TXA联合TEG监测用于儿童癫痫病灶切除术术中出血与凝血管理的临床研究

Application of tranexamic acid and thrombelastography monitoring for the management of blood loss and coagulation in pe⁃diatric epilepsy surgery

目的研究儿童癫痫病灶切除术术中应用氨甲环酸(tranexamic acid,TXA)联合血栓弹力图(thrombelastogra⁃phy,TEG)监测对患儿出血量、异体血输注率及术后并发症的影响。方法纳入行癫痫病灶切除术的患儿32例,按随机数字表法分为氨甲环酸组(T组)和对照组(C组),每组16例。T组麻醉诱导后静脉给予TXA 10 mg/kg,随后5 mg·kg^(−1)·h^(−1)持续输注,麻醉医师根据术中TEG数据指导血浆及纤维蛋白原(fibrinogen,Fib)的使用;C组麻醉诱导后静脉予生理盐水1 ml/kg,随后以0.5 ml·kg^(−1)·h^(−1)持续输注,术中对麻醉医师屏蔽TEG检测数据,麻醉医师根据临床经验选择性输注血制品及凝血物质。记录两组患儿手术开始(T_(1))、剪硬膜(T_(2))、关硬膜(T_(3))、术毕(T_(4))时的TEG数据。记录两组患儿术中出血量、悬浮红细胞输注率、新鲜冰冻血浆输注率、术前及术后凝血功能、术前及术后血常规、术后24 h引流量、术后住院天数、术后血栓栓塞及输血相关并发症发生情况。结果C组T_(4)时血栓形成的最大幅度(maximal amplitude,MA)低于T_(1)(P<0.05),T组T_(3)、T_(4)时MA高于C组(P<0.05);T组患儿术中出血量、悬浮红细胞输注率低于C组(P<0.05);两组患儿术后凝血酶原时间(prothrombin time,PT)、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)高于术前(P<0.05);T组术后Fib水平高于术前(P<0.05),低纤维蛋白血症发生率低于术前(P<0.05);T组术后Fib水平高于C组(P<0.05),术后低纤维蛋白血症发生率低于C组(P<0.05);T组术后血小板(platelet,PLT)计数高于C组(P<0.05);T组患儿术后24 h引流量低于C组(P<0.05),术后住院天数少于C组(P<0.05);两组患儿均未发生血栓栓塞及输血相关并发症。其余指标差异无统计学意义(P>0.05)。结论儿童癫痫病灶切除术术中应用TXA联合TEG监测可减少术中及术后出血量、降低异体血输注率、缩短术后住院天数,且不增加血栓栓塞风险。

Objective To evaluate the effects of tranexamic acid(TXA)and thrombelastography(TEG)monitoring on blood loss,allogenic transfusion percentage and postoperative complications in pediatric epilepsy surgery.Methods Thirty⁃two pediatric patients who underwent epilepsy surgery were enrolled.According to random number table method,they were divided into two groups(n=16):a tranexamic acid group(group T)and a control group(group C).After induction of anesthesia,group T was intravenously injected with 10 mg/kg TXA,followed by continuous infusion at 5 mg·kg^(−1)·h^(−1),and anesthetists guided the use of plasma and fibrinogen(Fib)based on TEG results.Meanwhile,group C was intravenously injected with 1 ml/kg normal saline after induction of anesthesia,fol⁃lowed by continuous infusion at 0.5 ml·kg^(−1)·h^(−1),and anesthetists selectively infused blood products and coagulators based on clinical experience without TEG results.The TEG data at the of beginning of surgery(T_(1)),when the dura mater was opened(T_(2)),when the dura mater was closed(T_(3))and at the end of surgery(T_(4))in both groups were recorded.Their volume of blood loss,transfusion rates of sus⁃pended red blood cells and fresh frozen plasma,coagulation function before and after surgery,blood routine results before and after surgery,24 h postoperative drainage volume,postoperative length of hospitalization stay,postoperative thrombosis risk and blood transfusion⁃related complications were recorded.Results For group C,the maximal amplitude(MA)value of TEG at T_(4) was lower than that at T_(1)(P<0.05).The MA value of TEG in group T was higher than that in group C at T_(3) and T_(4)(P<0.05).The volume of blood loss and red blood cell infusion rate in group T were lower than those in group C(P<0.05).The postoperative prothrombin time(PT)and activated partial thromboplastin time(APTT)of the two groups were higher than those before surgery(P<0.05).For group T,the postoperative level of Fib was higher than that before surgery(P<0.05),and the incidence of hypofibrinemia was lower than that before surgery(P<0.05).After surgery,the level of Fib in group T was higher than that in group C(P<0.05),and the incidence of hypofibrin⁃emia in group T was lower than that in group C(P<0.05).The level of postoperative platelets(PLT)in group T was higher than that in group C(P<0.05).The 24 h postoperative drainage volume in group T was lower than that in group C(P<0.05),and the postoperative length of hospitalization stay was less than that in group C(P<0.05).There was no thromboembolism and blood transfusion⁃related com⁃plications in the two groups.No other statistically significant difference was found between the two groups(P>0.05).Conclusions The combined use of TXA and TEG can significantly reduce blood loss during and after surgery,decrease the allogenic transfusion per⁃centage and shorten the length of hospitalization stay after surgery,without increasing thromboembolic risk.