抗Xa因子活性监测及ATⅢ活性检测在TKA术后血栓与出血预防中的应用价值

Application Value of Anti-Xa Factor Activity Monitoring and ATⅢActivity Detection in Prevention of Thrombosis and Hemorrhage after TKA

目的通过一项前瞻性研究探讨抗Xa因子活性监测联合抗凝血酶Ⅲ(antithrombin,ATⅢ)活性检测在人工全膝关节置换术(total knee arthroplasty,TKA)术后预防出血与静脉血栓中的应用价值。方法选取自2019年11月至2020年6月在我院行单侧TKA手术的骨关节炎患者74例,其中男性19例,女性55例;年龄56~80岁,平均(68.5±7.5)岁。随机分为试验组和对照组,每组37例。试验组术后12 h给予低分子肝素(low molecular weight heparin,LMWH)4250 IU皮下注射,4 h后检测凝血指标及抗Xa因子活性,根据抗Xa因子活性结果调整LMWH剂量,使抗Xa因子活性维持在0.3~0.7 IU/mL。对照组术后12 h后给予LMWH 4250 IU皮下注射,4 h后检测凝血指标,于术后第2天开始常规给予LMWH 4250 IU 1次/日皮下注射抗凝治疗。两组术后1 d、6 d、11 d常规检测活化部分凝血活酶时间(activated partial thromboplastin time,APTT)、D-二聚体(D-dimer,D-Di)、血红蛋白(hemoglobin,Hb)、下肢血管彩超,记录皮下出血情况,并进行分析。结果术后第1天两组APTT、D-Di、Hb与术前差值、血栓发生率、皮下出血面积(体表面积百分比)比较,差异无统计学意义(P>0.05)。术后6 d,两组APTT比较差异无统计学意义(P>0.05);试验组D-Di、Hb与术前差值、血栓发生率、皮下出血面积低于对照组,差异有统计学意义(P<0.05)。术后第11天,两组间APTT比较差异无统计学意义(P>0.05),试验组D-Di、Hb与术前差值、血栓发生率、皮下出血面积低于对照组,差异有统计学意义(P<0.05)。结论在TKA术后使用LMWH抗凝治疗时,术前予以ATⅢ活性检测,抗凝过程中根据监测抗Xa因子活性调整LMWH剂量,能有效地降低术后下肢静脉血栓发生率及出血风险,可在临床中推广使用。

Objective To study the value of anti-Xa factor activity monitoring combined with ATⅢactivity detection in preventing bleeding and venous thrombosis after total knee arthroplasty(TKA)by aprospective study.Methods 74 patients with osteoarthritis who underwent unilateral TKA surgery in our hospitalwere selected and randomly divided into the experimental group and the control group.The experimental group was given subcutaneous injection of low molecular weight heparin(LMWH)4250 IU 12 hours after operation.The coagulation index and the activity of anti-Xa factor were detected 4 hours later,and the dose of LMWH was adapted according to the activity of anti-Xa factor.The activity of anti-Xa factor was maintained between 0.3~0.7 IU/mL.The control group was given subcutaneous injection of LMWH 4250 IU 12 hours after operation.The coagulation index was detected 4 hours later,and the routine subcutaneous injection of LMWH 4250 IU once/day anticoagulation therapy was given on the second day after operation.In the two groups,APTT,D-two dimers(D-Di),Hb,lower limb color Doppler ultrasound the subcutaneous hemorrhagewere routinely recorded and analyzed in 1 d,6 d and 11 d after operation.Results On the 1st day after operation,there was no statistically difference in APTT,D-Di,Hb,thrombus incidence and subcutaneous hemorrhage area(percentage of body surface area)between the two groups(P>0.05).On the 6th day after operation,there was no statistically difference in APTT between the two groups(P>0.05).But,D-Di,Hb change afteroperation,thrombosis incidence,and the area of subcutaneous hemorrhage of the experimental group was lower then control group(P<0.05).On the 11th day after operation,there was no statistically difference in APTT between the groups(P>0.05).D-Di,Hb and preoperative difference,thrombosis incidence,and the area of subcutaneoushemorrhage of the experimental group was lower then control group(P<0.05).Conclusion Using LMWH anticoagulant therapy after TKA,detecting the activity of ATⅢbefore operationand adjusting the dosage of LMWH according to the activity of anti-Xa factorduring the anticoagulation can effectively reduce the incidence of postoperative lower extremity venous thrombosis and the risk of bleeding.Thistreatment should be promoted in clinical practice.