静脉联合关节腔内注射氨甲环酸后引流管夹闭时间对人工全膝关节置换术后失血量的影响及安全性评价

Effect on time of temporarily-closed wound drainage on blood loss of primary total knee arthroplasty after intravenous and intra-articular injection of tranexamic acid

目的探讨静脉滴注联合关节腔内注射氨甲环酸后引流管夹闭时间对人工全膝关节置换术(total knee arthroplasty,TKA)术后失血量的影响并评价其安全性。方法于2015年9月—2016年7月拟行单侧初次TKA的102例患者中,选取80例符合选择标准的女性患者纳入研究。所有患者随机分为对照组(A组)、30 min组(B组)、60 min组(C组)和90 min组(D组),每组20例。4组患者年龄、体质量指数、患膝侧别、病因、病程以及术前血红蛋白、白蛋白、红细胞压积等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。所有患者均于松止血带前10 min静脉滴注氨甲环酸氯化钠100 m L(含1 g氨甲环酸)。关闭切口后,B、C、D组通过引流管向关节腔内注射相同浓度氨甲环酸氯化钠60 m L并夹闭引流管,A组同法注射60 m L生理盐水;A、B组于引流管夹闭后30 min、C组于60 min、D组于90 min后恢复引流。记录各组患者术后24 h引流量、总失血量,术后血红蛋白、白蛋白减少量,术后输血次数及输血量,以及下肢深静脉血栓形成、肺栓塞发生情况。结果 B、C、D组术后24 h引流量及总失血量均少于A组,其中C、D组与A组比较差异有统计学意义(P<0.05),B组与A组比较差异无统计学意义(P>0.05)。B组术后24 h引流量高于C、D组,且与D组比较差异有统计学意义(P<0.05);C、D组间比较差异无统计学意义(P>0.05)。B、C、D组总失血量组间比较差异无统计学意义(P>0.05)。A^D组血红蛋白、白蛋白减少量呈逐渐降低趋势,但各组间差异无统计学意义(P>0.05)。所有患者术后均无下肢深静脉血栓形成及肺栓塞发生。D组1例患者术后第3天白蛋白28 g/L,静脉输入人血白蛋白20 g;其余患者均未输血。结论静脉滴注联合关节腔内注射氨甲环酸可减少TKA围手术期失血量;关节腔内注射氨甲环酸后引流管夹闭60 min后再恢复引流止血效果最佳,并且不增加症状性下肢深静脉血栓形成和肺栓塞发生率。

Objective To investigate the effect and safety of time of temporarily-closed wound drainage on blood loss of primary total knee arthroplasty （TKA） after intravenous and intra-articular injection of tranexamic acid （TXA）. Methods Eighty female patients were selected from 102 patients who underwent primary TKA between September 2015 and July 2016, who were randomly divided into 4 groups： control group （group A）, 30 minutes group （group B）, 60 minutes group （group C）, and 90 minutes group （group D）, 20 patients each group. No significant difference was found in age, body mass index, side, pathogen, duration, and preoperative hemoglobin, albumin, and hematocrit between 4 groups （P〉0.05）. All the patients received intravenous injection of 1 g TXA at 10 minutes before removing the tourniquet. The patients in group A were injected with 60 mL normal saline into the articular cavity and closed drainage after surgery, while the patients in groups B, C, and D were injected with 60 mL TXA into the articular cavity and closed drainage for 30, 60, and 90 minutes respectively. The volume of drainage at 24 hours after operation, the total blood loss, the postoperative hemoglobin level, maximum hemoglobin loss, albumin loss, the volume and frequency of blood transfusion, venous thrombo embolism rate, and pulmonary embolism rate were recorded and compared between groups. Results The volume of drainage and total blood loss in groups B, C, and D were less than those of group A, showing significant difference between groups C, D and group A （P〈0.05）, but no significant difference between group B and group A （P〉0.05）. The volume of drainage at 24 hours after operation in group B was higher than that in groups C and D, showing significant difference between groups B and D （P〈0.05）, but no significant difference was found between groups C and D （P〉0.05）. There was no significant difference in the total blood loss between groups B, C, and D （P〉0.05）. The hemoglobin loss and albumin loss gradually decreased from groups A to D, but no significant difference was found between groups （P〉0.05）. No venous thrombo embolism and pulmonary embolism occurred. The hemoglobin value decreased to 28 g/L at 3 days after operation in 1 patient of group D, who received venous transfusion of 20 g human albumin. Conclusion Intravenous and topical application of TXA in TKA can significantly decrease postoperative bleeding. Topical TXA combined with 60 minutes temporarily-closed wound drainage may reduce postoperative blood loss to the greatest extent without increasing the risk of venous thrombo and pulmonary embolism event after TKA.