全膝关节置换术后隐性失血危险因素的分析

目的探讨全膝关节置换术后的隐性失血量,并分析影响隐性失血的相关因素。方法收集48例行初次单侧全膝关节置换术的患者,其中女42例,男6例;年龄29～79岁,平均年龄65岁。通过Gross方程,根据患者身高、体重和手术前后的红细胞压积(Hct)计算患者的总失血量,减去显性失血量后得隐性失血量。分析年龄、性别、诊断、身高、体重、BMI、术中出血量、术后引流量、术者以及止血带时间、手术时间与隐性失血的相关性。结果术中出血量为(541±271)mL(200～1700mL),术后引流量为(479±249)mL(50～1010mL),显性出血量为(1020±327)mL(440～2 220 mL),总失血量为(1 963±734)mL(92～3 926 mL),隐性失血量为(942±692)mL(-502～2 716 mL)。因此,隐性失血占总失血的48.0%。隐性失血与身高、体重都有明显正相关,但与BMI没有明显相关性,另外,隐性失血还与术后引流量呈明显负相关。结论全膝关节置换术后隐性失血量约占总失血量的一半,应引起我们足够的重视,并且术后引流量少时更不能忽视隐性失血的存在。     

Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account

Following total hip arthroplasty (THA) and total knee arthroplasty (TKR) only the 'visible' measured blood loss is usually known. This underestimates the 'true' total loss, as some loss is 'hidden'. Correct management of blood loss should take hidden loss into account. We studied 101 THAs and 101 TKAs (with re-infusion of drained blood). Following THA, the mean total loss was 1510 ml and the hidden loss 471 ml (26%). Following TKA, the mean total loss was 1498 ml. The hidden loss was 765 ml (49%). Obesity made no difference with either operation. THA involves a small hidden loss, the total loss being 1.3 times that measured. However, following TKA, there may be substantial hidden blood loss due to bleeding into the tissues and residual blood in the joint. The true total loss can be determined by doubling the measured loss.     

Hidden blood loss during posterior spine fusion surgery

Background contextPosterior spine fusion is associated with significant intra- and postoperative blood losses. When referring to the total blood loss during spine surgery, the standard is to measure the intraoperative bleeding plus the postoperative drainage. This ignores the “hidden” blood loss that was found to be significant in other fields of surgery.PurposeThe purpose of this study was to examine whether posterior spine fusion carries a substantial hidden blood loss.Study design/settingA prospective study.Patient sampleWe prospectively studied 114 patients undergoing instrumented posterior spinal fusion at one center between January 2011 and April 2011.Outcome measuresTotal blood loss, visible blood loss, and hidden blood loss.MethodsFor each patient, the hidden blood loss was calculated by deducting the observed perioperative blood loss from the calculated total blood loss based on the hematocrit changes. We compared the percentage of the hidden blood loss out of the total blood loss for primary versus revision posterior spine fusion.ResultsPrimary decompression and posterior fusion patients had a mean total true loss of 1,439 mL. Their calculated hidden loss was 600 mL, 42% of the total loss. After revision posterior spinal fusion surgery, the mean total blood loss was 1,606 mL. The mean visible loss was 975 mL, and the mean hidden loss was 631 mL, 39% of the total loss. Thus, there was no statistical difference in the hidden blood loss between primary and revision posterior spinal fusion surgeries (p>.05). We did not find a significant difference in the percentage of the hidden blood loss between patients who underwent one, two, or three or more levels of surgery.ConclusionsAfter posterior spinal fusion, there may be a large amount of the hidden blood loss.     

应用髓外和髓内固定物治疗股骨转子间骨折显性和隐性失血量的比较

背景：股骨转子间骨折的微创治疗已广泛应用于临床,但隐性失血尚未得到广泛重视,对其研究较少。目的：比较应用髓外固定物动力髋螺钉（DHS）和髓内固定物（PFNA、InterTan）治疗股骨转子间骨折围手术期的显性和隐性失血量,分析隐性失血的影响因素,为内固定物的选择提供临床依据。方法：回顾性分析2010年1月至2011年12月应用DHS或PFNA、InterTan治疗的股骨转子间骨折患者89例,记录患者年龄、性别、身高、体重,记录术中及术后显性失血量,手术时间,手术前后的血红蛋白（Hb）和红细胞压积（Hct）。应用Gross方程计算总失血量和隐性失血量,对统计数据进行比较分析。结果：应用DHS 24例,总失血量平均为832 ml,其中显性失血量为187 m（l22.5%）,隐性失血量为645m（l77.5%）;应用PFNA 38例,总失血量平均为210 ml,其中显性失血量为123 m（l58.5%）,隐性失血量为87 m（l41.4%）;应用InterTan 27例,总失血量平均为1054 ml,其中显性失血量为153m（l14.5%）,隐性失血量为901 m（l85.5%）。结论：股骨转子间骨折患者常存在严重的隐性失血,极易引起术后贫血,需严密监控患者的失血量。髓外和髓内固定方法的出血量基本一致,髓内固定方法具有更强的力学稳定性,髓内固定物PFNA的操作简单,出血量相对较少,可作为治疗股骨转子间骨折的首选方法。     

牙齿脱落与女性桡骨远端骨折的相关性分析

目的分析牙齿脱落与桡骨远端骨折的关系,评估牙齿脱落是否可以用作预测桡骨远端骨折风险的指标。方法简易问卷调查了保定市骨科医院住院治疗的桡骨远端骨折病人,所有个体均为绝经后女性,调查项目包括牙齿脱落年龄,脱落数目,骨折发生时情况,骨质疏松骨折家族史,有无服用糖皮质激素药物史等。研究共纳入符合条件的骨折组112例,对照组98例。牙齿脱落率、牙齿脱落年龄和牙齿脱落个数对骨折风险的影响采用多因素1ogestic回归模型分析。结果骨折组牙齿脱落率显著高于对照组,平均牙齿脱落年龄显著低于对照组,骨折前牙齿脱落的数量显著多于对照组;多因素Logistic回归分析显示,校正骨折家族史后,牙齿脱落与桡骨远端骨折风险显著相关[OR=3.371,95%CI（1.714,6.629）];年龄小于59岁发生牙齿脱落的个体及牙齿脱落数目大于4颗的个体,骨折风险可能进一步显著增加。结论牙齿过早脱落与桡骨远端骨折风险高度相关,其临床应用前景尚需大样本前瞻性研究来证实。     

髓内固定治疗老年股骨转子间骨折的失血量分析

目的对接受髓内固定治疗的老年股骨转子间骨折围手术期失血量进行临床分析,探讨失血相关因素。方法回顾性分析2009年12月至2011年12月采用股骨髓内固定治疗的73例股骨转子间骨折患者的临床资料,对患者年龄、性别、身高、体重、骨折类型、手术时间、手术前后血常规以及术中、术后出血进行分析。结果73例患者术中平均失血72．4ml,术中均未输血,术后平均隐性失血量为312ml,占围手术期出血的81％。年龄、性别之间差异无统计学意义,手术时间不超过45min组可减少术中失血量及隐洼失血量,差异有统计学意义;骨折严重组可增加术中出血量,差异有统计学意义;肥胖组可增加围手术期出血量及隐性出血量,差异有统计学意义。结论髓内固定治疗老年股骨转子间骨折术中出血量少,术后的隐性失血量较多,肥胖、严重骨折及长时间手术可以增加出血,应严格监测患者的生命体征和及时复查血常规以减少贫血导致的并发症。     

Blood loss in total hip replacement

Summary Two hundred and twelve total hip replacements performed in one clinic over 1 year were reviewed. The mean operative time was 89 min and mean total blood loss 1090 ml. Homologous blood was administered to 74% of the patients. Blood loss was dependent on sex, body weight and height, but these correlations were eliminated when blood loss was related to estimated blood volume. There was no correlation to age. There was a positive correlation between operative time and intraoperative blood loss, but not between any of these factors and postoperative blood loss. Operative time varied significantly between surgeons, but there was no correlation between surgeon's experience and operative time or blood loss. Despite a mean of only 12 total hip replacements per surgeon, both operative time and blood loss were small compared to what was found in other studies. The use of a posterior approach is believed to contribute to a shorter operative time as well as to moderate blood loss. Intraoperative blood loss was less under epidural than under general anaesthesia, but in contrast to others we found higher postoperative blood loss after epidural anaesthesia.     

止血带的使用方式对膝关节置换术失血量和手术时间的影响

目的探讨不同止血带使用方式对全膝关节置换术中、术后失血量的影响及意义.方法 2006年5月至2009年4月行单侧全膝关节置换术的膝关节骨关节炎患者88例,排除凝血机制异常者,患者根据止血带使用方式不同分为手术开始时开始使用组和安装假体时开始使用组,手术开始时开始使用组46例,安装假体时开始使用组42例,其他操作两组相同,记录手术时间、止血带使用时间,记录术中失血量、术后引流量,计算总失血量和隐形失血量.用两独立样本t检验比较两组间的差异.结果 手术开始时开始使用组：手术时间75～140 min,平均95.9 min;止血带使用时间54～105 min,平均65.2 min.安装假体时开始使用组：手术时间85～150 min,平均98.2 min;止血带使用时间18～30 min,平均24.1 min.术中失血量：手术开始时开始使用组132～640 ml,平均251.8 ml;安装假体时开始使用组320～965 ml,平均570.5 ml,术中失血量有统计学意义（P＜0.01）.术后引流血量：手术开始时开始使用组560～1310 ml,平均630.3 ml;安装假体时开始使用组470～1 190 ml,平均576.9 ml,两组间比较有统计学意义（P＜0.05）.总失血量：手术开始时开始使用组平均1 371.7 ml,安装假体时开始使用组平均1 419.3 ml,两组比较总失血量无统计学意义（P＞0.05）.隐形失血量：手术开始时开始使用组574.7 ml,安装假体时开始使用组437.3 ml,隐形失血量比较有统计学意义（P＜0.05）.手术开始时开始使用组发生肌肉疼痛4例,神经麻痹1例,对照组未发生使用止血带发生的并发症.结论 手术开始时开始使用组可减少术中失血,提供良好的手术视野利于手术操作,但术后失血较多,尤其是隐形失血量较多,对总失血量无明显影响.止血带使用时机对手术时间无影响.     

Blood loss in transurethral prostatectomy: Epidural versus general anaesthesia

The peroperative and postoperative blood loss was determined in 36 patients undergoing transurethral prostatectomy (TUR-P) using a photometric method. Seventeen patients were randomly allocated to epidural and 19 patients to general anaesthesia. No significant differences were found between the two groups in the total blood loss peroperatively, the corrected blood loss peroperatively (ml/g/min) or the blood loss postoperatively. The systolic blood pressures were equal in the two groups and no correlation between blood loss and blood pressure was demonstrated. The blood loss per g resected tissue was fairly constant and independent of prostatic weight, but bleeding per minute operating time increased significantly with prostatic size. As the total peroperative blood loss increases with operating time, rapid surgery is a possibility of reducing blood loss in TUR-P. Visual estimation of blood loss during TUR-P of larger glands was unreliable with underestimates of about 100 per cent in one third of the patients, when bleeding exceeded 400 ml. Therefore we recommend an accurate determination of blood loss during resection of larger glands.     

全膝关节置换术隐性失血的初步研究

目的研究人工全膝关节置换术(totalkneearthroplasty,TKA)的隐性失血。方法对73例TKA患者进行回顾性分析,通过Gross方程推算术后平均隐性失血量。结果TKA组中使用自体血回输患者的总失血量为1625ml,隐性失血量为774ml(48%);未使用自体血回输患者的总失血量是1345ml,隐性失血量是783ml(58%);实际上两组的隐性失血相差不大。结论TKA隐性失血量占总失血量的比例为52%,且使用自体血回输不能完全满足机体恢复体循环的需要,在围手术期要特别注意及时补充血容量。     

术前服用阿司匹林对经尿道前列腺切除术出血量的影响

目的：探讨术前服用阿司匹林对经尿道前列腺电切术出血量的影响。方法：回顾分析2002年1月～2008年12月115例行经尿道前列腺切除术的患者。根据术前停服阿司匹林是否≥10天,分为阿司匹林组（31例）和对照组（84例）。使用Mann-Whitney检验比较两组术中和术后出血量、术中每分钟出血量、术中和术后每克切除组织出血量、输血量、膀胱冲洗天数和术后住院天数。结果：两组患者术后出血量、术后每克切除组织出血量、膀胱冲洗天数、术后住院天数均差异有统计学意义（P〈0．05）。两组患者年龄、前列腺体积、切除组织重量和手术时间均差异无统计学意义（P〉0．05）。两组患者术中出血量、术中每克切除组织出血量、术中每分钟出血量和输血量的均差异无统计学意义（P〉O．05）。结论：术前停用阿司匹林〈10天不增加术中出血量、术中每克切除组织出血量、术中每分钟出血量、输血量,增加术后出血量、术后每克切除组织出血量、膀胱冲洗天数和术后住院天数。建议TURP术前至少10天停服阿司匹林。     

Calcium-deficient diet in ovariectomized dogs limits the effects of 17 beta-estradiol and nandrolone decanoate on bone.

Postmortem measurements by dual-photon absorptiometry of the femur and the second lumbar vertebra in adult dogs indicated bone loss after ovariectomy, which was more pronounced when calcium-deficient diet was given in ovariectomized dogs. This bone loss was nonhomogeneous throughout the femur. Ovariectomy resulted in trabecular and cortical bone loss, and additional calcium-deficient diet resulted in a further highly significant trabecular bone loss at the proximal epiphysis of the femur and in the vertebra. This bone loss was presumably the result of increased bone turnover, as reflected by the highly significant increase in serum alkaline phosphatase. Estrogens could only partially prevent the bone loss induced by calcium deficiency after ovariectomy, and nandrolone decanoate was not effective. We conclude that (1) ovariectomy results in bone loss in adult dogs, (2) this bone loss is more pronounced after calcium-deficient diet, (3) calcium deficiency could be a limiting factor for the preventive effect of estrogens and nandrolone decanoate, and (4) dual-photon absorptiometry allows the evaluation of nonhomogeneous bone loss throughout excised bones.     

全膝关节置换术围手术期隐性失血的危险因素研究

目的探讨影响人工全膝关节置换术（TKA）术后隐性失血的危险因素及发生机制。方法选取2008年5月至2011年5月136位患者192例TKA,患者平均年龄67．5岁,其中单侧膝关节置换80例,双膝关节同期置换56例,同组医师采用同种术式完成,术后24h补液总量不超过2000ml。利用Gross方程,计算患者的术后总失血量,隐性失血量以及血红蛋白降低情况,记录年龄、性别、术侧、BMI、输血等危险因素,通过SPSS13．0进行统计学分析,比较各组之间隐性失血量有无差别,分析影响TKA围手术期隐性失血的危险因素。结果单侧TKA总失血量1650ml,隐性失血830ml;双膝同期置换者总失血量2864ml,隐性失血1487ml。无论是单侧还是双侧TKA,男性及应用自体血回输患者的围手术期失血量多于对照组（P〈0．01）,双膝同期置换隐性失血量比例较大（X^2=6．836,P〈0．01）,高龄肥胖患者隐性失血量明显多于对照组（单膝）X^2=21．587,P〈0．01,双膝X^2=29．233,P〈0．01）。结论TKA术后失血量较高,其中隐性失血比例占50％以上。男性双膝同期置换的患者,年龄〉70且BMI〉27．0,使用自体血回输均是增加围手术期隐性失血的危险因素。     

The association between loss of Medicare,immunosuppressive medication use,and kidney transplant outcomes

Kidney transplant recipients aged <65 years qualify for Medicare coverage, but coverage ends 3 years posttransplant. We determined the association between timing of Medicare loss and immunosuppressive medication fills and kidney allograft loss. Using data from the Scientific Registry of Transplant Recipients (SRTR), US Renal Data System, and Symphony pharmacy fill database, we analyzed 78 861 Medicare‐covered, kidney‐alone recipients aged <65 years, and assessed the timing of Medicare loss posttransplant: early (<3 years), on‐time (at 3 years), or late (>3 years). Immunosuppressant use was measured as medication possession ratio (MPR). Allograft loss was assessed using SRTR data. MPR was lower for recipients with early or late Medicare loss compared with no coverage loss for all immunosuppressive medication types. For calcineurin inhibitors, early Medicare loss was associated with a 53% to 86% lower MPR. On‐time Medicare loss was not associated with a lower MPR. When recipients were matched by age, posttransplant timing of Medicare loss, and donor risk, the hazard of allograft loss was 990% to 1630% higher after early Medicare loss, and 140% to 740% higher after late Medicare loss, with no difference in the hazard for on‐time Medicare loss. Ensuring ongoing Medicare access before and after 3 years posttransplant could affect graft survival.     

PHILOS钢板和Multiloc髓内钉治疗老年肱骨近端骨折的显性失血和隐性失血分析

目的分析PHILOS钢板和Multiloc髓内钉治疗老年肱骨近端骨折的显性失血和隐性失血的临床特点。 方法回顾性分析2016年1月至2019年12月分别采用PHILOS钢板治疗（45例）和Multiloc髓内钉治疗（37例）的老年肱骨近端骨折患者的临床资料，比较手术时间、显性失血量和隐性失血量，对患者围手术期失血情况进行评估和分析。 结果PHILOS钢板组平均手术时间（141.78±36.18）min，总失血量674.68（592.87,979.65）ml，显性失血量320.00（220.00,430.00）ml；Multiloc髓内钉组平均手术时间（102.70±22.10）min，总失血量589.23（430.80,714.82）ml，显性失血量100.00（100.00,125.00）ml，两组间差异具有统计学意义（P<0.05）。两组围手术期隐性失血量为383.55（253.17,575.48）ml和460.98（309.87,610.25）ml，差异无统计学意义（P>0.05），分别占总失血量56.85%和78.23%。 结论与PHILOS钢板比较，Multiloc髓内钉内固定治疗此类骨折患者的平均手术时间短，总失血量和显性失血量少。两种内固定治疗方式的隐性失血量无明显差异，但隐性失血量在总失血量中所占比重较大，临床上应该时刻重视，积极干预，改善患者预后。     

Hidden blood loss after total hip arthroplasty

A prospective study was carried out to analyze the characteristics of hidden blood loss after total hip arthroplasty (THA) in a series of 1232 patients. The method of deducting the observed perioperative blood loss from the calculated total blood loss based on hematocrit changes was used to calculate the hidden blood loss of each patient. The reinfused and transfused bloods were also considered. We found that the amount of hidden blood loss after THA was much larger than we observed perioperatively and significantly different between differently diagnosed patients. We concluded that THA can cause a large amount of hidden blood loss, which should be monitored carefully. Retaining and repairing the articular capsule is recommended during the operation, which can significantly decrease hidden blood loss.     

Blood loss in total hip arthroplasty for rapidly destructive coxarthrosis

We studied the perioperative blood loss in 100 total hip arthroplasties performed for rapidly destructive coxarthrosis and compared it with the blood loss in 100 total hip arthroplasties for regular coxarthrosis. The treatment protocol was identical in both groups. Total blood loss was calculated as the compensated blood loss (volume transfused during and immediately after surgery) and the non-compensated blood loss using Nadler and Mercuriali formula. The mean blood loss calculated in milliliters of red blood cells (100% haematocrit) was 578 ml in regular coxarthrosis and 945 ml in rapidly destructive coxarthrosis. The blood loss after total hip arthroplasty is greater when surgery is performed for rapidly destructive coxarthrosis than for regular coxarthrosis (P < 0.001).     

PFNA治疗老年股骨粗隆间骨折隐性失血量相关性分析

目的探讨股骨近端防旋髓内钉(proximal femoral nail antirotation,PFNA)治疗老年股骨粗隆间骨折围手术期阶段性隐形失血量的相关性。方法回顾性分析2010年1月至2012年1月,我院采用PFNA手术治疗老年股骨粗隆间骨折36例患者的临床资料,入选病例均为初次患病,24 h补液量不超过2 000 mL,排除严重内科疾病、自身免疫性疾病患者。对术前、术后1 d、3 d、5 d、7 d血常规以及术中、术后出血量,使用Gross方程进行计算,应用方差分析对不同时间段的隐性失血量进行比较(以P0.05为标准),同时,探讨总失血量和阶段性隐性失血量变化值的相关性。结果 36例患者平均总失血量为(956.82±207.61)mL,其中平均显性失血为(88.08±16.28)mL,占总失血量的9.88%,平均隐性失血为(820.96±164.34)mL,占总失血量的90.23%。1 d阶段性隐性失血量和2~3 d阶段性隐性失血量没有显著性差异,但二者与4~5 d阶段性隐性失血量相比,却有着显著性差异。Pearson相关性检验显示,围手术期总失血量与1 d内阶段性隐性失血量(r=0.770)、2~3 d阶段性隐性失血量(r=0.884)、4~5 d阶段性隐性失血量(r=0.589)呈正相关(P0.05)。得到最佳线性方程:围手术期总失血量=0.978×1d内阶段性隐性失血+1.029×2~3 d内阶段性隐性失血+0.779×4~5 d阶段性隐性失血量+58.327。结论 PFNA治疗老年股骨转子间骨折术后以隐性失血量为主,主要发生于术后前3 d,应严格监测患者的生命体征和及时复查血常规以减少贫血导致的并发症。     

股骨粗隆间骨折应用Intertan固定后隐性失血的初步分析

目的探讨Intertan治疗股骨粗隆间骨折术后隐性失血的特点和相关影响因素。方法回顾性分析2009年9月-2012年9月应用Intertan治疗股骨粗隆间骨折患者107例,其中男46例,女61例,平均年龄73．08岁。骨折依照OTA／AO分型：A1型41例,A2型66例。均为初次单侧新鲜股骨粗隆间骨折,术后24h补液总量不超过2000ml。通过Gross方程计算隐性失血量。结果本组手术时间平均（65．9±5．6）min,围手术期失血总量平均（1072．0±36．0）ml,其中显性失血量平均（182．0±13．6）ml,隐性失血量平均（917．0±16．3）ml。男女组间隐性失血量比较无统计学差异（P〉0．05）,但是在AO／OTA31A1和AO／OTA31A2组间隐性失血量和总失血量存在统计学差异（P〈0．05）。结论Intertan手术虽为微创手术,术中显性失血量较少,但隐性失血量较多,在临床工作中应当注意患者术后的生命体征变化,及时复查血常规和给予相应治疗。     

低分子肝素使用时机对关节置换手术失血量和DVT发生率的影响

目的 探讨全髋和全膝置换手术使用低分子肝素预防深静脉血栓(deep vein thrombosis,DVT)的时机对手术失血量和术后DVT发生率的影响.方法 单侧初次关节置换262例中全髋关节置换179例,术前开始使用低分子肝素82例,术后开始使用97例;全膝关节置换83例,术前开始使用低分子肝素44例,术后开始使用39例.根据患者身高、体重及手术前后红细胞压积和输血量,计算两种给药时机的总失血量、隐性失血量及其占原血容量的比例,并比较DVT发生率.结果 (1)全髋关节置换患者术前开始使用低分子肝素组总失血量平均为1638ml,占原血容量的38.1%;术后开始使用低分子肝素组1425ml,占原血容量的34.2%.全膝关节置换患者术前使用低分子肝素组1569ml,占原血容量的37.4%;术后开始使用低分子肝素组1319ml,占原血容量的31.6%.全髋和全膝置换术前开始使用与术后开始使用低分子肝素比较总失血量与其占原血容量比例的差异均有统计学意义.(2)全髋关节置换DVT的发生率为16.2%,全膝关节置换为25.3%,差异无统计学意义.结论 术前使用低分子肝素可增加全髋和全膝关节置换手术的总失血量和隐性失血量,使用低分子肝素的时机对术后DVT的发生率无影响,术后再使用低分子肝素更安全.