全关节置换术后关节腔引流问题的探讨

目的：探讨全关节置换术后关节腔引流放置的适当时间和正确的管理方法。方法：初次关节置换的80例患者，按术后引流管留置的时间，分成条件相似的实验组(24h组)和对照组(48h组)，分别记录8、16、24、48h引流量，拔管时引流管末端、中段及最接近引流口的皮下段各剪下1．0cm送细菌培养。结果：24h组其8h、16h引流量分别占总引流量的81％和88％，48h组其8h、16h、24h引流量分别占总引流量的71％、79％h及92％，80例引流管末端和中段细菌培养均为阴性，24h组l例皮下段细菌培养阳性，48h组3例细菌培养阳性。切口全部I期愈合。24h组有5例，48h组有l例术后拔管后出现引流管口外渗淡黄色分泌物。结论：全关节置换术后关节腔引流可在24h完成，若术后创口引流超过24h有增加术后感染的机会。     

全髋置换术后引流管两种处理方式的比较

目的探讨全髋关节置换术后两种不同方式处理引流管的临床意义。方法自2009年10月至2011年5月,共选择50例全髋置换患者,对其中20例术后引流管采用间断夹闭的方式(间断夹闭组),另30例术后引流管采用持续引流作为对比(持续引流组)。分别比较患者术后24 h血红蛋白浓度(hemoglobin,Hb)及红细胞压积(hematocrit,Hct)、术后24 h及48 h引流量、术后疼痛程度、切口愈合情况、术后2年髋关节功能评分(Harris评分)。结果两组患者术后24h血红蛋白浓度、红细胞压积以及术后24h引流量、48h引流量相比较差异有统计学意义(P0.05),术后第2天、第7天疼痛程度以及术后2年髋关节Harris评分相比较差异无统计学意义(P0.05)。结论全髋关节置换术后间断夹闭引流管能够有效减少术后引流量及控制关节腔内渗血,但在临床应用过程中需要注意引流量的变化及病例的选择。     

留置皮下或关节腔内引流在人工膝关节置换术中的比较研究

目的 比较留置皮下或关节腔内引流在人工膝关节置换术中对疗效的影响。方法 将2013年5月至2015年5月于我院行单侧全膝关节置换术的96例患者随机分为皮下组和关节腔组各48例,皮下组在缝合深筋膜后留置皮下引流管进行引流,而关节腔组缝合深筋膜前将引流管留置于关节腔内进行引流。对比两组患者术后失血情况(引流量、血红蛋白和红细胞压积下降程度、隐性失血量)、切口相关并发症以及术后不同时间点的关节功能评分。结果 皮下组患者的术后引流量、血红蛋白和红细胞压积下降程度分别为(163.45±83.53)ml、(26.34±8.26)g/L、(17.46±5.26)%,均显著低于关节腔组[(426.53±112.3)ml、(35.26±9.26)g/L、(23.26±6.34)%],差异有统计学意义(P<0.05)。两组患者在异体输血率、隐性失血量、切口相关并发症、术后膝关节功能等方面差异无统计学意义(P>0.05)。结论 在人工膝关节置换手术中,缝合深筋膜后留置皮下引流的方式相较于常规关节腔内引流,可以显著减少术后引流量、术后血红蛋白和红细胞压积下降程度,而且在隐性失血量、并发症发生率以及膝关节功能恢复方面并无明显差异。     

全膝关节置换术后引流管夹闭时间对失血量及并发症的影响

目的探讨全膝关节置换术后引流管不同夹闭时间对术后引流量、隐性失血量和总失血量及术后并发症的影响。方法将150例首次接受单侧全膝关节置换术患者按入院时间分为A、B、C、D、E五组,A组术后切口引流管持续开放,B、C、D、E组术后分别夹闭引流管1h、2h、3h、4h后放开引流管持续引流,均于术后24h拔管。观察各组术后24h切口引流量、术后并发症、膝关节功能评分。结果术后五组24h引流量、总失血量比较,差异有统计学意义(均P0.01),术后引流管夹闭3h、4h组较其余三组显著减少(均P0.05);五组隐性失血量、膝关节功能评分比较,差异无统计学意义(均P0.05);五组皮下淤斑、关节肿胀比较,差异有统计学意义(P0.05,P0.01),其中术后夹管4h组发生率相对高于其余四组。结论全膝关节置换术后引流管夹闭3h可减少术后引流量和总失血量,不会增加术后并发症,不影响术后膝关节活动度。     

30例巨大甲状腺肿术后颈部引流管护理体会

目的:通过观察巨大甲状腺肿病人术后引流情况,研究拔出引流管的最佳时间.方法:对30例巨大甲状腺肿病人术后引流管护理,术后8h内每1h记录1次引流液量,而后每8h记录1次引流液量,观察各时间段引流液量、颜色、皮下积液情况.结果:手术40h后引流液显著减少,平均拔管时间50.6h.无患者出现皮下积液情况.结论:8h引流量<5ml时拔除引流管是安全的,合理的拔管时间减少了皮下积液的出现、减轻患者负担,全部切口达到Ⅰ/甲愈合.     

屈膝位间断夹闭引流控制膝关节置换术后出血

[目的]探讨屈膝位间断夹闭引流在全膝关节置换术(total knee arthroplasty,TKA)后出血控制中的疗效。[方法]2012年7月~2015年11月,96例全膝关节置换术后患者纳入研究,随机分为两组,真空负压引流组(48例)术后行真空负压引流,间断夹闭引流管并维持患肢屈髋屈膝90°位,传统负压引流组(48例)行传统负压持续引流并维持髋膝关节伸直位。记录并比较两组患者术后24 h引流量、术后5 d血红蛋白丢失量、输血率、输血量、膝关节活动度、关节感染、伤口皮缘坏死、肢体肿胀及皮下淤斑情况。[结果]真空负压引流组在术后24 h引流量、术后5 d血红蛋白丢失量、输血量方面均显著低于传统负压引流组(P<0.05),两组术后输血率、膝关节活动度、肢体肿胀及皮下淤斑差异均无统计学意义(P>0.05),所有患者术后均无感染及伤口皮缘坏死发生。[结论]屈膝位间断夹闭引流对减少人工膝关节置换术后失血量及人均输血量有明显效果。     

初次关节置换术后引流拔除时机的研究进展

尽管缺乏确切的证据支持,但目前临床上绝大部分骨科医生在关节置换术后仍常规应用闭式负压引流(closed suction drainage,CSD),以达到预防切口血肿,减少切口延迟愈合及深部感染机率的目的.但对于拔除引流管的最佳时机,目前仍无统一标准.长期以来,留置引流至24 h引流量小于50 ml时,予以拔出引流管,一般引流管留置48～72 h不等,但有学者认为,若术后切口引流时间超过24 h,会增加术后感染的机会.作者对近年关于初次关节置换术后引流管拔除时机研究的文献做一综述,发现术后24 h拔除引流管对机体最有利.     

肺叶切除术后早期拔除胸腔引流管的前瞻性随机对照研究

目的 探讨肺叶切除术后早期拔除胸腔引流管的指征以及其安全性.方法 将2012年3至9月70例肺叶切除术患者随机分为两组,其中41例于胸腔引流量≤300 ml/24 h时拔除引流管(早期组),29例于胸腔引流量≤100 ml/24 h时拔除引流管(常规组).记录两组术后24、48 h胸腔引流液的量和性状,检测术后24 h及拔管即刻的胸腔积液常规、生化指标;记录术后胸腔引流管留置时间及术后住院时间,评估术后及早期拔管后胸腔并发症的发生率、再次置管率及胸腔穿刺率.结果 两组患者一般资料、术后24 h胸腔积液常规和生化指标水平差异无统计学意义.全部70例患者术后24、48 h胸腔引流量中位数为300 ml(200～ 400 ml,第一、三四分位数,下同)、250 ml(200 ～300 ml)(Z=-2.059,P=0.039).早期组术后24、48 h平均胸腔引流量为(296±153) ml、(285±103) ml,与常规组(332±149) ml、(252±109) ml差异无统计学意义(P＞0.05).早期组术后住院时间中位数为5.0 d(4.5～6.0d),短于常规组的6.0 d(6.0～8.0 d)(Z=-3.882,P=0.000).早期组拔管时间中位数为术后44 h(44 ～68 h),短于常规组的67 h(65 ～90 h)(Z=-2.914,P=0.004).两组术后及拔管后并发症发生率、胸腔积液复发率、再次置管率及胸腔穿刺率差异无统计学意义(P＞0.05).结论 将术后拔除胸腔引流管的指征设定为引流量≤300 ml/24 h是可行并且安全有效的,有利于患者术后的快速康复.     

不同氨甲环酸应用方法对老年股骨头置换术引流量的影响

目的观察不同氨甲环酸应用方法对老年股骨颈骨折股骨头置换术后引流量的影响。 方法前瞻性收集中南大学湘雅医学院附属海口医院骨科中心收治的75例行股骨头置换术的股骨颈骨折患者,随机分为A组、B组、C组,三组各25例。A组关闭切口前静脉滴注1%氨甲环酸1 g+关节周围软组织局部注射5%氨甲环酸20 ml+缝合伤口后经引流管推注5%氨甲环酸20 ml浸泡2 h,B组关闭切口前静脉滴注生理盐水100 ml+关节周围软组织局部注射5%氨甲环酸20 ml+缝合伤口后经引流管推注5%氨甲环酸20 ml浸泡2 h,C组关闭切口前静脉滴注生理盐水100 ml+关节周围软组织局部注射生理盐水20 ml+缝合伤口后经引流管推注生理盐水20 ml浸泡2 h。观察术后24 h三组患者伤口引流量,术后48 h血红蛋白变化值。 结果A组术后24 h引流量[（47±10）ml]、48 h血红蛋白变化值[（10±4）g/L]均低于B组[（110±25）ml、（16±5）g/L]及C组[（131±22）ml、（18±6）g/L],差异均有统计学意义（P<0.05）。B组术后24 h引流量低于C组,差异有统计学意义（q=5.241,P<0.05）,B组术后48 h血红蛋白变化值与C组比较,差异无统计学意义。 结论老年股骨颈骨折患者行人工股骨头置换术关闭切口时静脉滴注1%氨甲环酸1 g+关节周围软组织局部注射5%氨甲环酸20 ml+缝合伤口后经引流管注射5%氨甲环酸20 ml浸泡2 h可以明显减少术后引流量及血红蛋白变化值。人工股骨头置换术中关节周围软组织局部注射氨甲环酸+缝合伤口后经引流管推注氨甲环酸浸泡2 h可减少术后引流量,对血红蛋白变化值无影响。     

全髋关节置换术后引流管不同处理方式的临床比较研究

目的探讨全髋关节置换（THA）术后关节腔引流管不同处理方式在减少术后失血量及恢复髋关节功能方面的临床效果。方法将自2011-03—2012—08首次行单侧THA的105例随机分为3组：实验组暂时夹闭引流管4h（A组,n=34）和6h（B组,n=38）后开放,对照组（C组,n=33）持续引流。记录各组术后8、12、24、48h的切口引流量,术前、术后24h、术后48h血红蛋白含量（Hb）和红细胞压积（Ht）值,异体血输入量,引流管顶端细菌培养,切口并发症发生率以及出院时髋关节功能Harris评分。结果A、B组术后8h切口引流量较C组明显减少（P〈0．05）,但A组与B组差异无统计学意义（P〉0．05）;术后12、24、48h3组切口引流量差异无统计学意义（P〉0．05）。A、B组术后24、48h的Hb与Ht明显高于C组,异体血输入量明显少于C组（P〈0．05）;但A组与B组差异无统计学意义（P〉0．05）。3组术后出院时Harris评分差异无统计学意义（P〉0．05）,引流管顶端细菌培养均为阴性。结论THA术后早期短期夹闭引流管对于减少异体血输入量和切口引流量是一种简单可靠的方法．且早期夹闭4h较6h更具有临床意义。     

直接前方入路全髋关节置换术后是否放置引流管的对比研究

目的比较直接前方入路(direct anterior approach,DAA)全髋关节置换术后引流管放置与否的差异性及临床效果。方法选择自2018年1月至2018年12月在中国科学技术大学附属第一医院骨科接受直接前方入路全髋关节置换术患者50例,其中男28例,女22例;左髋27例,右髋23例;年龄29~87岁,平均(56.5±12.6)岁。25例放置引流管,25例未放置引流管,均采用生物型假体,均使用生理盐水20 mL加氨甲环酸1.0 g关节腔注射。引流管组夹闭引流至第2天早上开放,24~48 h拔除引流管。观察术后24 h及第3天的血红蛋白量和红细胞比积、术后疼痛视觉模拟评分(visual analogue scale,VAS)、切口愈合情况及术后1年的髋关节功能评分(Harris评分)。结果两组术后24 h和术后3 d的血红蛋白量和红细胞比积、术后3 d的VAS评分、术后1年的Harris评分组间比较,差异均无统计学意义(P>0.05)。结论对于直接前方入路全髋关节置换,不放置引流管不影响临床效果,不增加并发症的发生率,减少了护理流程,建议常规不用放置引流管。     

Closed suction drainage after knee arthroplasty. A prospective study of the effectiveness of the operation and of bacterial contamination

A prospective investigation was designed to determine the volume and the evolution of bleeding after closure of the surgical wound following knee arthroplasty, as well as the incidence of infection and bacterial contamination in relation with the time that the suction drain was left in place. The drain was removed either 12, 24 or 48 hours after the operation. The presence of any signs of clinical infection was recorded. The tip of the drain, 1 cm of its subcutaneous portion and a sample from the collecting bottle were studied for bacterial contamination. In the 12-hr group, no microorganisms were isolated in cultures either from the tip, the subcutaneous portion or the bottle of the drain. In the 24-hr group, 87% of the total postoperative bleeding was collected during the first 12 hours. In two cases, the samples obtained from the tip and the subcutaneous portion of the drain were positive for Staphylococcus epidermidis. In the 48-hr group, 91% and 97% of the total bleeding volume was collected during the first 12 and 24 hours, respectively. In two cases, St. epidermidis was isolated in cultures from the subcutaneous portion of the drain. The clinical evaluation of wound healing was comparable in all three groups.     

Closed suction drainage following knee arthroplasty. Effectiveness and risks

A prospective investigation was performed to determine when to remove a suction drain following total knee arthroplasty (TKA). Forty-one TKAs were randomly allocated to closed suction drainage for either 24 or 48 hours. The drain was removed and the tip was cut off and processed by a method giving quantitative cultures. In the 48-hour group, 85% of the total volume was drained during the first 24 hours. During the following 24-hour period, a mean volume of only 50 ml was drained. No organism was isolated from cultures of drain tips sampled at 24 hours. However, at 48 hours, 25% of the drain tips yielded light growths of coagulase-negative staphylococci (four drain tips) and Staphylococcus aureus (one drain tip). Clinical evaluations of wound healing were comparable in the two groups. Clearly, nothing is to be gained by continuing drainage beyond 24 hours. If drainage is maintained for longer periods, there is an increased risk of contamination by bacteria.     

减少全膝关节置换术围手术期出血的探讨

背景：全膝关节置换术（TKA）是关节外科失血较多的手术之一,如何有效降低TKA围手术期失血一直是关节外科医师研究的重点。 目的：通过术中选择性应用止血带及术后适当关闭引流管对TKA失血量的影响,探讨减少TKA围手术期失血量的方法。方法：2013年1月至2013年5月,因膝骨关节炎拟行单膝TKA患者53例,根据术中应用止血带方式及术后引流管开放形式分为两组。观察组30例,采用截骨完成后短期应用止血带联合术后早期夹闭4 h引流管;对照组23例,术中全程使用止血带及术后引流管处于自然开放引流状态。记录术中出血量及术后引流量,根据患者身高、体重和手术前后红细胞压积（Hct）,通过Gross方程计算患者的总失血量,进而得出隐性失血量,记录两组术后输血的病例数,并计算平均输血单位,记录术后1、3、5 d的晨起体温,记录出院前后膝关节功能评分（HSS）。 结果：观察组的术中出血量明显多于对照组,术后引流量少于对照组,总出血量及隐性失血量少于对照组,均存在统计学差异（P＜0.05）;观察组的输血例数及平均输血单位均少于对照组;两组的围手术期晨起体温、膝关节HSS功能评分无统计学差异（P＞0.05）。 结论：采用截骨完成后短期应用止血带联合术后早期夹闭4 h引流管可明显减少TKA围手术期出血量。     

A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty

The routine use of surgical drains in total hip arthroplasty remains controversial. They have not been shown to decrease the rate of wound infection significantly and can provide a retrograde route for it. Their use does not reduce the size or incidence of post-operative wound haematomas. This prospective, randomised study was designed to evaluate the role of drains in routine total hip arthroplasty.We investigated 552 patients (577 hips) undergoing unilateral or bilateral total hip arthroplasty who had been randomised to either having a drain for 24 hours or not having a drain. All patients followed standardised pre-, intra-, and post-operative regimes and were independently assessed using the Harris hip score before operation and at six, 18 and 36 months follow-up.The rate of superficial and deep infection was 2.9% and 0.4%, respectively, in the drained group and 4.8% and 0.7%, respectively in the undrained group. One patient in the undrained group had a haematoma which did not require drainage or transfusion. The rate of transfusion after operation in the drained group was significantly higher than for undrained procedures (p < 0.042). The use of a drain did not influence the post-operative levels of haemoglobin, the revision rates, Harris hip scores, the length of hospital stay or the incidence of thromboembolism. We conclude that drains provide no clear advantage at total hip arthroplasty, represent an additional cost, and expose patients to a higher risk of transfusion.     

Effect of drain pressure in total knee arthroplasty

PURPOSE: To study the effect of drain suction pressure on drainage volume, decrease in haemoglobin level, blood transfusion, and wound complications following total knee arthroplasty. METHODS: Primary total knee arthroplasty for degenerative osteoarthritis was performed in 60 (49 female and 11 male) patients. Patients were randomised for high-pressure (600 mm Hg) or low-pressure (350 mm Hg) postoperative suction drainage. Drain output was recorded daily and the drain removed after 48 hours. Postoperative haemoglobin level was measured on the evening of the operation day and on postoperative day 2. RESULTS: The high-pressure group had a significantly higher drainage volume and decrease in haemogloblin level than the low-pressure group. However, there was no significant difference between groups in the transfusion rate, number of units of blood transfused, wound discharge, or Knee Society knee and function scores. No wound infection was detected in any patient. CONCLUSION. Low-pressure suction drainage results in less blood loss without a significant increase in wound complications.     

Drainage versus nondrainage in simultaneous bilateral total hip arthroplasties

A prospective study of 48 patients (96 hips) who had undergone primary simultaneous bilateral total hip arthroplasty was conducted to assess the effect of postoperative suction drainage on wound healing and infection. A suction drain was placed by randomization of the drained versus undrained side. The same surgical technique was used in all total hip arthroplasty wounds. Statistical analysis of the results showed significant differences with respect to drainage from the wound, soaked dressings requiring reinforcements, ecchymosis, and erythema about the wound in the group without drainage. There was no specific correlation between the incidence of wound complications and infection after total hip arthroplasty and the use or nonuse of closed-suction drainage. The hip score and range of motion of the hip were unaffected by the use or nonuse of the drains. The cost of 1 set of hemovac drains is $135 and the cost for 4–5 dressings and bed sheet changes is about $50. Although the hemovac is more expensive, the authors recommend the routine use of suction drains for wounds after primary total hip arthroplasty to reduce drainage, soaked dressings requiring reinforcement, ecchymosis and erythema around the wound, and psychological impact on the patient's fear of bleeding.     

Optimal timing of wound drain removal following total joint arthroplasty

Closed suction drains reduce postoperative hematoma formation, but create an entry portal for bacteria and thus increase the risk of infection. This study attempts to establish when the risks of wound drainage outweigh the benefits. In a prospective clinical trial, wound drains were used in all patients having a total knee or total hip arthroplasty. Timing of drain removal and amount drained were recorded. Drain-site swabs were sent with drain tips for bacteriology. Results suggest that the likelihood of bacterial colonization increases while wound drainge decreases with time. The authors conclude that the optimal time to remove drains is 24 hours after total joint arthroplasty.