狭颅症儿童颅骨修补术中出血量的影响因素

doi:10.3969/j.issn.1674-8115.2023.04.007

摘要/Abstract

摘要：

目的·分析和探讨择期行开放性颅骨修补手术的狭颅症（颅缝早闭）患儿术中出血量的影响因素。方法·回顾性收集2013年6月—2019年6月在上海交通大学医学院附属上海儿童医学中心诊断为颅缝早闭，并择期行开放性颅骨修补术患儿的临床资料，包括年龄、性别、身长、体质量、早闭颅缝类型、早闭颅缝数量、既往颅面部手术史、症状持续时间、家族史、手术时间、手术方式、术中出血量、术中血制品输注量、术中输液量以及止血药物使用等。根据术中出血量是否超过其自身循环总血容量的20%分为大出血组（≥20%）和非大出血组（<20%）。采用单因素分析和二元Logistic回归模型对2组的临床资料进行比较。结果·共纳入239例患儿，其中大出血组215例、非大出血组24例。单因素分析结果显示2组患儿在年龄、体质量、身长、术中最低体温、早闭颅缝类型和手术方式等方面的差异存在统计学意义，其中大出血组患儿年龄、体质量、身长、术中最低体温均低于非大出血组（均P<0.05），大出血组患儿术中红细胞悬液输入量高于非大出血组（P<0.05）。其余临床资料在2组间差异无统计学意义。二元Logistic回归分析结果提示体质量（B=-0.24，OR=0.79，95%CI 0.64~0.96，P=0.018）是儿童开放性颅骨修补术中大量出血的独立危险因素。根据二元Logistic回归分析结果绘制受试者操作特征曲线（receiver operator characteristic curve，ROC曲线），曲线下面积（area under the curve，AUC）为0.69（95%CI 0.57~0.81）。进一步计算约登指数为0.392，对应的体质量界值为10.45 kg。结论·狭颅症择期行颅骨修补术患儿体质量越小，术中发生大出血的风险越大，特别是体质量小于10.45 kg的患儿。

关键词: 颅缝早闭, 儿童, 颅骨修补手术, 大出血, 危险因素

Abstract:

Objective ·To analyze and explore the risk factors influencing intraoperative blood loss in pediatric patients during open cranial repair for craniosynostosis. Methods ·The clinical data of pediatric patients diagnosed as having craniosynostosis undergoing open cranial repair from June 2013 to June 2019 in Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine were retrospectively collected, including age, gender, weight, body length, type of craniosynostosis, number of sutures, previous craniofacial surgery, the duration of symptoms, family history, operation duration, operation type, intraoperative blood loss, amount of blood products, amount of fluid transfusion, the use of hemostatic drugs and so on. According to whether intraoperative blood loss exceeded 20% of the total blood volume, all patients were divided into massive bleeding group (≥20%) and non-massive bleeding group (<20%). The clinical data of the two groups were compared and analyzed by univariate analysis and binary Logistic analysis, and the risk factors of intraoperative blood loss were explored. Results ·A total of 239 children were included, including 215 cases in the massive bleeding group and 24 cases in the non-massive bleeding group. Univariate analysis showed that there were differences in age, weight, body length, lowest body temperature during operation, craniosynostosis type and operation type between the two groups. Patients with massive bleeding amounts had lower age, weight, body length, and lowest body temperature than those in the non-massive bleeding group (all P<0.05). There was no difference in other clinical data between the two groups. Binary Logistic regression analysis showed that body weight (B=-0.24, OR=0.79, 95%CI 0.64?0.96, P=0.018) was an independent risk factor for intraoperative massive bleeding in craniosynostosis surgery. Receiver operator characteristic curve (ROC curve) was obtained based on binary Logistic regression model. The area under the curve (AUC) was 0.69 (95%CI 0.57?0.81). Youden index was further calculated to be 0.392, and the corresponding body weight threshold was 10.45 kg. Conclusion ·The lower body weight of children with craniosynostosis are, the higher incidence of massive hemorrhage they have during open cranial repair, especially in children with body weight less than 10.45 kg.

Key words: craniosynostosis, child, craniosynostosis surgery, massive hemorrhage, risk factor

中图分类号:

R614.1

姜静, 卞勇, 郑吉建, 黄悦. 狭颅症儿童颅骨修补术中出血量的影响因素[J]. 上海交通大学学报（医学版）, 2023, 43(4): 453-458.

JIANG Jing, BIAN Yong, ZHENG Jijian, HUANG Yue. Factors influencing the amount of blood loss in pediatric patients during craniosynostosis surgery[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(4): 453-458.

图/表 2

参考文献 14

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Item	Massive bleeding group (n=215)	Non-massive bleeding group (n=24)	Z/χ² value	P value
Gender/n(%)			0.941	0.332
Male	140 (65.1)	18 (75.0)
Female	75 (34.9)	6 (25.0)
Age/month	11 (7, 21)	22 (10, 30)	-2.301	0.021
Weight/kg	9.6 (8.4, 11.0)	12.0 (10.1, 13.8)	-3.089	0.002
Body length/cm	75 (70, 82)	85 (74, 94)	-3.436	0.001
Previous craniofacial surgery/n(%)	14 (6.5)	3 (12.5)	1.172	0.507
Syndromic/n(%)	12 (5.6)	1 (4.2)	0.084	0.772
Hydrocephalus/n(%)	10 (4.7)	0 (0)	1.165	0.590
Family history/n(%)	2 (0.9)	0 (0)	0.225	0.642
Duration of symptom/month	9 (6, 17)	14 (6, 24)	-1.901	0.057
Preoperative Hb/(g·L^-1)	121 (113, 126)	125 (116, 130)	-1.369	0.171
Preoperative hematocrit/%	36.45 (38.00, 34.10)	37.20 (38.90, 35.30)	-1.664	0.096
Preoperative albumin/(g·L^-1)	41.4 (39.5, 44.2)	42.7 (39.9, 44.0)	-0.584	0.559
Lowest temperature in operation/℃	35.6 (35.0, 36.1)	36.1 (35.2, 36.4)	-2.131	0.033
Duration of surgery/min	215.5 (184.0, 243.0)	216.0 (176.0, 251.0)	-0.367	0.713
Amount of crystalloid and colloids infusion/mL	350 (200, 500)	400 (263, 575)	-0.763	0.446
Amount of blood products using
RBC transfusion/mL	300 (200, 300)	150 (150, 300)	-3.169	0.002
Plasma transfusion/mL	100 (0, 100)	100 (0, 100)	-1.506	0.132
FFP/n(%)	7 (3.3)	0 (0)	1.430	1.000
Cryoprecipitate/n(%)	8 (3.7)	0 (0)	0.924	1.000
Use of hemostatic drugs/n(%)
Hemocoagulase injection	111 (5.2)	8 (3.3)	2.890	0.089
Tranexamic acid	18 (8.3)	0 (0)	2.173	0.140
PPSB	13 (6.0)	0 (0)	1.535	0.373
Number of sutures/n(%)			4.148	0.126
1	134 (62.3)	10 (45.8)
2	64 (29.8)	12 (50.0)
≥3	17 (7.9)	1 (4.2)
Craniosynostosis type/n(%)			13.268	0.010
Scaphocephaly	64 (29.8)	6 (25.0)
Brachycephaly	16 (7.4)	2 (8.3)
Trigonocephaly	39 (18.1)	3 (12.5)
Plagiocephaly	17 (7.9)	1 (4.2)
Multiple	79 (36.7)	12 (50.0)
Type of operation/n(%)			8.482	0.033
CVR	117 (54.5)	15 (62.5)
FOA	8 (3.7)	2 (8.3)
CVR＋FOA	87 (40.5)	5 (20.8)
Others	3 (1.4)	2 (8.3)

Item	Massive bleeding group (n=215)	Non-massive bleeding group (n=24)	Z/χ² value	P value
Gender/n(%)			0.941	0.332
Male	140 (65.1)	18 (75.0)
Female	75 (34.9)	6 (25.0)
Age/month	11 (7, 21)	22 (10, 30)	-2.301	0.021
Weight/kg	9.6 (8.4, 11.0)	12.0 (10.1, 13.8)	-3.089	0.002
Body length/cm	75 (70, 82)	85 (74, 94)	-3.436	0.001
Previous craniofacial surgery/n(%)	14 (6.5)	3 (12.5)	1.172	0.507
Syndromic/n(%)	12 (5.6)	1 (4.2)	0.084	0.772
Hydrocephalus/n(%)	10 (4.7)	0 (0)	1.165	0.590
Family history/n(%)	2 (0.9)	0 (0)	0.225	0.642
Duration of symptom/month	9 (6, 17)	14 (6, 24)	-1.901	0.057
Preoperative Hb/(g·L^-1)	121 (113, 126)	125 (116, 130)	-1.369	0.171
Preoperative hematocrit/%	36.45 (38.00, 34.10)	37.20 (38.90, 35.30)	-1.664	0.096
Preoperative albumin/(g·L^-1)	41.4 (39.5, 44.2)	42.7 (39.9, 44.0)	-0.584	0.559
Lowest temperature in operation/℃	35.6 (35.0, 36.1)	36.1 (35.2, 36.4)	-2.131	0.033
Duration of surgery/min	215.5 (184.0, 243.0)	216.0 (176.0, 251.0)	-0.367	0.713
Amount of crystalloid and colloids infusion/mL	350 (200, 500)	400 (263, 575)	-0.763	0.446
Amount of blood products using
RBC transfusion/mL	300 (200, 300)	150 (150, 300)	-3.169	0.002
Plasma transfusion/mL	100 (0, 100)	100 (0, 100)	-1.506	0.132
FFP/n(%)	7 (3.3)	0 (0)	1.430	1.000
Cryoprecipitate/n(%)	8 (3.7)	0 (0)	0.924	1.000
Use of hemostatic drugs/n(%)
Hemocoagulase injection	111 (5.2)	8 (3.3)	2.890	0.089
Tranexamic acid	18 (8.3)	0 (0)	2.173	0.140
PPSB	13 (6.0)	0 (0)	1.535	0.373
Number of sutures/n(%)			4.148	0.126
1	134 (62.3)	10 (45.8)
2	64 (29.8)	12 (50.0)
≥3	17 (7.9)	1 (4.2)
Craniosynostosis type/n(%)			13.268	0.010
Scaphocephaly	64 (29.8)	6 (25.0)
Brachycephaly	16 (7.4)	2 (8.3)
Trigonocephaly	39 (18.1)	3 (12.5)
Plagiocephaly	17 (7.9)	1 (4.2)
Multiple	79 (36.7)	12 (50.0)
Type of operation/n(%)			8.482	0.033
CVR	117 (54.5)	15 (62.5)
FOA	8 (3.7)	2 (8.3)
CVR＋FOA	87 (40.5)	5 (20.8)
Others	3 (1.4)	2 (8.3)

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