氨甲环酸不同给药途径在双侧同期全膝关节置换手术中的应用

Application of tranexamic acid by different administration routes in bilateral simultaneous total knee arthroplasty

目的:探讨氨甲环酸(TXA)不同给药途径对双侧同期全膝关节置换术(TKA)围手术期失血量的影响。方法:前瞻性选择2020年1月至2020年7月行初次双侧TKA的膝关节骨关节炎患者83例,随机分为3组,氨甲环酸使用剂量均为2 g,患者术后双侧术区均不放置引流管。静脉组25例患者采用静脉注射氨甲环酸:切皮前静脉滴注1 g,待手术完成时缝皮前再追加1 g。局部组30例患者采用关节腔局部注射:缝合关节囊后,双侧膝关节腔内各注射1 g。静脉+局部组28例患者采用静脉+局部注射:切皮前静脉滴注1 g,缝合关节囊后,膝关节腔内各注射0.5g。比较三组患者隐性失血量,术后3 d血红蛋白水平、红细胞计数、血小板计数,术后3 d股四头肌肿胀程度,术后6 d双下肢瘀斑面积,术后1个月美国膝关节外科学会膝关节功能评分(KSS),以及深静脉血栓及肺栓塞发生情况。结果:三组患者隐性失血量、术后3 d血红蛋白水平、红细胞计数、血小板计数差异均无统计学意义;静脉组患者股四头肌肿胀程度均高于局部组及静脉+局部组患者,且差异均有统计学意义(P<0.05);局部组患者及静脉+局部组患者术后6 d大腿瘀斑面积均小于静脉组患者,且差异有统计学意义(P<0.05),局部组与静脉+局部组患者术后6 d大腿瘀斑面积差异无统计学意义(P>0.05)。三组患者术后1个月KSS评分差异无统计学意义(P>0.05)。静脉组3例患者输血,局部组、静脉+局部组各2例患者输血。血管彩色多普勒超声检查结果证实,术后5 d三组患者均未发生深静脉血栓。术后1个月内三组患者均未发现症状性深静脉血栓和肺栓塞。结论:与单纯静脉给药相比,在双侧同期TKA中采用关节腔局部注射或静脉+关节腔局部注射氨甲环酸,不仅能有效减少术中及围手术期出血和输血,同时对术后关节肿胀、皮下瘀斑等近期并发症能起到良好地抑制作用,从而使患者能够早期、积极的进行运动。

Objective:To explore different routes of administration of tranexamic acid(TXA)on perioperative blood loss during bilateral total knee arthroplasty(TKA).Methods:A total of 83 patients with knee osteoarthritis who underwent primary bilateral TKA from January 2020 to July 2020 were prospectively selected and randomly divided into 3 groups.The dose of trantranic acid was 2 g,and no drainage tubes were placed in the bilateral surgical areas after surgery.In venous group,25 patients received TXA intravenously:1 g before skin resection and 1 g before skin suture.In local group,30 patients received local injection in the joint cavity:1 g TXA was injected into each side of the knee joint after suturing the joint capsule.28 patients in intravenous+local group were given 1 g intravenously before skin excision and 0.5 g intravenously after suturing joint capsule.The hidden blood loss,hemoglobin levels,red blood cell count,platelet count,quadriceps swelling,ecchymosis of lower limbs,Knee Society Score(KSS),and the incidence of deep vein thrombosis and pulmonary embolism were recorded.Results:There were no significant differences in hidden blood loss,hemoglobin level 3 d after operation,red blood cell count or platelet count among the three groups.The swelling of quadriceps femoris in the venous group was significantly severer than that in the local group and venous+local group(P<0.05).At 6 d after surgery,the area of thigh petechiae in the local group and venous+local group was significantly smaller than that in the venous group(P<0.05),while there was no significant difference in the area of thigh petechiae between local group and venous+local group(P>0.05).There was no significant difference in KSS one month after surgery among the three groups(P>0.05).Three patients in the venous group,two patients in the local group and two patients in the venous+local group received blood transfusion.The results of color Doppler ultrasonography confirmed that no patients in the three groups had deep vein thrombosis in 5 d after operation.No symptomatic deep vein thrombosis or pulmonary embolism was found in the three groups within 1 month after surgery.Conclusions:Compared with intravenous administration,local injection or intravenous+TXA local injection in the articular cavity can not only effectively reduce intraoperative and perioperative bleeding and transfusion in the bilateral TKA,but also have good inhibitory effect on recent complications(postoperative joint swelling,subcutaneous ecchymosis).