小剂量静脉联合心包内注射氨甲环酸减少心肺转流心脏手术后出血量的有效性及安全性研究

Efficacy and safety of low-dose intravenous combined with intrapericardial injection of tranexamic acid in reducing postoperative bleeding after open heart surgery in adults

目的 通过回顾性分析,探讨小剂量静脉联合心包内注射氨甲环酸(TxA)在成人心肺转流开胸心脏手术中可能产生的减少术后出血量、减少血制品输入的益处和相关风险。方法 回顾性分析2021年2月到2021年5月期间在非急诊胸骨正中切开心肺转流下行成年心脏手术患者,其中111例符合标准纳入本次研究。将患者按TxA不同应用方式分为三组:静脉组(A组)37例,心包内注射组(B组)37例,联合组(C组)37例。A组患者麻醉诱导后20 min内静脉给予TxA负荷剂量10 mg/kg,之后维持量10 mg/(kg·h)术中持续泵注;B组患者于鱼精蛋白注射完毕和关闭胸腔前,分别在患者心包内注射2.5 g TxA;C组参照A、B组给药方法及剂量给予TxA。比较三组患者术前及术后3天的肌酐、尿素、红细胞压积、术中出血、术后48 h内的心包及纵膈引流量、血制品需求量和术后癫痫的发生率以及相关并发症发生情况。结果 与A组与B组患者相比,C组患者术后48 h心包及纵膈引流量和红细胞需要量低(P<0.05);与B组患者相比,A组和C组患者术后尿素和血清肌酐水平较高(P<0.05)。患者均无死亡,无癫痫发作或其他神经事件或血栓栓塞并发症。结论 小剂量静脉联合心包内注射TxA可有效减少成人正中开胸心肺转流下心脏手术术后出血量和血液制品需求,且不发生癫痫、肾或血栓栓塞并发症;在手术中将两者联合应用的临床疗效强于二者单独使用。

Objective To retrospectively investigate the benefits and related risks of low-dose intravenous combined with intrapericardial injection of tranexamic acid(TxA) in reducing postoperative blood loss and blood products input during open heart surgery with cardiopulmonary bypass(CPB) in adults.Methods From February 2021 to May 2021,111 adult patients who underwent cardiac surgery with a non-emergency median sternotomy under CPB were retrospectively analyzed.These patients were divided into three groups according to different methods of TxA application:intravenous group(group A,n=37),intrapericardial injection group(group B,n=37),combined group(group C,n=37).In group A,TxA loading dose of 10 mg/kg was given intravenously within 20 min after induction of anesthesia,followed by 10 mg/(kg·h) as a maintenance dose in continuous infusion during cardiac surgery.In group B,2.5 g TxA was injected into the pericardium before protamine injection and chest closure,respectively.Group C was given TxA according to the method and dose of group A and group B.The creatinine,urea,hematocrit,intraoperative bleeding,pericardium and mediastinal drainage flow within 48 h after operation,blood product demand,incidence of postoperative epilepsy and related complications were compared among the three groups before and after operation.Results Compared with group A and group B,48 h postoperative pericardial and mediastinal drainage and red blood cell requirement were lower in group C(P<0.05).Compared with group B,postoperative urea and serum creatinine levels were higher in groups A and C(P<0.05).There were no deaths,postoperative seizures or other neurological events,or thromboembolic complications in patients enrolled in this retrospective study.Conclusion Low-dose intravenous combined with intrapericardial injection of TxA can effectively reduce the amount of blood loss and the need for blood products after cardiac surgery under CPB in adults with median thoracotomy without epilepsy,renal or thromboembolic complications.In addition,the clinical efficacy of the combination of the two TxA application methods is better than that of the two methods alone.