接受围手术期标准加速康复管理的颅内动脉瘤患者营养状态与显微外科夹闭术后并发症关系研究 The Relationship between Nutritional Status and Postoperative Complications in Patients Undergoing Microsurgical Clipping of Intracranial Aneurysms Based on Peri-operative Enhanced Recovery

目的 调查接受围手术期标准加速康复管理的颅内前循环动脉瘤患者营养状态、营养支持与显微外科夹闭术后并发症的关系。 方法 前瞻性连续入组2018年1月-2019年3月接受显微外科夹闭手术治疗的颅内前循环动脉瘤患者，围手术期采用标准加速康复管理。收集患者的人口学资料，动脉瘤特点（部位、直径、是否破裂），既往病史（高血压和糖尿病），手术前后营养相关指标（营养风险、人体测量、实验室检查、营养支持方式等），术后并发症包括肺部感染、颅内感染、下肢深静脉血栓、卒中（缺血性卒中和颅内出血）等。根据术后至出院是否出现上述1项及以上并发症，分为并发症组和无并发症组，比较2组患者临床指标的差异，并通过多元logistic回归分析营养相关指标对颅内动脉瘤术后并发症的影响。 结果 共纳入颅内前循环动脉瘤患者97例，其中33例（34.02%）发生术后并发症，64例（65.98%）无并发症。并发症组术前动脉瘤破裂（12.1% vs. 0，P=0.009），高血压（72.7% vs. 50.0%，P=0.005）和糖尿病比例（9.0% vs. 3.1%，P=0.032）高于无并发症组；营养相关指标中术前BMI（26.37±6.58 kg/m2 vs. 24.61±3.32 kg/m2，P=0.015）、三头肌皮褶厚度（24.92±8.57 mm vs. 18.61±8.09 mm，P=0.001）、小腿围（37.60±3.067 cm vs. 36.06±3.44 cm，P=0.039）高于无并发症组，血红蛋白水平（136.06±13.93 g/L vs. 143.27±12.08 g/L，P=0.010）低于无并发症组；术后营养干预的比例（84.8% vs. 40.6%，P=0.030）以及口服营养补充（33.3% vs. 26.5%，P＜0.001）、肠内营养（12.1% vs. 0，P＜0.001）、肠外营养（39.3% vs. 14.0%，P＜0.001）支持的比例均高于无并发症组，肠外营养持续时间长于无并发症组[5.0（3.0～11.5）d vs. 1.0（1.0～3.5）d，P=0.009]。多元logistic分析显示术前高TSF（OR 1.230，95%CI 1.056～1.363，P=0.008）是动脉瘤患者术后并发症的危险因素，术后1 d白蛋白水平高（OR 0.734，95%CI 0.561～0.961，P=0.025）是术后并发症的保护因素。 结论 皮下脂肪增多可能会增加颅内动脉瘤患者显微外科夹闭术后至出院期间并发症的风险，而术后1 d时的白蛋白水平高可能减少术后并发症风险。 Abstract: Objective To investigate the effect of nutritional status on postoperative complications in patients who received microsurgical clipping of intracranial aneurysm and perioperative standard enhanced recovery. Methods This study prospectively enrolled consecutive patients who received microsurgical clipping of intracranial aneurysms and perioperative standard enhanced recovery at Beijing Tiantan Hospital from January 2018 to March 2019. The following data were collected including demographic information, aneurysm characteristics (location, diameter, rupture or not), medical history (hypertension, diabetes), perioperative nutritional parameters (nutritional risk, anthropometric measurements, laboratory test results, nutritional support, etc.), postoperative complications including pneumonia, intracranial infection, deep vein thrombosis of lower extremity and stroke (ischemic stroke and intracranial hemorrhage), etc. The patients were divided into complication group and non-complication group according to having at least one complication or not from the end of operation to discharge. The above indexes were compared between the two groups. Multivariate logistic regression analysis were used to evaluate the effects of perioperative nutritional indexes on the complications after microsurgical clipping of intracranial aneurysms. Results A total of 97 patients with intracranial aneurysm were recruited and underwent microsurgical clipping. Postoperative complications occurred in 33 patients (34.02%). The proportion of preoperative aneurysm rupture (12.1% vs. 0, P=0.009), hypertension (72.7% vs. 50.0%, P=0.005) and diabetes (9.0% vs. 3.1%, P=0.032) in complication group were higher than those in non-complication group, and nutritional parameters such as the preoperative BMI (26.37±6.58 kg/m2 vs. 24.61±3.32 kg/m2, P=0.015), triceps skin fold thickness (TSF) (24.92±8.57 mm vs. 18.61±8.09 mm, P=0.001), and calf circumference (37.60±3.067 cm vs. 36.06±3.44 cm, P=0.039) in complication group were higher than those in non-complication group, and the hemoglobin level (136.06±13.93 g/L vs. 143.27±12.08 g/L, P=0.010) was lower than that in non-complication group. The proportion of postoperative nutritional intervention (84.8% vs. 40.6%, P=0.030), oral nutrition supplements (33.3% vs. 26.5%, P