静脉滴注氨甲环酸对减少髋臼骨折围术期失血量的前瞻性研究

A prospective study of intravenous tranexamic acid to reduce perioperative blood loss of acetabular fracture surgery

目的探讨静脉滴注氨甲环酸(tranexamic acid,TXA)对髋臼骨折围术期失血量的影响。方法对2016年1月至2019年6月我院收治的75例髋臼骨折患者,其中男60例,女15例。按随机数字表法分为三组。单次治疗组(25例):术前20 min静脉滴注TXA(15 mg/kg);重复治疗组(25例):术前20 min静脉滴注TXA(15 mg/kg)及手术开始后3 h再次静脉滴注TXA(10 mg/kg);对照组(25例):术前20 min静脉滴注生理盐水。骨折类型按照Letournel-Judet分型分为:简单骨折(前壁,前柱,后壁,后柱,横型)和复杂骨折(后壁伴后柱,横型伴后壁,双柱,T型,前方伴后半横型),对照组、单次治疗组、重复治疗组的简单骨折与复杂骨折分别为14/11例、13/12例、12/13例。比较三组的总失血量、术中出血量、术后1天血红蛋白(Hb)下降值、手术相关输血率、术后血栓发生率及手术时间。结果三组的年龄、性别比、血小板、PT、APTT、髋臼骨折类型、术前Hb、术前输血率及术前输血量相比,差异无统计学意义。对照组、单次治疗组、重复治疗组手术总失血量分别为(926.0±161.4)ml、(873.2±155.2)ml、(754.0±149.1)ml;术中出血量为(606.0±97.1)ml、(565.6±124.4)ml、(502.8±78.7)ml;术后Hb下降值为(35.0±7.2)g/L、(28.2±6.4)g/L、(23.5±5.7)g/L。治疗组(单次治疗组和重复治疗组)总失血量及术中出血量均少于对照组,重复治疗组总失血量及术中出血量低于单次治疗组,差异有统计学意义(P<0.05);手术相关输血率分别为56.0%(14/25)、24.0%(6/25)、20.0%(5/25),对照组输血率高于(单次/重复)治疗组。三组均无肺栓塞及深静脉血栓发生且三组肌间静脉血栓发生率相比,差异无统计学意义。结论髋臼骨折手术中静脉滴注TXA能够降低手术总失血量、术中出血量及术后Hb下降值且不增加静脉血栓形成风险。相对于单次静滴TXA,术前及手术开始后3 h重复使用更加有效。

Objective To investigate the effect of intravenous tranexamic acid(TXA)on perioperative blood loss of acetabular fracture surgery.Methods From January 2016 to June 2019,75 patients(60 males;15 females)with acetabular fractures were divided into single treatment group,repeated treatment group,and control group according to the random number table.Single treatment group(25 cases):intravenous infusion of TXA(15 mg/kg)20 minutes before surgery.Repeated treatment group(25 cases):intravenous infusion of TXA(15 mg/kg)20 minutes before surgery and 10 mg/kg TXA 3 hours from the surgery beginning.Control group(25 cases):intravenous infusion of normal saline 20 minutes before surgery.Letournel-Judet classification:simple fractures(anterior wall,anterior column,posterior wall,posterior column,transverse type);complex fractures(posterior wall with posterior column,transverse type with posterior wall,double column,T Type,anterior with posterior semitransverse type).Ratios of simple fractures to complex fractures were 14/11 in the control group,13/12 in the single treatment group,and 12/13 in the repeated treatment group.The total blood loss,intraoperative blood loss,hemoglobin decline 1 day postoperatively,surgical-related blood transfusion rate,postoperative thrombosis rate,and operation time were compared among the three groups.Results No significant differences were found in the baselines of the three groups,including age,sex ratio,platelet,PT,APTT,acetabular fracture type,preoperative Hb,preoperative blood transfusion rate and volume.The total blood losses were(926.0±161.4)ml,(873.2±155.2)ml,(754.0±149.1)ml,respectively in the control group,single treatment group and repeated treatment group,while intraoperative blood loss(606.0±97.1)ml,(565.6±124.4)ml,(502.8±78.7)ml,respectively,and Hb drop(35.0±7.2)g/L,(28.2±6.4)g/L,(23.5±5.7)g/L,respectively.The total blood loss and intraoperative blood loss were significantly lower in the treatment group(single treatment group;repeated treatment group)than that in the control group,and that of the repeated treatment group was significantly lower than the single treatment group(P<0.05).Surgery-related blood transfusion rates of the control group,single treatment group and repeated treatment group were 56.0%(14/25),24.0%(6/25),20.0%(5/25),respectively,while that of the control group was higher than the treatment group.No pulmonary embolism or deep vein thrombosis occurred in the three groups.No statistically significant differences were found in the incidence of intermuscular venous thrombosis.Conclusions Intravenous TXA during acetabular fracture surgery can reduce total blood loss,intraoperative blood loss and postoperative Hb decline without increasing the risk of venous thrombosis.Compared with single intravenous TXA,repeated infusion preoperatively and 3 hours from the surgery beginning is recommended.