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中华关节外科杂志(电子版) ›› 2021, Vol. 15 ›› Issue (05) : 521 -527. doi: 10.3877/cma.j.issn.1674-134X.2021.05.001

临床论著

全髋关节置换患者延迟出院相关危险因素分析
刘思源1, 唐晓宁2,†(), 陈攀宇2, 蒋欣余2, 刘玲2   
  1. 1. 610081　成都大学附属医院麻醉科
    2. 400042　重庆医科大学附属第一医院麻醉科
  • 收稿日期:2020-10-25 出版日期:2021-10-01
  • 通信作者: 唐晓宁

Analysis of risk factors for delayed discharge following total hip arthroplasty

Siyuan Liu1, Xiaoning Tang2,†(), Panyu Chen2, Xinyu Jiang2, Ling Liu2   

  1. 1. Department of Anesthesiology, Affiliated Hospital of Chengdu University, Chengdu 610081, China
    2. Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
  • Received:2020-10-25 Published:2021-10-01
  • Corresponding author: Xiaoning Tang
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引用本文：

刘思源, 唐晓宁, 陈攀宇, 蒋欣余, 刘玲. 全髋关节置换患者延迟出院相关危险因素分析[J/OL]. 中华关节外科杂志(电子版), 2021, 15(05): 521-527.

Siyuan Liu, Xiaoning Tang, Panyu Chen, Xinyu Jiang, Ling Liu. Analysis of risk factors for delayed discharge following total hip arthroplasty[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2021, 15(05): 521-527.

目的

探讨全髋关节置换(THA)术后延迟出院的危险因素。

方法

选择2017年1月至2020年6月重庆医科大学附属第一医院的择期单侧THA患者，排除多发损伤、病理性骨折等。以术后住院时间>6 d为延迟出院组，术后住院时间≤6 d为对照组。收集资料包括人口学特征、合并症数量、美国麻醉医师协会(ASA)分级、诊断、术前活动能力、术前住院时间、手术时长、麻醉方式、术中补液、术中尿量、术中失血量、是否输血、术后镇痛方法、Clavien-Dindo分级、术后24 h视觉模拟评分和下床时间。分析延迟出院的危险因素。单因素分析用卡方检验，多因素分析用logistic分析并计算比值比(OR)和95%置信区间(CI)。

结果

纳入756例患者中，术后住院时间中位数6 d，延迟出院组420例(55.6%)，对照组336例(44.4%)。多因素分析发现，年龄≥65岁[65~79岁与年龄<65岁比较：OR＝1.561，95%CI(1.097，2.222)，P＝0.013；年龄>79岁与年龄<65岁比较：OR＝2.787，95%CI(1.497，5.186)，P＝0.001]、骨折[OR＝1.710，95%CI(1.151，2.540)，P＝0.008]、术前住院时间[4~6 d与住院时间<4 d比较：OR＝2.024，95%CI(1.027，3.987)，P＝0.042；住院时间>6 d与住院时间<4 d比较：OR＝3.821，95%CI(1.766，8.267)，P＝0.001]、术中失血量>100 ml[OR＝1.773，95%CI(1.207，2.604)，P＝0.004]、Clavien-Dindo分级[2级与1级比较：OR＝2.437，95%CI(1.730，3.434)，P<0.001；分级>2级与1级比较：OR＝7.157，95%CI(1.581，32.400)，P＝0.011]和下床时间>24 h[OR＝1.683，95%CI(1.206，2.348)，P＝0.002]是THA患者延迟出院的独立危险因素。

结论

年龄、髋部骨折、术前住院时间、术中失血、并发症Clavien-Dindo分级和术后下床时间与THA术后延迟出院独立相关，临床中需要针对性地干预这些因素，以缩短术后住院时间，降低THA术后延迟出院的发生率。

关键词: 髋关节, 关节成形术, 住院时间, 危险因素
Objective

To investigate the risk factors of delayed discharge after total hip arthroplasty(THA).

Methods

The patients who underwent elective unilateral THA in the First Affiliated Hospital of Chongqing Medical University from January 2017 to June 2020 were enrolled and reviewed, the patients with multiple injuries and pathologic fractures were excluded. The patients with postoperative length of stay more than six days were assigned to the delayed discharge group, and with postoperative length of stay less than six days assigned to the control group.The correlation between clinical data, including demographic characteristics, American Society of Anesthesiologists(ASA) grade, diagnosis, preoperative activity of mobility, preoperative length of stay, duration of operation, anesthesia techniques, intraoperative rehydration, intraoperative urine output, intraoperative blood loss, blood transfusion, complications, postoperative analgesia, Clavien-Dindo classification, visual analogue scale for 24 h after operation and mobilization time and delayed discharge was analyzed. Chi-square test was used for univariate analysis. Logistic regression analysis was used for multivariate analysis and to calculate odds ratios(OR) and 95% confidence intervals(CI).

Results

Among the 756 cases, the median postoperatire hospital stay was six days, 420 cases in the delayed discharge group (55.6%), and 336 cases in the control group (44.4%). Age over 65 years[65 years to 79 years vs. age<65 years, OR=1.561, 95%CI(1.097, 2.222), P=0.013; age>79 years vs. age<65 years, OR=2.787, 95%CI(1.497, 5.186), P=0.001], hip fracture[OR=1.710, 95%CI(1.151, 2.540), P=0.008], preoperative hospital stay[4 d to 6 d vs. hospital stay<4 d, OR=2.024, 95%CI(1.027, 3.987), P=0.042; hospital stay>6 d vs. hospital stay<4 d, OR=3.821, 95%CI(1.766, 8.267), P=0.001], intraoperative blood loss>100 ml[OR=1.773, 95%CI(1.207, 2.604), P=0.004], Clavien-Dindo classification [level Ⅱ vs. under level Ⅰ, OR=2.437, 95%CI(1.730, 3.434), P<0.001; above level Ⅱ vs. levelⅠ, OR=7.157, 95%CI(1.581, 32.400), P=0.011], and mobilization>24 h[OR=1.683, 95%CI(1.206, 2.348), P=0.002] were independent risk factors for delayed discharge.

Conclusions

Age, hip fracture, preoperative hospital stay, intraoperative blood loss, Clavien-Dindo classification and postoperative mobilization were risk factors of delayed discharge after THA.These risk factors need to be intervened early to reduce the incidence of delayed discharge after THA.

Key words: Hip, Arthroplasty, Length of stay, Risk factor
表1 延迟出院危险因素的单因素分析[例(%)]
变量 正常出院组 延迟出院组 χ2值 P值
年龄(岁)        
  <65 200(59.5) 155(36.9)    
  65~79 117(34.8) 181(43.1) 51.774 <0.001
  >79 19(5.7) 84(20.0)    
性别     15.736 <0.001
  男 174(51.8) 157(37.4)    
  女 162(48.2) 263(62.6)    
BMI(kg/m2)        
  18.5~24 185(55.1) 238(56.7)    
  <18.5 20(6.0) 45(10.7) 7.145 0.028
  >24 131(39.0) 137(32.6)    
已婚        
  是 292(67.9) 335(79.8) 6．730 <0.01
  否 44(13.1) 85(20.2)
吸烟        
  是 108(32.1) 107(25.5) 4．077 0．043
  否 228(86.9) 313(74.5)
饮酒        
  是 92(27.4) 82(19.5) 6．504 0．011
  否 244(72.6) 338(80.5)
ASA分级        
  Ⅰ~Ⅱ 202(60.1) 177(42.1)    
  Ⅲ 130(38.7) 229(54.5) 25.487 <0.01
  >Ⅲ 4(1.2) 14(3.3)    
合并症数量        
  0 193(57.4) 172(41.0)    
  1 95(28.3) 140(33.3) 23.863 <0.001
  >1 48(14.3) 108(25.7)    
骨折        
  是 65(19.3) 180(42.9) 46．427 <0.001
  否 271(80.7) 240(57.1)
术前住院时间(d)        
  <4 27(8.0) 19(4.5)    
  4~6 272(81.0) 307(73.1) 19.212 <0.001
  >6 37(11.0) 94(22.4)    
术前独立活动        
  是 298(88.7) 305(72.6) 29．868 <0.001
  否 38(11.3) 115(27.4)
手术时长(h)        
  <2 246(73.2) 276(65.7)    
  2~3 84(25.0) 128(30.5) 6.144 0.046
  >3 6(1.8) 16(3.8)    
麻醉方式        
  全身麻醉 229(68.2) 303(72.1) 1．424 >0.05
  全身麻醉+神经阻滞 107(31.8) 117(27.9)
术中补液量(ml)        
  <1 500 254(75.6) 292(69.5) 3．430 >0.05
  ≥1 500 82(24.4) 128(30.5)
术中失血量(ml)        
  ≤100 274(81.5) 301(71.7) 10．008 <0.01
  >100 62(18.5) 119(28.3)
输血        
  是 7(2.1) 25(6.0) 6．893 <0.01
  否 329(97.9) 395(94.0)
术中少尿        
  是 14(4.2) 27(6.4) 1．862 >0.05
  否 322(95.8) 393(93.6)
术后镇痛        
  PCIA 147(43.8) 160(38.1)    
  单次神经阻滞+PCIA 51(15.2) 70(16.7) 2.475 >0.05
  PCNA 138(41.1) 190(45.2)    
术后口服曲马多        
  是 72(21.4) 119(25.3) 4．713 0．03
  否 264(78.6) 301(71.7)
术后24 h VAS评分        
  0~3 150(44.6) 188(44.8)    
  4~6 136(40.5) 189(45.0) 4.160 >0.05
  7~10 50(14.9) 43(10.2)    
Clavien-Dindo分级        
  1级 255(75.9) 197(46.8)    
  2级 79(23.5) 205(48.8) 67.646 <0.001
  >2级 2(0.6) 18(4.3)    
术后下床时间(d)        
  ≤1 155(46.1) 109(26.0) 33．444 <0.001
  >1 181(53.9) 311(74.0)
表2 延迟出院危险因素的多因素分析
变量 β 标准误 Wald值 OR 95% CI P值
年龄(岁)            
  <65 - - - 1.000 - -
  65~79 0.445 0.180 6.116 1.561 (1.097，2.222) 0.013
  >79 1.068 0.322 10.457 2.787 (1.497，5.186) 0.001
  骨折 0.536 0.202 7.046 1.710 (1.151，2.540) 0.008
术前住院时间(d)            
  <4 - - - 1.000 - -
  4~6 0.705 0.346 4.154 2.024 (1.027，3.987) 0.042
  >6 1.341 0.394 11.593 3.821 (1.766，8.267) 0.001
  术中失血>100 ml 0.572 0.196 8.511 1.773 (1.207，2.604) 0.004
Clavien-Dindo分级            
  1级 - - - 1.000 - -
  2级 0.891 0.175 25.926 2.437 (1.730，3.434) <0.001
  >2级 1.968 0.770 6.524 7.157 (1.581，32.400) 0.011
术后下床时间>24 h 0.520 0.170 9.371 1.683 (1.206，2.348) 0.002
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