氨甲环酸术前足量单剂给药对多节段腰椎后路椎间融合术失血量及安全性的影响

Effect of adequate amount of tranexamic acid before operation on blood loss and safety in posterior lumbar fusion with multiple segments

目的探讨氨甲环酸(TXA)术前足量单剂给药对多节段腰椎后路椎间融合术(PLIF)失血量及安全性的影响。方法回顾分析2017年3月至2019年12月本院接受多节段PLIF的腰椎管狭窄症患者105例。根据干预方法分为对照组、A组和B组(n分别=30、39、36)。对照组不使用TXA;A组术前30 min静脉滴注含2g TXA的生理盐水混合液100 mL;B组术前30 min静脉滴注含1g TXA的生理盐水混合液100 mL,手术时以10 mg/(kg·h)速率静脉泵注TXA。对3组围手术期总失血量、显性失血量、隐性失血量、术中失血量、术后引流量、输血率及手术前后血红蛋白(Hb)、血细胞比容(Hct)、凝血酶原时间国际标准化比值(PT-INR)、血小板计数(Plt)、D-二聚体(D-D)、C反应蛋白(CRP)、中性粒细胞百分比(NP)、谷丙转氨酶(ALT)、血尿素氮(BUN)进行比较。追踪术后药物相关不良事件。结果 1)A组、B组总失血量(mL)(892.6±193.5、887.7±320.8)、显性失血量(mL)(409.1±109.2、408.6±98.3)、术中失血量(mL)(193.7±69.3、189.6±65.6)、术后24h内引流量(mL)(130.5±53.4、128.3±53.5)、术后24h后引流量(mL)(63.1±17.6、60.9±13.5)及输血率(%)[7.7(3/39)、8.3(3/36)]明显低于C组(mL)(1 296.8±329.2、807.6±231.5、270.9±65.5、365.4±127.8、172.3±66.4、36.7(11/30)(P<0.05),A组、B组间以上指标比较无明显差异(P<0.05)。3组隐性失血量无明显差异(P<0.05)。2)与术前比较,3组术后3d Hb、HCT、Plt水平降低[Hb(g/L):91.5±14.0、107.6±16.4、105.9±17.1;HCT(%):25.6±3.1、31.2±3.9、30.5±4.4;Plt(×109/L):146.6±31.8、172.8±40.1、169.7±39.5](P<0.05),D-D、CRP、NP升高[D-D(mmol/L):365.6±67.1、280.9±50.5、286.1±53.1;CRP(mg/L):65.4±22.0、53.4±19.6、56.8±17.7;NP(%):87.3±15.6、73.1±13.7、71.9±11.8](P<0.05),PT-INR、ALT、BUN无显著变化(P>0.05),术后3d A组、B组Hb、HCT、Plt、D-D、CRP、NP的变化程度小于C组[Hb(g/L):107.6±16.4、105.9±17.1、91.5±14.0;HCT(%):31.2±3.9、30.5±4.4、25.6±3.1;Plt(×109/L):172.8±40.1、169.7±39.5、146.6±31.8;D-D(mmol/L):280.9±50.5、286.1±53.1、365.6±67.1;CRP(mg/L):53.4±19.6、56.8±17.7、65.4±22.0;NP(%):73.1±13.7、71.9±11.8、87.3±15.6](P<0.05),而A组、B组间以上指标数值,P>0.05。3)术后未发现A组和B组有下肢深静脉血栓形成及肺栓塞,所有患者术后切口均获一期愈合,未发生药物过敏、心脑血管意外、硬膜外血肿、癫痫等严重并发症。结论 TXA术前足量单剂给药与术前联合术中持续给药相比,止血疗效相同,且不增加血栓形成风险,但操作上更为简单方便。

Objective To investigate the effect of adequate amount of tranexamic acid(TXA)before operation on blood loss and safety in posterior lumbar fusion with multiple segments. Methods A retrospective analysis was conducted on 105 patients with lumbar spinal stenosis, submitted to our hospital for multilevel PLIF, from March 2017 to December 2019. According to the intervention method, they were divided into control group, group A and group B(n =30, 39 and 36, respectively). TXA was not used in the control group. Dripping of saline solution(100 mL) containing TXA 2 g and 1 g was given in Group A and Group B, and extra intravenous pumping of TXA [10 mg/(kg·h)] during surgery was conducted in Group B besides the pre-operation dripping of TXA. Total blood loss, dominant blood loss, recessive blood loss, intraoperative blood loss, postoperative drainage volume, transfusion rate and hemoglobin(Hb), hematocrit(Hct), prothrombin time international standardized ratio(PT-INR), platelet count(Plt), D-dimer(D-D), C-reactive protein(CRP), neutrophil percentage(NP), alanine aminotransferase(ALT), and blood urea nitrogen(BUN) before and after operation were compared in the three groups. Postoperative drug-related adverse events were traced.Results 1)The total blood loss, dominant blood loss(mL), intraoperative blood loss(mL), drainage volume(mL) within and after 24 h after surgery, and the transfusion rate(%) in group A and B were 892.6±193.5 vs 887.7±320.8, 409.1±109.2 vs,408.6±98.3, 193.7±69.3 vs 189.6±65.6, 130.5±53.4 vs 128.3±53.5, 63.1±17.6 vs 60.9±13.5 and 7.7(3/39) vs 8.3(3/36), respectively, which were significantly lower than that in group C as 1 296.8±329.2, 807.6±231.5, 270.9±65.5, 365.4±127.8, 172.3±66.4 and 36.7(11/30), respectively(P< 0.05). There were no significant differences in the above indexes between group A and group B(P < 0.05). The differences in recessive blood loss was not significant by groups(P<0.05). 2) Compared with pre-operation, the levels of Hb, Hct and Plt in the three groups at 3 d after operation decreased: Hb(g/L) 91.5±14.0, 107.6±16.4 and 105.9±17.1;Hct(%) 25.6±3.1, 31.2±3.9 and 30.5±4.4;Plt(×10~9/L)146.6±31.8, 172.8 ±40.1 and 169.7±39.5(P < 0.05);while D-D, CRP and NP increased: D-D(mmol/L)365.6±67.1, 280.9±50.5 and 286.1±53.1;CRP(mg/L): 65.4±22.0, 53.4±19.6 and 56.8±17.7;NP(%): 87.3±15.6, 73.1±13.7, and 71.9±11.8(P < 0.05), and Pt-INR, ALT and BUN showed no significant changes(P > 0.05). The changes of Hb, Hct, Plt, D-D, CRP and NP in group A and B were significantly lower than those in group C at 3 days after operation [Hb(g/L) : 107.6±16.4, 105.9±17.1, 91.5±14.0;Hct(%) : 31.2±3.9, 30.5±4.4,25.6±3.1;Plt(×10~9/L) : 172.8 ±40.1, 169.7±39.5, 146.6±31.8;D-D(mmol/L) : 280.9±50.5, 286.1±53.1, 365.6±67.1;CRP(mg/L) : 53.4±19.6, 56.8±17.7, 65.4±22.0;NP(%) :73.1±13.7, 71.9±11.8, 87.3±15.6](P < 0.05), and no significant differences in the above index were noticed between group A and B(P> 0.05).3)No lower limb deep vein thrombosis nor pulmonary embolism were found in group A and group B after operation, and all the incisions were healed in the first stage, and no serious complications such as drug allergy, cardiovascular and cerebrovascular accident, epidural hematoma, epilepsy occurred. Conclusion The preoperative TXA administration with sufficient single dose showed equivalent hemostatic effect in comparison with intraoperative continuous administration additional to preoperative dripping, which is simple and convenient and does not increase the risk of thrombosis.