鸡尾酒疗法减少全膝关节置换后隐性失血

Cocktail therapy reduces hidden blood loss after total knee arthroplasty

背景:全膝关节置换术后失血是比较常见的临床问题,会影响患者的置换效果。氨甲环酸作为一种止血药物,越来越多的被应用于减少人工关节置换术后出血,但是对同时使用氨甲环酸和其他药物止血效果的研究还很少。目的:评估初次单侧全膝关节置换术中局部应用鸡尾酒(氨甲环酸和肾上腺素混合液)对减少患者围手术期失血量、降低输血率的有效性和安全性。方法:将中日友好医院骨关节外科2013年7月至2015年10月入院拟行初次单侧全膝关节置换的113患者随机分为鸡尾酒组(57例)和氨甲环酸组(56例)。手术过程中在鸡尾酒组患者关节腔内注射鸡尾酒[3 g氨甲环酸和0.25 mg稀释肾上腺素(1∶200 000)的混合溶液],氨甲环酸组关节腔内单纯注射3 g氨甲环酸溶液,所有患者置换术后均不放置引流管。围手术期观察患者术中失血量、术后显性失血量、隐性失血量及异体输血量;在术后90 d内,观察患者有无症状性深静脉血栓和肺动脉栓塞的发生。结果与结论:(1)全膝关节置换时,与单纯局部应用氨甲环酸相比,鸡尾酒组患者手术总失血量(P=0.007)、隐性失血量(P=0.000)以及术后异体输血率(0%vs.5.4%)均较低,并且不增加患者血栓栓塞及血栓形成等并发症的风险(P>0.05);(2)结果提示,全膝关节置换时稀释肾上腺素联合使用氨甲环酸的止血效果优于单纯使用氨甲环酸,而且不会产生严重的不良反应,可作为减少全膝关节置换术后失血的重要方法。

BACKGROUND： Blood loss after total knee arthroplasty is a common problem that will affect the clinical effects. As a kind of hemostatic medicine, tranexamic acid has been more and more used in reducing bleeding after joint replacement. However, there are few studies concerning the combined use of tranexamic acid with other hemostatic drugs. OBJECTIVE： To evaluate the efficacy and safety of intra-articular administration of cocktail wine（tranexamic acid plus diluted-epinephrine） on perioperative blood loss and transfusion in primary unilateral total knee arthroplasty. METHODS： From July 2013 to October 2015, 113 patients scheduled to undergo total knee arthroplasty were randomized into two groups. Cocktail wine group（57 patients） received intra-articular cocktail wine（3 g tranexamic acid plus 0.25 mg diluted-epinephrine; 1：200 000）. Tranexamic acid group（56 patients） received 3 g topical tranexamic acid alone. All patients were not drain inserted after the operation. During perioperative period, intraoperative blood loss, postoperative dominant blood loss, occult blood loss and allogeneic blood transfusion were observed. Within postoperative 90 days, the incidences of symptomatic deep venous thrombosis and pulmonary embolism were observed.RESULTS AND CONCLUSION：（1） The topical administration of cocktail wine significantly reduced total blood loss（P = 0.007）, hidden blood loss（P=0.000） and transfusion rate（0% vs. 5.4%）, without increasing the risk of thromboembolic and hemodynamic complications（P〈0.05）.（2） Therefore, the hemostatic effect of topical tranexamic acid plus diluted-epinephrine was better than tranexamic acid alone. Their combination does not produce severe adverse reactions, and can be used as an important method to reduce blood loss after total knee arthroplasty.