人工全髋、膝关节置换术围术期血液管理

Perioperative blood management for total hip/knee arthroplasty

目的对人工全膝关节置换术(total knee arthroplasty,TKA)及人工全髋关节置换术(total hip arthroplasty,THA)的围术期血液管理(perioperative blood managment,PBM)措施进行综述。方法全面阅读并总结近年国内外关于TKA及THA的PBM措施的进展,结合四川大学华西医院临床实践经验,从优化造血、减少失血和输血三方面深入评价并分析各种措施的优劣,为临床选择提供依据。结果目前用于TKA及THA的PBM方式较多,其中优化造血主要包括围术期应用铁剂及促红细胞生成素;减少失血措施包括使用止血带、术中进行控制性降压及围术期应用抗纤溶药物;自体输血主要包括预存自体输血、血液稀释法自体输血以及术中自体血液回输;而异体输血则为治疗贫血的最终手段。其中术前应用促红细胞生成素联合铁剂进行血液动员,术中控制性降压减少失血,再结合多模式氨甲环酸的应用可以取得满意效果。结论TKA及THA围术期应根据患者身体及经济情况,个性化选择单一或多种血液管理措施以减少失血及异体输血需求,加速患者术后康复。

Objective To review the perioperative blood management(PBM)of total knee arthroplasty(TKA)and total hip arthroplasty(THA).Methods Recent researches on PBM for TKA and THA were comprehensively read and summarized.Then the advantages and disadvantages of various measures together with the clinical experience of West China Hospital of Sichuan University were evaluated from three aspects,including optimizing hematopoiesis,reducing blood loss and blood transfusion,which could provide a basis for clinical selection.Results There are many PBM methods in TKA and THA,among which the optimization of hematopoiesis mainly includes the application of perioperative iron and erythropoietin.Measures to reduce bleeding include the use of tourniquet,intraoperative controlled hypotension,and perioperative antifibrinolytic agents.Autologous blood transfusion includes preoperative autologous blood donation,hemodilution and cell salvage.Allogeneic blood transfusion is the ultimate treatment for anemia.The application of erythropoietin combined with iron therapy for blood mobilization before surgery together with intraoperative controlled hypotension for bleeding control and the multiple use of tranexamic acid can achieve satisfactory clinical results.Conclusion In the perioperative period of TKA and THA,single or multiple use of different blood management measures should be considered carefully according to the physical and economic conditions of patients individually,so as to reduce the blood loss and allogeneic blood transfusion optimally,and finally accelerate the recovery of patients.