氨甲环酸静脉联合局部用药减少初次单侧膝关节置换出血

Clinical study of tranexamic acid combined with topical application for reducing blood loss in primary unilateral knee arthroplasty

目的探讨氨甲环酸静脉联合局部用药在初次单侧膝关节置换的减少出血量的临床效果。方法于2017年1月至2018年1月选取青岛大学附属医院西海岸医疗中心符合标准的初次行单侧膝关节置换术的患者100例,按照随机数字表法分成实验组和对照组。实验组在切皮前给予氨甲环酸1 g溶于100 ml 5%葡萄糖溶液静脉滴注,并在关闭切口后通过引流管向关节腔注射氨甲环酸20 ml(含氨甲磺酸1 g)。对照组在切皮前给予氨甲环酸1 g溶于100 ml 5%葡萄糖溶液静脉滴注,但在关闭切口后通过引流管向关节腔注射生理盐水20 ml。术后均夹闭引流管闭2 h,术后24 h拔除引流管。分析两组患者的总失血量、置换后引流量、术前和术后第2、3、5天的血红蛋白含量,术后3 h的凝血指标,术后输血人数,术后3个月出现下肢深静脉血栓及肺栓塞人数、有无膝关节感染发生。计量资料采用t检验,计数资料采用卡方检验进行统计学分析。结果实验组的总失血量(t=-5. 29,P <0. 01)、术后引流量(t=-5. 35,P <0. 01)均明显低于对照组,差异有统计学意义;两组患者血红蛋白的量都有下降,实验组的血红蛋白的含量术后第2天(t=2. 19,P <0. 05)、第3天(t=2. 07,P <0. 05)及第5天(t=2. 23,P <0. 05)明显高于对照组,差异有显著统计学意义;实验组的输血率(10%)明显少于对照组的输血率(27%)(2=4. 356,P <0. 05);置换3 h后两组患者的凝血指标包括PT(t=2. 19,P <0. 05)、APTT(t=-0. 78,P <0. 05)、TT(t=-1. 69,P <0. 05)及纤维蛋白原(t=-0. 82,P <0. 05)无明显差异;两组患者3月随访时间内均未出现下肢深静脉血栓及肺栓塞、膝关节感染。结论氨甲环酸静脉滴注联合关节腔注射能够显著地减少膝关节置换术后患者的出血量,减缓血红蛋白的降低,减少对输血的需求,同时不增加血栓的风险。

Objective To investigate the clinical study of tranexamic acid combined with topical drug in reducing the amount of bleeding in the first unilateral knee joint replacement.Methods From January 2017 to January 2018,100 patients who underwent primary knee replacement at the West Coast Medical Center of Qingdao University Affiliated Hospital were randomly divided into experimental group and control group according to the random number table method.In the experimental group,1g of tranexamic acid was intravenously instilled in 100 ml of 5%glucose solution before the incision,and 20 ml of tranexamic acid(containing 1 g of methanesulfonic acid)was injected into the joint cavity through the drainage tube after the incision was closed.The control group was given intravenous infusion of 1 g of tranexamic acid in 100 ml of 5%glucose solution before the incision,but 20 ml of physiological saline was injected into the joint cavity through the drainage tube after the incision was closed.The drainage tube was closed in the first 2 h after operation in both groups,and the drainage tube was removed 24 h after operation.The total blood loss,drainage fluid after replacement,preoperative hemoglobin content,hemoglobin content on the 2 nd,3 rd,and 5 th postoperative day,and coagulation index at 3 h postoperatively were recorded and analyzed.The number of postoperative blood transfusions,the number of deep venous thrombosis and pulmonary embolism in the lower extremities three months after the surgery,and the number of knee joint infections were also recorded and analyzed.The t test or chi-square test data were performed for statistical analysis.Results The total blood loss(t=-5.29,P<0.01)and postoperative total volume of drained blood(t=-5.35,P<0.01)were less in the study group than in the control group.There was a decrease on the postoperative hemoglobin in both groups.Hemoglobin evolution in postoperative 48 h(t=2.19,P<0.05),72 hours(t=2.07,P<0.05)and 5 d(t=2.23,P<0.05)was significantly higher in the study group than in the control group.The rate of transfusion was less in the study group than in the control group,10%and 27%respectively(t=4.356,P<0.05).There was no significant difference on certain coagulation index,including PT(t=2.19,P<0.05),APTT(t=-0.78,P<0.05),TT(t=-1.69,P<0.05)and fibrinogen(t=-0.82,P<0.05),in both groups three hours postoperatively.There was no case of symptomatic deep vein thrombosis or pulmonary embolism or knee joint infection in both groups during the three months of follow-up.Conclusion Tranexamic acid of intravenous infusion in combination with intra-articular injection can significantly reduce the amount of blood loss after knee arthroplasty,slow the decrease of hemoglobin,and reduce the need for blood transfusion without increasing the risk of thrombosis.