperative pulmonary complications(OR=1.33,95%CI 1.06-1.68,P=0.014)and in-hospital mortality(OR=2.88,95%CI 1.04-7.96,P=0.042).Conclusions1.Preoperative anemia is an independent risk factor for increased incidence of postoperative pulmonary complications and mortality during hospitalization in craniotomy patients.2.Optimizing hemoglobin levels through preoperative anemia screening and multidisciplinary management is recommended to improve patient outcomes.更多还原