股骨近端防旋髓内钉内固定治疗股骨转子间骨折失血量与静脉联合局部应用氨甲环酸的关系

Relationship between blood loss of proximal femoral nail anti-rotation fixation and local use combined with intravenous injection of tranexamic acid

背景:已经有相关文献研究证明,氨甲环酸能有效降低股骨近端防旋髓内钉内固定治疗股转子间骨折患者围术期的显性失血和隐性失血,且安全有效。目前对于该术中氨甲环酸的使用方式主要分为静脉输注及局部髓腔内灌注,静脉输注又分为单次使用或多次使用;而局部使用多为单次使用,对于静脉联合局部使用,现有国内外文献尚少有报道。而氨甲环酸的静脉联合局部使用在髋膝关节置换中已被证明安全有效。目的:探究静脉联合局部应用氨甲环酸减少股骨近端防旋髓内钉内固定治疗股骨转子间骨折围术期失血量的有效性及安全性。方法:纳入汕头市中医医院2016年1月至2018年12月行股骨近端防旋髓内钉内固定治疗股骨转子间骨折的90例患者,随机分为联合组、静脉组及局部组,每组30例。所有患者对治疗方案均知情同意,且得到医院伦理委员会批准。联合组在术前30 min时静脉滴注氨甲环酸(20 mg/kg,溶于100 mL生理盐水),并在近端扩髓后,于股骨髓腔内注射氨甲环酸(1g,溶于20mL生理盐水);静脉组患者仅术前静滴氨甲环酸(剂量、方法同联合给药组);局部组仅在近端扩髓后,于股骨髓腔内注射氨甲环酸(剂量、方法同联合给药组)。统计3组患者总失血量、显性出血量、隐性失血量、国际标准比率、凝血酶原时间、部分活化凝血酶原时间、输血率及深静脉血栓发生率,并进行比较。结果与结论:①总失血量比较:联合组低于静脉组及局部组,差异均有显著性意义(P<0.01);静脉组与局部组差异无显著性意义(P>0.05);②隐性失血量比较:联合组明显低于静脉组及给药组,差异均有显著性意义(P<0.001);静脉组与局部组差异无显著性意义(P>0.05);③显性出血比较;3组间差异无显著性意义(P>0.05);④术前、术后国际标准比率、凝血酶原时间,部分活化凝血酶原时间对比:3组差异无显著性意义(P>0.05);⑤输血率:3组差异无显著性意义(P>0.05);⑥3组患者术后均未发现深静脉血栓;⑦结果表明,与氨甲环酸单纯静脉滴注及单纯髓腔内注射相比,术前静滴联合术中髓腔内注射氨甲环酸能明显减少股骨近端防旋髓内钉内固定后股骨转子间骨折患者的总失血量、隐性失血量,且不增加术后深静脉血栓发生率;而单独静脉使用及单独髓腔内注射氨甲环酸在减少总失血量及隐性失血量方面无明显差异。

BACKGROUND:Tranexamic acid has been shown to effectively reduce dominant and hidden blood loss in patients undergoing proximal femoral nail antirotation fixation,and it is safe and effective.At present,the use of tranexamic acid in this operation is mainly divided into intravenous infusion and local intramedullary perfusion;intravenous infusion can be divided into single use or multiple uses,and most of the local use is single use.For the combined local use with intravenous infusion is rarely reported.However,the combined use of tranexamic acid in hip and knee arthroplasties has been proven to be safe and effective.OBJECTIVE:To explore the effectiveness and safety of intravenous combined with local application of tranexamic acid on the perioperative blood loss in proximal femoral nail antirotation.METHODS:Ninety patients with intertrochanteric fracture who underwent proximal femoral nail antirotation in Shantou Hospital of Traditional Chinese Medicine from January 2016 to December 2018 were enrolled,and randomly divided into combined,intravenous and local groups(n=30/group).All patients signed the informed consents and the study was approved by the hospital ethical committee.In the combined group,tranexamic acid(20 mg/kg dissolved in 20 mL normal saline) was injected intravenously at 30 minutes before surgery,followed by femoral intracavitary injection of tranexamic acid(1 g,dissolved in 20 mL normal saline) after proximal femoral nail antirotation.Intravenous group only underwent intravenous injection of tranexamic acid.Local group only received femoral intracavitary injection of tranexamic acid.The total blood loss,dominant blood loss,hidden blood loss,International Normalized Ratio,prothrombin time,activated partial thromboplastin time,blood transfusion rate and the incidence of deep venous thrombosis were counted and compared in the three groups.RESULTS AND CONCLUSION:(1) The total blood loss in the combined group was significantly less than that in the intravenous and local groups(P <0.01),while the difference between intravenous and local groups was insignificant(P> 0.05).(2) The hidden blood loss in the combined group was significantly less than that in the intravenous and local groups(P <0.001).The difference of hidden blood loss between intravenous and local groups was insignificant(P> 0.05).(3) There was no significant difference in the dominant blood loss among groups(P> 0.05).(4) The International Normalized Ratio,prothrombin time,and activated partial thromboplastin time before and after surgery showed no significant difference among groups(P> 0.05).(5) The blood transfusion rate showed no significant difference among groups(P>0.05).(6) None presented with deep venous thrombosis.(7) These results suggest that compared with single intravenous and intracavitary injection of tranexamic acid,their combination can obviously reduce total and hidden blood loss of proximal femoral nail antirotation without increasing the risk of deep venous thrombosis.In addition,single intravenous and intramedullary injection of tranexamic acid has no significant difference in total or hidden blood loss.