Clinical Study Of Perioperative Stroke-associated Pneumonia In Patients With Aneurysmal Subarachnoid Hemorrhage

Background:Stroke-associated pneumonia(SAP)is one of the common perioperative complications in patients with aneurysmal subarachnoid hemorrhage(a SAH).The latest literature has found that SAP may lead to an increased risk of poor prognosis in a SAH patients after interventional surgery,which is related to longer hospital stay and increased medical costs.The purpose of this study was to explore the risk factors of SAP in patients with a SAH after interventional surgery and to establish a risk score.Objective:1.To investigate the risk factors of stroke-associated pneumonia in patients with subarachnoid hemorrhage of aneurysms after interventional surgery and to establish a risk score for stroke-associated pneumonia after interventional surgery.2.To investigate the relationship between postoperative complications,in-hospital mortality and sex and age in patients with subarachnoid hemorrhage after interventional surgery.3.To explore whether there is weekend effect in the treatment of aneurysm subarachnoid hemorrhage after interventional surgery.Methods:the clinical data of 411 patients with a SAH who received interventional surgery in the Department of Neurosurgery of Qingdao Municipal Hospital were collected retrospectively.The baseline data of the patients(including past medical history,Hunt-Hess score,GCS,WFNS score,modified Fisher grade,etc.),related blood indexes and prognosis at discharge(modified Rankin score)were collected.1.The case data were divided into training group(n=318)and verification group(n=93).In the training group,χ~2 test,Fisher exact test,independent sample t test,Mann-Whitney U test and multivariate logistic regression analysis were used to explore the risk factors of SAP after interventional operation.Multivariate logistic regression was used to establish a new risk score for predicting the occurrence of SAP after interventional surgery.2.Draw the ROC curve of the new score and calculate the area under the curve(AUC)to reflect the recognition ability of the score.The fitting degree of the new score was evaluated by Hosmer-Lemeshow test and drawing correction curve.The stability of the new score was tested by 1000 times of Bootstrap self-help sampling.3.The new score was brought into the verification group to calculate the probability of SAP after interventional surgery and draw the ROC curve and calculate AUC to further verify the score.4.The patients were divided into 4 groups according to their sex and age(young and middle-aged men,young and middle-aged women,old men,and old women).Logistic regression analysis was used to evaluate the relationship between sex,age,complications,and prognosis of a SAH patients.5.According to the hospitalization time of working days or legal rest days,the patients were divided into two groups to analyze whether there was weekend effect in the treatment of a SAH in our hospital.Results:1.Among all a SAH patients after interventional surgery,young and middle-aged men accounted for 27.7%(median age 52 years old),elderly male group accounted for 6.3%(median age 71 years old),young and middle-aged female group accounted for40.1%(median age 55 years old),and elderly female group accounted for 25.9%(median age 72 years).The proportion of men who had a history of smoking was higher,while The levels of hemoglobin and serum potassium were lower in the female group at admission.Compared with other groups,the incidence of hypertension and coronary heart disease was higher,the level of blood glucose was higher,and the level of hemoglobin was lower in the elderly female group.In addition,the WFNS score,and modified Fisher grade of the elderly group were higher than those of the young and middle-aged group.The hospital mortality rate was higher in the elderly male group,and there was no significant difference among the other groups.2.In terms of complications after interventional surgery,the incidence of SAP in young and middle-aged women was lower(OR=0.318,95%CI 0.131-0.773,p=0.012),and the incidence of hypokalemia was higher(OR=6.307,95%CI 3.07-12.955,p<0.001).The incidence of SAP(OR=2.297,95%CI 1.017-5.188,p=0.046)and hypokalemia(OR=7.493,95%CI 3.314-16.944,p<0.001)were higher in the elderly female group than those in the control group.3.Of the 318 patients with a SAH in the training group,63developed SAP after interventional surgery,with an incidence of 19.8%.Univariate analysis showed that the age,WFNS score,modified Fisher grade and Hunt-Hess score of patients in SAP group were higher.In laboratory examination,white blood cells,neutrophils,lymphocytes,monocytes,blood glucose and serum creatinine in SAP group were higher than those in non-pneumonia group.4.Multivariate Logistic regression analysis showed that age>65 years old(OR=3.17,P=0.002),smoking history(OR=2.824,P=0.026),World Federation of Neurosurgical Associations(WFNS)grade≥4(OR=2.465,P=0.029),modified Fisher grade≥3(OR=3.114,P=0.01)and admission leukocyte count(OR=1.176,P<0.001)were independent risk factors for SAP in patients with a SAH after interventional surgery.5.Using the results of multivariate Logistic regression,the new risk score(AUC)for predicting the occurrence of SAP in a SAH patients after interventional surgery was 0.856(95%CI 0.807-0.904).The average AUC of the score obtained by 1000 Bootstrap self-sampling was 0.856 and 95%confidence interval was0.854-0.858.The results of Hosmer-Lemeshow test showed that there was no significant difference between the predicted value of the score and the actual observation(P=0.993).6.The AUC of the new score in the verification group was 0.968(95%CI 0.938-0.998),indicating that the differentiation of the new score in the verification group was good.6.Regarding the weekend effect,the baseline data of the weekend group and the weekday group were similar,except that the incidence of hypertension was higher in the weekday group(64.5%vs.49.0%).There was no significant difference in neurological function score at admission,prognosis score at discharge,complications and in-hospital death between the two groups,but the length of stay in the weekend group was shorter than that in the working day group,and the number of cases with modified Fisher grade≥3 was less.Conclusion:1.Advanced age,smoking history,high WFNS score,high modified Fisher grade and elevated white blood cells at admission are independent risk factors for SAP in patients with a SAH after interventional surgery.The new risk score combined with the above five risk factors is helpful for clinicians to assess the risk of SAP on admission,identify people at high risk of SAP as early as possible,and adjust treatment strategies in time.two。2.In the young and middle-aged female group,the complications and hospital mortality of a SAH patients after interventional operation were lower.The risk of postoperative complications increased in the elderly female group,and the hospital mortality rate was higher in the elderly male group.There was no obvious weekend effect in the process of interventional surgery in Qingdao Municipal Hospital for 3.a SAH patients.This shows that standardized procedures such as green channels and stroke units can provide the same quality of treatment for a SAH patients in need of emergency treatment.