Correlation between hidden blood loss and nutritional status in elderly patients after total hip replacement

doi:10.3969/j.issn.2095-4344.2016.31.001

Abstract

Abstract:

BACKGROUND: Perioperative high hidden blood loss affects the recovery of joint function after total hip replacement.

OBJECTIVE: To analyze the reliability of the Mini Nutritional Assessment on evaluating the nutritional status in elderly patients with femoral neck fracture on admission, and to investigate the effect of nutritional status variation on hidden blood loss after total hip replacement.

METHODS: 234 elderly patients with femoral neck fracture underwent total hip replacement. By using Mini Nutritional Assessment, patients were randomly divided into three groups: well-nourishment group (n=52), malnourishment at risk group (n=92), and malnourishment group (n=90). The results were used to analyze the correlation of Mini Nutritional Assessment and serological nutrition indicators, and to hidden blood loss.

RESULTS AND CONCLUSION: (1) Hidden blood loss: 101 patients suffered from high hidden blood loss. Hidden blood loss, its proportion to total blood loss and incidence of high hidden blood loss gradually increased with the deterioration of the nutritional status (P < 0.05). (2) Mini Nutritional Assessment: Pre-operative Mini Nutritional Assessment score, and the incidence of hidden blood loss evaluated by albumin, prealbumin, transferrin, lymphocyte count, the percentage of lymphocytes and hemoglobin was significantly higher in patients with high hidden blood loss than those with low hidden blood loss (P < 0.01). (3) Results of correlation analysis: High hidden blood loss was positively correlated with pre-operative Mini Nutritional Assessment, albumin, prealbumin, transferrin, the percentage of lymphocytes and hemoglobin (P < 0.05). (4) These findings confirm that risk evaluation with Mini Nutritional Assessment is a reliable method to assess the nutritional status in elderly patients undergoing total hip replacement. Its combination with various serum nutrition indicators can determine high hidden blood loss and the prognosis.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Tissue Engineering, Femoral Neck Fractures, Hip Joint

CLC Number:

R318

Zhu Dong-mei, Liu Guo-yin, Bao Lei, Wang Meng-ru, Ye Ming-zhu, Leng Nan-nan, Yang Zheng-qian, Xu Xiao-xiao, Chen Jian-min. Correlation between hidden blood loss and nutritional status in elderly patients after total hip replacement[J]. Chinese Journal of Tissue Engineering Research, 2016, 20(31): 4565-4574.

Figures/Tables 4

2.3 各种营养评价方法评定患者置换前营养状况 2.3.1 置换前传统营养学指标与微型营养评价法评分结果的关系在3组患者中，置换前体质量指数、上臂肌围、小腿腓肠肌围和肱三头肌皮褶厚度平均值的变化趋势均与微型营养评价法评分相关，并随营养状态的恶化而呈现下降趋势(表1)。各组患者置换前平均微型营养评价法评分，两两间比较差异有显著性意义(图1A)，营养不良组患者置换前体质量的平均值低于营养良好组和潜在营养不良组(P < 0.05；图1B)。由于各组患者的营养学指标数值差异变化波动较大，会对试验结果造成误差。为了排除这些因素的干扰，文章进一步对比分析置换前传统营养学指标评估营养不良的发生率(置换前分别按照上臂肌围、小腿腓肠肌围和肱三头肌皮褶厚度标准评估为营养不良患者的数量/每组患者的总数量)，结果表明：营养不良患者置换前上臂肌围、小腿腓肠肌围和肱三头肌皮褶厚度评估营养不良的发生率明显高于营养良好患者(图1C-E)，营养不良患者置换前上臂肌围和肱三头肌皮褶厚度评估营养不良的发生率明显高于潜在营养不良患者(图1C，E)，潜在营养不良患者置换前小腿腓肠肌围评估营养不良的发生率明显高于营养良好患者(图1D)。 2.3.2 置换前血清营养学指标与微型营养评价法评分的关系对各组患者的血清营养学指标分析后发现，置换前这些指标平均值的变化趋势均与微型营养评价法评分评估的营养状态存在相关性(表2)。随着营养不良状态的加重，血清营养学指标的平均值逐渐降低。为排除指标差异变化波动对实验的干扰，文章分别对置换前血清营养学指标评估营养不良的发生率(置换前分别按照血清营养学指标的标准评估为营养不良患者的数量/每组患者的总数量)进行了对比分析：营养不良患者总蛋白、白蛋白、前白蛋白、转铁蛋白、淋巴细胞百分比和血红蛋白评估的置换前营养不良发生率明显高于营养良好患者(图2A-D，图2F，G)；潜在营养不良患者总蛋白、白蛋白、前白蛋白、转铁蛋白和淋巴细胞百分比评估的置换前营养不良发生率明显高于营养良好患者(图2A-D，图2F)；营养不良患者总蛋白、白蛋白、前白蛋白、转铁蛋白、淋巴细胞百分比和血红蛋白评估的置换前营养不良发生率明显高于潜在营养不良患者 (图2A-D，图2F，G)。 2.4 不同营养状态患者关节置换前后血清营养学指标的变化表2显示，各分组患者置换后血清营养学指标的数值均低于入院时(置换前)的总体水平(P < 0.05)。为了进一步明确置换后这些指标评估营养不良发生率的变化，并排除这些指标数值的差异变化波动对实验结果的影响，文章将关节置换前后分别按照血清营养学指标的标准评估为营养不良患者的数量/每组患者的总数量进行对比分析后发现：营养良好患者置换后按照血红蛋白标准评估的营养不良发生率高于置换前(P < 0.01；图2G)，但是，营养良好患者关节置换前后分别按照总蛋白、白蛋白、前白蛋白、转铁蛋白、淋巴细胞百分比和淋巴细胞计数评估的营养不良发生率之间差异无显著性意义(图2A-F)；潜在营养不良患者置换后按照总蛋白、白蛋白、前白蛋白、转铁蛋白、淋巴细胞百分比和血红蛋白标准评估的营养不良发生率明显高于置换前(P < 0.05)(图2A-D，图2F，G)；营养不良患者置换后按照总蛋白、白蛋白、前白蛋白、转铁蛋白、淋巴细胞计数、淋巴细胞百分比和血红蛋白标准评估的营养不良发生率显著高于置换前，差异有显著性意义(P < 0.01；图2A-G)。 2.5 微型营养评价法评分与各种营养评价指标的相关性微型营养评价法评分与传统营养学指标(体质量指数、上臂肌围、小腿腓肠肌围和肱三头肌皮褶厚度)和血清实验室指标(白蛋白、前白蛋白、转铁蛋白和淋巴细胞百分比)均呈正相关，差异有显著性意义(P < 0.05)；微型营养评价法评分与总蛋白、淋巴细胞计数和血红蛋白之间的相关系数分别为0.159、0.187和0.196，差异无显著性意义(P > 0.05)。见表3。 2.6 隐性失血发生情况分析试验中234例患者的总失血量平均为1 298.47 mL，占原血容量的30.1%；隐性失血总量平均为517.03 mL，占总失血量的39.8%。各分组患者置换前后红细胞压积、总失血量及其占原血容量比例、置换后失血量、置换后出血量、隐性失血量及其占总失血量比例和发生高隐性失血量的患者例数，见表4。根据平均隐性失血量占总失血量的比例将患者分为低隐性失血量组(< 39.82%)和高隐性失血量组 (> 39.82%)，其中低隐性失血量组有133例患者，高隐性失血量组有101例患者。高隐性失血发生率分析：如图2H所示，在营养良好、潜在营养不良和营养不良3组患者中，高隐性失血发生率随着营养状态的恶化而逐渐升高，高隐性失血发生率两两之间比较，差异均有显著性意义(P < 0.05)； 2.7 隐性失血与微型营养评价法评分和血清营养学指标的关系见表5。高隐性失血量组置换前微型营养评价法评分、白蛋白、前白蛋白、转铁蛋白和淋巴细胞百分比的平均值明显低于低隐性失血量组(P < 0.05，P < 0.01)；高隐性失血量组置换后白蛋白、前白蛋白、转铁蛋白、淋巴细胞百分比和血红蛋白的平均值明显低于置换前(P < 0.05，P < 0.01)。为了进一步明确隐性失血患者的血清营养学指标在关节置换前后的变化规律及隐性失血量与血清营养学指标之间的关系，并排除这些指标数值的差异变化波动对实验结果的干扰，文章对经关节置换前后血清营养学指标评估的隐性失血发生率(按照血清营养学指标标准评估为营养不良患者的数量/高或低隐性失血量患者的总数量)进行比较后发现：置换前高隐性失血量组白蛋白、前白蛋白、转铁蛋白、淋巴细胞计数、淋巴细胞百分比和血红蛋白评估的隐性失血发生率明显高于低隐性失血量组(图3B-G；P < 0.01)，置换后高隐性失血量组总蛋白、白蛋白、前白蛋白、转铁蛋白、淋巴细胞计数、淋巴细胞百分比和血红蛋白评估的隐性失血发生率明显高于低隐性失血量组(图3A-G；P < 0.01)；高隐性失血量组置换后总蛋白、白蛋白、前白蛋白、转铁蛋白、淋巴细胞百分比和血红蛋白评估的隐性失血发生率明显高于置换前(图3A-D，F-G；P < 0.01)。 2.8 高隐性失血与微型营养评价法评分和血清营养学指标的相关性高隐性失血与置换前微型营养评价法评分、白蛋白、前白蛋白、转铁蛋白、淋巴细胞百分比和血红蛋白均呈正相关，差异有显著性意义(P < 0.05)；高隐性失血与总蛋白和淋巴细胞计数之间的相关系数分别为0.133和0.197，差异无显著性意义(P > 0.05)。见表6。"

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