不同方式应用氨甲环酸对PFNA治疗老年不稳定股骨转子间骨折围手术期失血量研究

Effect of different application routes of tranexamic acid for perioperative bleeding of PFNA operation in elderly patients with unstable femoral intertorchanteric fracture

目的评估术前静脉滴注和局部应用氨甲环酸对老年不稳定股骨转子间骨折的患者行股骨近端防旋髓内钉(proximal femoral anti rotation intramedullary nail,PFNA)围手术期失血量的影响。方法2014年1月—2017年1月承德医学院附属医院收治的不稳定股骨转子间骨折行PFNA内固定的老年患者105例,根据患者入院顺序分为静脉治疗组、局部治疗组和对照组。静脉治疗组术前30min静脉滴注20mg/kg氨甲环酸,局部治疗组术中扩髓前给予2g氨甲环酸溶于20mL生理盐水打入髓腔,对照组不使用氨甲环酸。记录术前、术后1、3、5d血红蛋白及红细胞压积,3组隐性失血量、显性失血量、围手术期总失血量、输血率,记录术后5、28d血栓性并发症发生情况。结果静脉治疗组、局部治疗组、对照组围手术期失血量分别为(710. 6±120. 5) mL、(750. 7±115. 5) mL、(950. 8±110. 9) mL,隐性失血量(550. 5±42. 5) mL、(575. 5±43. 8) mL、(775. 5±41. 7) mL,与对照组比较均有统计学意义(P <0. 05),但静脉治疗组、局部治疗组相比,差异无统计学意义(P>0. 05)。显性失血量分别为(150. 5±42. 5) mL、(155. 5±43. 8) mL、(170. 5±41. 7) mL,静脉治疗组、局部治疗组、对照组两两相比,差异无统计学意义(P> 0. 05)。静脉治疗组、局部治疗组、对照组输血率为分别为8. 5%、11. 4%、42. 8%,与对照组相比,均有明显差异(P <0. 05),静脉治疗组和局部治疗组相比,差异无统计学意义(P> 0. 05)。结论氨甲环酸静脉滴注及局部髓腔用药均可明显降低PFNA固定不稳定股骨转子间骨折术后的失血量及输血率,以隐性失血为主,显性失血降低不明显,且不增加术后深静脉血栓、肺栓塞等并发症发生率。

Objective To evaluate the effect of preoperative intravenous infusion and topical tranexamic acid on perioperative blood loss in elderly patients with unstable femoral intertrochanteric fractures undergoing proximal femoral anti-rotation intramedullary nail(PFNA).Methods From Jan.2014 to Jan.2017,105 elderly patients with unstable intertrochanteric fractures in our hospital were treated with PFNA internal fixation.They were divided into the venous treatment group(group A),the local treatment group(group B)and the control group(group C).In group A,30min intravenous drip of 20mg/kg methicate was used before operation.In group B,2g tranexamic acid was dissolved in 20mL physiological saline into medullary cavity before expansion of the pulp,and group C did not use tranexamic acid.The hemoglobin and hematocrit before operation and at 1,3,5d after operation were recorded,the recessive blood loss,dominant blood loss,the blood transfusion rate,blood loss in the perioperative period were recorded,and the occurrence of thrombotic complications at 5,25d was recorded.Results The perioperative blood loss of the groups A,B and C was(710.6±120.5)mL,(750.7±115.5)mL,(950.8±110.9)mL,respectively,the recessive blood loss was(550.5±42.5)mL,(575.5±43.8)mL,and(775.5±41.7)mL,respectively,which had statistical difference in groups A and B when compared with group C(P >0.05).The dominant blood loss was(150.0±42.5)mL,(155.5±43.8)mL,(170.5±41.7)mL,respectively,and there was no difference among the three groups(P >0.05).The rate of blood transfusion in groups A,B and C was 8.5%,11.4%and 42.8%,respectively.There was significant difference between groups A and B in comparison to group C,and there was no significant difference between group A and B(P >0.05).Conclusion The intravenous drip of tranexamic acid and the use of local medullary cavity can significantly reduce the amount of blood loss and blood transfusion after PFNA fixation of unstable intertrochanteric fracture,mainly with recessive blood loss,obviously decrease the amount of dominant bleeding,and also can increase the incidence of postoperative complications such as DVT and PE.