氨甲环酸联合不同抗凝药对初次单侧人工全髋关节置换术止血效果及安全性的影响研究

Comparison of hemostatic effect and safety in primary unilateral total hip arthroplasty receiving different anticoagulants after anti-fibrinolysis with tranexamic acid

目的比较氨甲环酸(tranexamic acid,TXA)抗纤溶后应用速碧林、克赛、拜瑞妥及艾乐妥对初次单侧人工全髋关节置换术(total hip arthroplasty,THA)止血效果及安全性的影响,以期探索最佳疗效的抗凝药。方法回顾分析2014年1月—2018年12月收治的184例行初次单侧THA且手术切皮前静脉滴注15 mg/kg TXA,术后应用速碧林、克赛、拜瑞妥或艾乐妥的患者临床资料。其中速碧林组46例、克赛组45例、拜瑞妥组47例、艾乐妥组46例。4组患者的年龄、性别、体质量、体质量指数、髋关节疾病类型、合并症、麻醉方式、手术时间及术前实验室指标(血红蛋白、红细胞比容、血小板、凝血酶原时间、活化部分凝血酶原时间、血容量)等一般资料比较差异均无统计学意义(P>0.05)。记录并比较各组围术期血液资料(总失血量、隐性失血量、显性失血量、术后引流量、术后血红蛋白最大丢失量及输血率)和并发症(切口并发症、出血并发症、血栓并发症)发生情况。结果4组患者围术期总失血量、隐性失血量、显性失血量、术后引流量、术后血红蛋白最大丢失量及输血率比较差异均无统计学意义(P>0.05)。术后并发症比较显示,拜瑞妥组发生1例(2.1%)切口红肿,其余3组各发生1例(2.2%)切口愈合不良,4组均无切口感染、脂肪液化等并发症发生;各组切口并发症发生率比较差异均无统计学意义(P>0.05)。速碧林组出现2例(4.3%)出血事件(1例为右腹股沟血肿、1例为左小腿前方出现皮下瘀斑),其余3组未发生出血事件,各组出血并发症发生率比较差异无统计学意义(χ^2=5.612,P=0.132)。速碧林组出现1例(2.2%)下肢肌间静脉血栓形成,其余3组未发生下肢肌间静脉血栓形成,各组发生率比较差异无统计学意义(χ^2=2.789,P=0.425);4组均无下肢深静脉血栓形成及肺动脉栓塞发生。结论TXA抗纤溶后使用速碧林、克赛、拜瑞妥和艾乐妥,对初次单侧THA止血效果和并发症发生率的影响无明显差异。临床上经TXA抗纤溶后可任意选择4种抗凝药之一来预防血栓形成,均具有一定安全性。

Objective To compare the hemostatic effect and safety in primary unilateral total hip arthroplasty(THA)receiving nadroparin calcium,enoxaparin sodium,rivaroxaban,or apixaban after anti-fibrinolysis with tranexamic acid(TXA)and explore the best anticoagulant.Methods A retrospective analysis was conducted on 184 patients who underwent the primary unilateral THA between January 2014 and December 2018,administrated 15 mg/kg TXA before surgery and received nadroparin calcium,enoxaparin sodium,rivaroxaban,or apixaban.The patients were divided into four groups based on the different anticoagulants:46 patients received nadroparin calcium;45 patients received enoxaparin sodium;47 patients received rivaroxaban;the other 46 patients received apixaban.There was no significant difference in age,gender,body mass,body mass index,the types of hip joint diseases,complications,anesthesia mode,operation time,and preoperative laboratory indexes(hemoglobin,hematocrit,platelet,prothrombin time,activated partial prothrombin time,blood volume)(P>0.05).Perioperative blood data(total blood loss,hidden blood loss,dominant blood loss,postoperative drainage volume,maximum loss of hemoglobin,and blood transfusion rate)and complications(incision,bleeding,and thrombosis)were recorded and compared between groups.Results There was no significant difference in total blood loss,hidden blood loss,dominant blood loss,postoperative drainage volume,maximum loss of hemoglobin,and blood transfusion rate between groups(P>0.05).The comparison of postoperative complications showed that 1 case(2.1%)of redness and swelling of incision occurred in the rivaroxaban group,and 1 case(2.2%)of the other3 groups each had poor incision healing.No incision infection,fat liquefaction,or other incision complications occurred in the 4 groups.There was no significant difference in incision complication between groups(P>0.05).There were 2 cases(4.3%)bleeding events(1 case of right inguinal hematoma and 1 case of subcutaneous ecchymosis in front of left leg)in the nadroparin calcium group,while no bleeding event occurred in the other 3 groups,which had no significant difference in bleeding complication between groups(χ^2=5.612,P=0.132).There was 1 case(2.2%)of intermuscular vein thrombosis of the lower extremity in the nadroparin calcium group and no case in the other 3 groups,which had no significant difference between groups(χ^2=2.789,P=0.425).Neither deep venous thrombosis nor pulmonary embolism occurred in any group.Conclusion No significant difference in the hemostatic effect and incidences of complications for patients underwent primary unilateral THA receiving nadroparin calcium,enoxaparin sodium,rivaroxaban,or apixaban after anti-fibrinolysis with TXA.One of the four anticoagulants can be selected to prevent thrombosis after anti-fibrinolysis with TXA,which has certain safety.