氨甲环酸不同用药方法对膝关节置换术术后失血量和凝血功能的影响

Effects of different methods of tranexamic acid on blood loss and coagulation function after total knee arthroplasty

目的探讨氨甲环酸局部注入和静脉应用对膝关节置换术患者术后失血量和凝血功能的影响。方法选取2017年2月至2018年5月深圳市人民医院收治的120例拟行膝关节置换术患者为研究对象,根据随机数表法将患者分为局部应用组38例、静脉应用组42例和对照组40例。局部应用组患者在行膝关节置换术成功后放置引流管并缝合关节囊,夹闭引流管4 h后通过引流管注入氨甲环酸;静脉应用组患者在术毕缝合切口前静脉滴注氨甲环酸10 mg/kg;对照组在术毕缝合切口前静脉滴注同等剂量的0.9%氯化钠溶液并不夹闭引流管。比较三组患者术后血红蛋白(Hb)水平和纤维蛋白原浓度以及凝血酶原时间、活化部分凝血活酶时间,并通过容积法计算患者术中出血量、术后引流量、隐性失血量、总失血量,于术后1周行双下肢静脉超声检查是否存在下肢深静脉血栓(DVT),于术后1个月、3个月、6个月复查有无下肢DVT。应用WOMAC指数比较三组治疗前后膝关节功能。结果局部应用组、静脉应用组和对照组患者术后引流量[(182.54±41.05) mL vs (265.77±50.61) mL vs (355.64±52.06) mL]及总失血量[(891.04±151.28) m L vs (1006.33±157.91) mL vs (1121.28±162.42) mL]比较,局部应用组、静脉应用组明显低于对照组,差异均有统计学意义(P<0.05);局部应用组、静脉应用组和对照组患者第1天[(113.54±11.72) g/L vs (105.72±10.08) g/L vs (90.82±9.88) g/L]、第3天[(107.05±10.66) g/L vs (94.77±9.62) g/L vs (85.38±9.24) g/L]、第5天[(119.04±10.71) g/L vs (112.42±10.08) g/L vs (100.15±9.52) g/L] Hb水平比较,局部应用组和静脉应用组均明显高于对照组,并且局部应用组在第1天、第3天Hb水平明显高于静脉应用组,差异均有统计学意义(P<0.05);局部应用组、静脉应用组和对照组患者纤维蛋白原[(3.73±0.28) g/L vs (3.64±0.21) g/L vs (3.48±0.22) g/L]比较,局部应用组明显高于静脉应用组和对照组,静脉应用组明显高于对照组,差异均有统计学意义(P<0.05);三组患者术后行下肢静脉超声未查出深静脉血栓发生,随访6个月同样未查出下肢静脉血栓;局部应用组、静脉应用组和对照组患者术后WOMAC指数分别为37.5±2.6、36.7±2.2和35.8±3.4,差异无统计学意义(P>0.05)。结论局部应用氨甲环酸较静脉滴注更能够有效地减少患者手术失血量,阻止纤维蛋白原的降解,且不会增加下肢深静脉血栓发生,相对于静脉滴注效果更好。

Objective To investigate the effects of local injection and intravenous application of tranexamic acid on blood loss and coagulation function after knee arthroplasty. Methods A total of 120 patients undergoing knee arthroplasty were divided into local injection group (38 cases), intravenous application group (42 cases), and control group (40 cases) according to random number table. In local injection group, after successful knee arthroplasty, drainage tube was placed and articular capsule was sutured, and tranexamic acid was injected through the drainage tube 4 hours after the drainage tube was clamped. In the intravenous application group, 10 mg/kg tranexamic acid was infused intravenously before suture incision. In the control group, the same dose of 0.9% sodium chloride solution was infused intravenously before suture incision after operation, and the drainage tube was not clamped. The concentration of hemoglobin (Hb) and fibrinogen, prothrombin time, and activated partial thromboplastin time were compared among the three groups. The volume method was used to calculate the intraoperative blood volume, postoperative drainage volume, occult blood loss, and total blood loss. The lower extremity deep venous thrombosis (DVT) was examined one week after operation. WOMAC index was used to compare knee joint function before and after treatment in three groups. Results The postoperative drainage volume, total blood loss were (182.54±41.05) mL,(891.04±151.28) mL in the local injection group, and (265.77±50.61) mL,(1 006.33±157.91) mL in the intravenous application group, significantly lower than (355.64± 52.06) mL,(1 121.28±162.42) mL in the control group (P<0.05). The levels of Hb in the three groups were (113.54± 11.72) g/L,(105.72±10.08) g/L,(90.82±9.88) g/L on the first day,(107.05±10.66) g/L,(94.77±9.62) g/L,(85.38±9.24) g/L on the third day,(119.04±10.71) g/L,(112.42±10.08) g/L,(100.15±9.52) g/L on the fifth day. The Hb levels in local injection group and intravenous application group were significantly higher than those in the control group, and the Hb levels in local injection group were significantly higher than those in intravenous application group on the first and third day (P<0.05). The fibrinogen of patients in local injection group, intravenous application group, and control group were (3.73±0.28) g/L,(3.64±0.21) g/L,(3.48±0.22) g/L, respectively, which was significantly higher in local injection group than the intravenous application group and the control group, and also in the intravenous application group than the control group (P<0.05). No deep venous thrombosis was found in the three groups after operation, and no lower limb venous thrombosis was found in the follow-up period of 6 months. There was no significant difference in WOMAC index among the three groups (P>0.05), which were 37.5±2.6, 36.7±2.2, 35.8±3.4, respectively. Conclusion Local injection of tranexamic acid is more effective than intravenous drip in reducing blood loss and preventing fibrinogen degradation, and does not increase the occurrence of deep vein thrombosis of lower extremity, which is therefore considered more effective than intravenous drip.