局部应用不同剂量氨甲环酸对胸科手术后止血效果的研究

Hemostatic effect of topical application of tranexamic acid in different doses after thoracic surgery

目的探讨胸膜腔内局部应用不同剂量氨甲环酸(tranexamic acid,TXA)对胸科手术患者术后总失血量、术后引流量、凝血功能和术后疼痛的影响。方法选取2015年9月至2016年1月首都医科大学附属北京朝阳医院择期行胸腔镜肺叶切除术的患者60例,随机分为2 g TXA组(A组)、3 g TXA组(B组)和对照组(C组)。于淋巴结清扫充分止血后,关胸放置胸腔闭式引流管前,A、B、C 3组分别将2 g TXA溶液、3g TXA溶液、等体积(40 ml)的生理盐水均匀喷洒于胸腔内,随即夹闭胸腔闭式引流管并记录夹闭时间。观察术后1、3、6、12、24 h引流量,计算总失血量,监测患者术前及术后血常规、凝血功能,随访术后第1天疼痛视觉模拟评分(visual analogue score,VAS)及引流管拔除时间和出院时间。结果A组和B组术后各时点的引流量均低于C组,且在术后3 h[A组与C组:(109.75±60.12)ml比(155.25±77.57)ml;B组与C组:(109.50±44.83)ml比(155.25±77.57)ml]和术后24 h[A组与C组:(449.50±98.76)ml比(479.50±142.03)ml;B组与C组:(384.50±81.75)ml比(479.50±142.03)ml]的差异均有统计学意义(P<0.05)。A组和B组的总失血量较C组降低7.9%和15.9%,但差异无统计学意义(P>0.05)。3组术后PLT及凝血功能比较,差异均无统计学意义(P>0.05)。B组的住院时间较A组和C组缩短[(5.05±1.27)d比(5.23±1.42)d,(5.05±1.27)d比(6.10±1.56)d],差异有统计学意义(P<0.05)。所有患者未出现心肌梗死、脑梗死等并发症。结论胸膜腔内局部应用2 g和3 g TXA溶液均可减少胸腔镜肺叶切除术患者术后总失血量及胸腔引流量,缩短住院时间,不增加血栓形成的风险。胸膜腔内局部应用3 g TXA较2 g TXA在减少术后24 h引流量方面有优势,但对于总失血量无明显影响,尚不能证实局部应用TXA存在剂量-反应关系。

Objective To investigate the effects of topical application of tranexamic acid(TXA)in pleural space on postoperative total blood loss,postoperative drainage,coagulation function and postoperative pain in the patients undergoing chest surgery.Methods This prospective randomized placebo-controlled comparative study included 60 patients scheduled to undergo elective thoracoscopic lobectomy,who were randomly assigned to three groups.Group A were received 2 g TXA solution,group B were received 3 g TXA solution,group C were received the same volume of saline solution as placebo.After lymph node dissection for sufficient hemostatic,equal volume(40 ml)of normal saline,2 g of TXA solution and 3 g of TXA solution were evenly sprayed into pleural space before thoracic closed drainage tube was placed.Then the thoracic closed drainage tube was clamped and the clamping time was recorded.The volume of drainage was observed at 1,3,6,12 and 24 h after surgery,the total blood loss was calculated,postoperative blood routine tests,blood coagulation function were monitored,VAS on the first day,placement time of drainage and discharge time after operation were compared.Results Postoperative drainage volume at all times was less in group A and B than that in group C,there were significant differences in 3 h[group A and C:(109.75±60.12)ml vs.(155.25±77.57)ml;group B and C:(109.50±44.83)ml vs.(155.25±77.57)ml;P<0.05]and24 h[group A and C:(449.50±98.76)ml vs.(479.50±142.03)ml;group B and C:(384.50±81.75)ml vs.(479.50±142.03)ml;P<0.05].The total blood loss were higher in group C compared with the group A and B,it were reduced about 7.9%and 15.9%,but there were no significant differences(P>0.05).There were no significant differences of post-operative Hb,HCT,PLT,blood coagulation function.The length of hospital stay was significantly shorter in group B than that in group A and C[(5.05±1.27)d vs.(5.23±1.42)d,(5.05±1.27)d vs.(6.10±1.56)d,P<0.05].The complications such as myocardial infarction and cerebral infarction had not been found in all patients.Conclusions Topical use of TXA either 2 g or 3 g could reduce postoperative total blood loss and drainage volume,shorten the hospital stay,but could not increase the risk of thrombosis.Topical application of 3 g TXA has an advantage than 2 g TXA in reducing postoperative 24 h drainage volume,but it has no effect on total blood loss.Dose-response relationship of topical application of TXA could not be confirmed.