围术期体温保护对全膝关节置换过程中凝血功能的影响

Effect of perioperative temperature protection on the coagulation function during total knee arthroplasty

背景:围术期低体温可能造成全膝关节置换患者凝血功能紊乱,导致手术失血增多。目的:对比观察围术期体温保护与非体温保护对全膝关节置换患者凝血功能的影响。方法:纳入40例ASAⅠ-Ⅱ级择期行全膝关节置换术患者,随机分为体温保护组和非体温保护组,毎组20例。体温保护组手术开始前保持室温26℃,手术开始后调节室温24℃;充气式保温毯覆盖非手术区域,38℃持续主动体表加温至术毕;输液加温装置保持输液温度37℃,术中冲洗液加温至37℃,全程减少不必要的身体暴露。非体温保护组患者仅予棉被覆盖,室温22℃;不用主动体表加温装置,室温液体输注,室温液体冲洗。分别记录2组患者在术前10 min、手术开始后1 h、手术结束后1 h的鼻咽温度,并分别抽取1.25 m L静脉血应用血栓弹力描记仪测定纤维蛋白形成时间、血凝块生成时间、最大振幅。记录手术失血量、术后24 h引流量。结果与结论:(1)与体温保护组比较,非体温保护组在手术结束后1 h时鼻咽温度显著低于体温保护组,差异有显著性意义(P<0.05);(2)体温保护组的出血量和24 h引流量均低于非体温保护组(P<0.05);(3)与体温保护组相比,手术开始后1 h、手术结束后1 h非体温保护组纤维蛋白形成时间、血凝块生成时间明显延长,手术结束后1 h非体温保护组的最大振幅明显缩短,差异有显著性意义(P<0.05);(4)综上,术中低体温造成膝关节置换患者血小板功能障碍、凝血因子活性抑制,导致手术失血量和引流量增加。使用术中体温保护措施减少体热丢失可以改善凝血功能,减少术中失血。

BACKGROUND： Perioperative hypothermia may lead to coagulation function for patients undergoing total knee arthroplasty, and an increase in blood loss. OBJECTIVE： To compare the influence of temperature protection with non-temperature protection on coagulation function in patients undergoing total knee arthroplasty. METHODS： Forty ASA I-II patients scheduled for total knee arthroplasty were randomly divided into temperature protection and non＊temperature protection groups （n=20 per group）. The patients in the temperature protection group underwent heat-preservation including preheating room temperature, actively blanket warmer, were infused or flushed with fluids of 37℃ by heating apparatus; the patients in the non-temperature protection group received full-body-covered cotton quilt only. The nasopharyngeal temperature were detected at postoperative 10 minutes, intraoperative 1 hour and postoperative 1 hour, and 1.25 mL of venous blood were collected to detect the fibrin formation time, blood clot formation time, and maximum amplitude using thrombelastography. Additionally, the intraoperative blood loss and volume of drainage at postoperative 24 hours were recorded. RESULTS AND CONCLUSION： （1） The nasopharyngeal temperature in the non-temperature protection group was significantly lower than that in the temperature protection group at postoperative 1 hour （P 〈 0.05）. （2） The intraoperative blood loss and volume of drainage at postoperative 24 hours in the temperature protection group were significantly less than those in the non-temperature protection group （P 〈 0.05）. （3） Compared with the temperature protection group, fibrin formation time and blood clot formation time at intraoperative and postoperative 1 hour were significantly lengthened, and maximum amplitude at postoperative 1 hour was significantly shortened in the non-temperature protection group （P 〈 0.05）. （4） These findings show that intraoperative hypothermia can weaken platelet function, inhibit coagulation factor activity, and increase the amount of blood loss and drainage. In the meanwhile, heat-preservation is able to reduce the loss of body heat, improve coagulation function and reduce blood loss for patients undergoing knee replacement.