Retrospective Study Of Influencing Factors Of Postoperative Outcomes In Patients With Traumatic Fractures In Our Hospital

ObjectiveThe retrospective cohort study was used to explore the outcome and prognosis of patients with traumatic fractures under different anesthesia methods in the real medical treatment in our hospital,and the relevant factors affecting the patient’s outcome were explored using multivariate regression analysis.It aims to improve the perioperative anesthesia management level,achieve the purpose of rapid recovery of patients,and provide real-world clinical research evidence.MethodsThe information of 699 patients with hip fracture and shoulder fracture in our hospital from March 1,2016 to August 31,2018 were enrolled through our hospital’s electronic medical record system（EMR,Zhejiang Renhe Technology）and networked anesthesia monitoring information management system（AIMS V5.1,Beijing Easymonitor Technology Co Ltd）.According to the use of anesthesia,the patients were divided into 331 patients receiving general anesthesia（GA）and 361 patients receiving regional block anesthesia（RA,including nerve block,spinal anesthesia,and spinal epidural anesthesia）.Collect basic information of patients during the perioperative period including the basic information of the patients（including age,gender,ASA classification,Charlesson comorbidity index（CCI））,surgical methods（open reduction and internal fixation,closed reduction internal fixation）,perioperative Mean arterial pressure（MAP）,heart rate（HR）（including MAP/HR1 during operation,MAP/HR₂ during operation,and MAP/HR₃ during operation）,preoperative and postoperative hemoglobin content（Hb）,intraoperative blood loss,blood transfusion volume,and postoperative complications（including postoperative delirium,new cerebral infarction,respiratory failure,heart failure,renal failure,deep vein thrombosis and death）.The patient’s basic situation and postoperative complications were based on the records in the hospital EMR case system;the surgical method,anesthesia method,and patient intraoperative circulation data were collected from the AIM V5.1 anesthesia monitoring system.The clinical retrospective cohort study was used to explore the impact of different anesthesia methods on the perioperative period of patients with traumatic fractures,and further multi-factor logistic regression analysis was used to explore the related factors of postoperative outcomes of patients with traumatic fractures.Results1.Effects of different anesthesia methods on perioperative period in patients with traumatic fractures1)Baseline characteristics of patients:There were no significant differences in gender,preoperative comorbidities,and ASA classification between the two groups of different anesthesia methods（all P values were>0.05）.However,in patients with lower extremity fractures,the RA group was older than the GA group（72.69±14.83 vs 76.29±14.51,P=0.003）,respectively;Compared with the GA group,intraspinal anesthesia is more used clinically,especially for patients>80 years old（P<0.001）.321 patients had hypertension before operation（45.9%）;186 patients with cardiovascular diseases which included coronary heart disease,arrhythmia,and valvular disease（26.6%）;99 patients with respiratory diseases（14.2%）;132 patients with cerebral infarction and senile dementia（accounting for 18.9%）;151 patients with diabetes（accounting for 21.6%）;16 patients with kidney disease（accounting for 2.3%）;8 patients with history of thrombosis（1.1%）;8patients with malignant tumor（1.1%）.There was no statistical difference in the preoperative comorbidities among patients with different anesthesia methods（all P values were>0.05）.According to the Charlson comorbidity index score,there was no statistical difference in the preoperative comorbidities between patients with different fracture sites and different age groups in the GA and RA groups（P values>0.05）.The comparison of surgical methods found that RA was applied more frequently in patients with closed reduction and internal fixation and artificial femoral head replacement,while GA was more selected in patients with open reduction and internal fixation and total hip replacement,and there were significant statistics between groups.The difference was significant（P=0.002,0.005）.2)Intraoperative baseline characteristics of patients:The intraoperative MAP and HR fluctuations were within 35%in all patients;The basic MAP of patients with different anesthesia methods had significant statistical differences at room admission（GA group 97.17±14.71mm Hg,RA group102.87±14.53mm Hg,P<0.001）;The intraoperative MAP and HR change rates were found to be significantly decreased in both groups.There was no statistically significant difference in the rate of change inΔMAP_1-2（P=0.342）.At the same time,HR was increased,compared with patients in the GA group.ΔHR_1-2in the RA group is relatively stable and has significant statistical differences（P<0.001）;Patients with upper limb fractures in the RA group had relatively stable intraoperative circulation,while patients with lower limb fractures in the RA group had the same blood pressure decline as the GA group;Before leaving the room after surgery,the MAP and HR in the GA group basically returned to the patient’s room level.Before leaving the room after surgery,the MAP and HR in the GA group basically returned to the patient’s room level.The changes inΔMAP_1-3 andΔHR_1-3 were small,but the MAP in the RA group when leaving the room was still significantly lower than the baseline MAP,especially in the RA group and it was lower than that of entering the room（13.64±15.60mm Hg）,and there was a significant statistical difference（P<0.001）.Compared with patients in the GA group,the blood loss and blood transfusion in the RA group were less,and there was a significant statistical difference（both P<0.001）.There was no significant statistical difference between the groups of the perioperative hemoglobin content change rate（ΔHb）（GA group 12.75±15.07 g/L,RA group 10.82±14.70 g/L）（P=0.094）.3)Postoperative outcome:Patients in the GA group and RA group had an ICU rate of 29.30%and 28.80%after surgery;Postoperative complication rates were 12.38%and 10.05%;Mortality during hospitalization was 1.2%and 1.4%,there was no statistical difference between the groups（P=1.000）.However,according to age group,further analysis of patients in the two groups of GA and RA found that compared with the GA group,the selection of RA in patients over80 years of age significantly reduced the occurrence of total postoperative complications,and there were statistical differences（24.1%and 14.7%,respectively,P=0.039）;There was no significant statistical difference between different age groups with different complications（all P>0.05）.It is suggested that the advantage of RA for postoperative outcomes is more significant in patients over 80 years old.In addition,no matter what type of anesthesia is received,the postoperative concurrency rate increases significantly with the patient’s age,and there is a significant statistical difference（P=0.000,0.003）.The incidence of delirium,respiratory failure,heart failure and postoperative acute renal failure in patients in the GA group increased with age and had significant statistical differences（P=0.030,0.000,0.014,0.042）;With the increase of age in the RA group,the complication rate also increased,but only postoperative heart failure had significant statistical significance（P=0.014）.The comparison of preoperative preparation time found that compared with the GA group,the preoperative preparation time of the RA group was relatively shorter（3.40±2.80 vs.2.85±2.15,P=0.004）.The operation time and hospital stay were shorter in the RA group,with significant statistical differences（all P values<0.05）.Hospitalization costs were lower in the RA group and significantly different from those in the GA group（P=0.003）.2、Analysis of influencing factors of postoperative outcome in patients with traumatic fractures1)Univariate analysis of postoperative outcomes in patients with traumatic fractures:Dividing the patient’s age into three age groups（<65,65～80,and>80）and found that as the age increased,the postoperative complication rate increased gradually,1.1%,7.8%,and 13.2%,respectively.There was a significant statistical difference between age groups（P=0.000）.In addition,as patients’ASA grade and Charlson comorbidity index increased gradually before surgery,their complication rate also increased significantly;There was a significant statistical difference between grades（P<0.001）.Patients with different surgical sites also had different postoperative outcomes.Compared with patients with upper limb fractures,patients with lower limb fractures had more postoperative complications,with significant statistical differences（9.5%and 2%,P=0.014）.Compared with different anesthesia methods,patients in the GA group had more postoperative complications.Compared with RA patients,there were significant statistical differences（11.9%and 5.4%,P=0.003）.The postoperative Hb of patients was divided into three categories according to>110g/L,90～110 g/L and<90 g/L.It was found that with the decrease of postoperative Hb,the postoperative complications gradually increased,with significant statistics difference（2.3%,9.5%and 13.8%,P<0.001）.Compared with patients who returned to the ward directly after surgery,the postoperative complications rate was higher in patients who were admitted to ICU after surgery（P<0.001）.2)Multivariate regression analysis of postoperative outcomes in patients with traumatic fractures:Multivariate Logistic regression analysis revealed that the elderly（>65 years old）,Charlson comorbidity index>2,Hb<110 g/L and postoperative ICU were all related factors of adverse outcomes in patients with traumatic fracture（all P<0.05）.In univariate analysis,preoperative ASA classification,surgical methods,and anesthesia methods that have an impact on the outcome of patients with traumatic fractures did not yield positive results in multivariate logistic regression analysis,suggesting that patient age,preoperative complications,post-hemoglobin content and postoperative ICU admission were more predictive of patient outcomes and more relevant to postoperative complications.3)Multivariate analysis of postoperative outcomes in patients with hip fractures of different anesthesia:Further univariate analysis of postoperative outcomes of patients with hip fractures under different anesthesia methods found that postoperative outcomes of patients receiving GA were associated with patient age,CCI,postoperative Hb,and postoperative transfer to ICU;while in the RA group,Postoperative outcomes were related to age,preoperative ASA classification,CCI,postoperative Hb,and postoperative ICU transfer（all P<0.05）.Multivariate logistic regression analysis was performed and found that the postoperative adverse outcomes of patients receiving GA were associated with CCI>2 and postoperative ICU transfer.In patients receiving RA,postoperative adverse outcomes were associated with preoperative ASA grade IV,preoperative Hb between 90-110g/L,postoperative Hb<110g/L,and postoperative ICU transfer（all P<0.05）.It is suggested that the related factors affecting the outcome of patients with hip fractures receiving different anesthesia methods are different.However,patients with more preoperative complications and transferred to ICU after surgery are at high risk for adverse outcomes.4)Multivariate analysis of correlation between perioperative MAP change rate and postoperative outcome:The multivariate logistic regression analysis of perioperative MAP fluctuations and postoperative outcomes collected from the electronic anesthesia recording system found that when the MAP maximum change rate（ΔMAPmax）≤15%during the perioperative period,Hb 90～110g/L and postoperative Hb<90g/L are risk factors for postoperative complications（P=0.047,0.049）.When the intraoperativeΔMAPmax（15%～30%）,the preoperative comorbidities CCI>2 and transferred to ICU was a risk factor for adverse outcomes（P=0.046,P<0.001）;whenΔMAPmax>30%,CCI>2 and receiving GA were risk factors for postoperative complications（P=0.019,0.014）.ConclusionsA clinical retrospective study of 699 patients with shoulder and hip trauma fractures in our hospital found that the effects of general anesthesia and regional block anesthesia on the perioperative circulation of fracture patients,the ICU rate,complications and mortality were also no significant differences.In elderly patients with hip fracture,spinal anesthesia is often used clinically,but general anesthesia is usually used for shoulder and hip complex fracture surgery.In addition,as patients age,postoperative complications increase,and the advantages of regional block anesthesia are mainly reflected in patients with fractures over 80 years of age.Multivariate Logistic regression analysis found that no matter what type of anesthesia,patient age,preoperative comorbidities,postoperative ICU transfer,and postoperative hemoglobin content are the relevant influencing factors for postoperative outcomes in patients with traumatic fractures.