氨甲环酸在脊柱外科手术中的应用进展

脊柱外科手术特别是脊柱开放手术创伤大、时间长、出血多,而大量出血会导致患者重要脏器功能受损,凝血功能异常,甚至危及生命。氨甲环酸（TXA）是一种人工合成的赖氨酸类似物,具有抑制纤溶活化、降低纤维蛋白分解的作用,是近年来脊柱外科常用的一种抗纤溶药物。该文就TXA的作用机制、给药方式、使用剂量和并发症等方面的研究进展进行综述,以期为TXA在脊柱外科手术中的应用提供参考。     

氨甲环酸在患儿围术期血液保护作用的研究进展

围术期出血和血液制品的输注会升高患者并发症的发生率和死亡率。优化血液管理策略可以降低围术期风险、改善预后及减少医疗成本。预防性使用氨甲环酸(TXA)是围术期患者血液管理(PBM)策略的重要组成部分。TXA是一种抗纤维蛋白溶解药，竞争性抑制纤溶酶原的激活，可减少手术或创伤出血，进而减少围术期输血量，已广泛应用在成人的各类手术中。在患儿围术期使用TXA的经验多数来源于成人数据，TXA在患儿中的药代动力学研究数量较少，TXA精准使用策略未完全明确。本文着眼于患儿，从TXA的药理学特性、在患儿围术期应用的方法及不良反应等几个方面进行综述，为如何在患儿围术期血液保护中使用TXA并减少其并发症提供参考。     

术后口服氨甲环酸在全髋关节置换术中的安全性和有效性研究

[目的]在加速康复流程下,以连续多次静脉应用氨甲环酸(TXA)的患者作为对照,探究术后口服TXA在初次单侧全髋关节置换术(THA)围术期的安全性和有效性。[方法]前瞻性纳入2016年10月~2017年1月于四川大学华西医院关节外科中心行初次单侧THA的患者61例,随机分为试验组(30例,术前5~10 min静滴TXA 20ml/kg,第一剂后3 h静滴浓度1%的TXA 1 g,第一剂后6、12及24 h各口服TXA 1 g)和对照组(31例,术前5~10 min静滴TXA 20 ml/kg,第一剂后3、6、12及24 h静滴浓度1%的TXA 1 g),比较两组患者的围术期失血量(隐性失血量、总失血量、血红蛋白变化量和异体输血率)、炎性指标(C反应蛋白和白细胞介素-6)、纤溶指标[D-二聚体和纤维蛋白(原)降解产物]及术后并发症。[结果]两组患者的围术期失血量,术后6、24、48 h,术后14 d的炎性指标和纤溶指标水平的差异均无统计学意义。试验组和对照组分别有2例和3例发生肌间静脉血栓,差异无统计学意义。两组患者均没有发生肺栓塞和伤口并发症。[结论]在加速康复流程下,术后口服与多次重复静脉应用TXA拥有同样的效果,可减少患者的围术期失血量,降低异体输血率,缩短术后住院时间,同时抑制炎症反应和纤溶过程,且不增加并发症的发生率。     

纤溶酶原激活、抑制系统及其在女性生殖中的作用

纤溶酶原激活、抑制系统及其在女性生殖中的作用朱艳陈贵安刘以训纤维蛋白溶解与抑制系统主要包括无活性的纤溶酶原（Ｐｌａｓｍｉｎｏｇｅｎ）、纤溶酶（ｐｌａｓｍｉｎ）、纤溶酶原激活因子（ｐｌａｓｍｉｎｏｇｅｎａｃｔｉｖａｔｏｒ，ＰＡ）及纤溶酶原激活因子抑制因...     

氨甲环酸在人工全膝关节置换术中的应用

一、临床应用历史氨甲环酸（TranexamicAcid,TXA）是一种抗纤溶药物,其结构与赖氨酸类似,能竞争性阻抑纤溶酶原在纤维蛋白上的吸附,防止其激活,保护纤维蛋白不被纤溶酶所降解和溶解,从而达到止血的效果。自上世纪60年代以来,氨甲环酸在临床多个领域中的应用,均取得了良好的效果。Ker等对多学科手术后使用氨甲环酸的随机对照研究进行了荟萃分析,筛选出自1972年到2011年发表的共129篇文献,     

氨甲环酸在初次全髋关节置换术中的应用

全髋关节置换术(total hip arthroplasty,THA)是骨科常见的大手术之一。近年来随着我国老年化进程的不断加快,THA术在全国范围内的不断推广,围手术期如何减少出血、降低输血量已成为众多关节骨科医生关注的焦点。氨甲环酸(tranexamic acid,TXA)属纤溶蛋白溶解药,与纤溶酶原的赖氨酸结合位点(LBS)具有高亲和性,可竞争性结合LBS位点,阻断纤溶酶重链与纤维蛋白间的结合,抑制纤维蛋白降解从而达到止血的目的,被广泛应用于心脏外科、儿童外科、妇产科等手术中。但就TXA在初次THA术中的使用方式、临床效果以及可能存在的潜在风险等方面则缺乏足够的研究且充满争议。本文拟就TXA的药理机制、临床功效及安全性、经济社会效益等加以综述。     

复杂胫骨平台骨折术后多次静脉应用氨甲环酸的有效性及安全性

目的 探讨复杂胫骨平台骨折（Schatzker Ⅴ、Ⅵ）术后多次静脉应用氨甲环酸（Tranexamic acid, TXA）抑制纤溶及减少失血的安全性及有效性。方法 将2018年3月至2019年1月西安交通大学医学院附属红会医院骨科收治拟行手术,且符合本研究纳入与排除标准的70例复杂胫骨平台骨折病人,按照就诊顺序分为两组,每组各35例。对照组：松止血带前5~10 min静脉点滴TXA（15 mg/kg）;观察组：松止血带前5~10 min静脉点滴TXA（15 mg/kg）,术后3 h、6 h后各再次静脉追加1 g TXA。记录并比较两组病人的总失血量、隐性失血量、输血率、48 h引流量、纤溶水平、静脉血栓性疾病、术后伤口并发症等情况。结果 两组病人均无输血者。对照组总失血量为（792.86±202.86） ml,观察组为（692.29±124.90） ml;对照组隐性失血量为（318.01±83.41） ml,观察组为（266.29±60.98） ml;对照组术后48 h引流量为（277.14±129.24） ml,观察组为（207.14±124.35） ml;对照组术后24 h D-二聚体值为（5.16±4.23） mg/L,观察组为（3.98±1.42） mg/L;对照组术后24 h纤维蛋白降解产物为（4.38±3.41） mg/L,观察组为（3.98±1.11） mg/L;对照组术后伤口红肿渗出率1例（3.70%）,观察组未发生术后伤口红肿渗出;以上指标两组间比较,差异均有统计学意义（P均＜0.05）。两组间术后下肢静脉血栓、肺栓塞及其他伤口并发症发生率比较,差异均无统计学意义（P均＞0.05）。结论 对于Schatzker Ⅴ、Ⅵ复杂胫骨平台骨折,术后3 h、6 h静脉追加1 g TXA,可以进一步抑制术后机体纤溶亢进,降低术后的总失血量、隐性失血量、48 h引流量,减少术后血红蛋白丢失,且不增加血栓性疾病发生风险。同时,TXA有一定的抗炎作用,能减少术后伤口红肿渗出的发生。     

蛋白C途径在创伤性脑损伤后凝血功能异常中的作用研究

目的探讨蛋白C途径在不同损伤程度创伤性脑损伤(TBI)患者凝血功能障碍中的作用。方法依据格拉斯哥评分(GCS)入组30例TBI患者,其中轻度、中度和重度TBI各10例,入院早期采集患者血液样本,检测其凝血功能及蛋白C途径相关凝血纤溶因子,比较不同损伤程度TBI患者凝血功能障碍及蛋白C途径在凝血功能障碍中的作用。结果 TBI患者纤维蛋白原(FIB)在中重度患者中明显降低(P<0.05),活化部分凝血酶原时间(APTT)和凝血酶原时间(PT)则显著性的延长(P<0.05),随着损伤程度加重D-二聚体水平显著增加。蛋白C(PC)在重度TBI患者中显著提高(P<0.05);凝血酶原片段1+2(PF1+2)在中重度TBI患者中较轻度TBI患者显著提高;组织纤溶酶原激活物(t PA)和1型纤溶酶原激活物抑制剂(PAI-1)在重度TBI患者中显著升高(P<0.05)。结论中重度TBI患者早期出现凝血功能障碍,蛋白C途径可能参与这一过程,这一结果有助于TBI患者早期凝血功能障碍的诊断和治疗。     

激素性股骨头坏死与凝溶紊乱的实验研究

目的：观察激素性股骨头坏死家兔模型的血液凝溶功能变化,探讨激素性股骨头坏死的发病机理。方法：健康雄性成年家兔36只,随机分为对照组（注射生理盐水）,实验组（冲击注射地塞米松）。检测血脂、血浆组织纤溶酶原激活物（tPA)、纤溶酶原激活物抑制物（PAI）、血栓素A2（TXA2）、前列环素（PGI）的阶段性变化。观察实验35、70d双侧股骨头的病理变化。结果：实验组15d甘油三脂、总胆固醇、TXA2／PGI比值均显著高于对照组。实验30、60d,实验组tPA／PAI比值显著低于对照组。实验组35、70d双侧股骨头软骨下区骨陷窝空虚率均较对照组显著增高。结论：地塞米松冲击应用可引起家兔血液高凝、低纤溶。血液凝溶功能紊乱可能参与兔激素性股骨头坏死的发病。     

抑肽酶在非体外循手术中应用研究进展

抑肽酶可以抑制激肽释放酶原，阻断内源性凝血途径而减少凝血因子及血小板的消耗;同时可以抑制蛋白水解酶产物，抑制组织型纤溶酶原激活物（t-PA)、尿激酶型纤溶酶原激活物（u-PA)等使纤溶系统抑制而减少围术期失血及异体输血。抑肽酶可于肝移植外科、矫形外科、肿瘤外科、颅脑外科等非体外循手术中，尤其是易致纤溶系统激活的体腔手术有很好的应用前景。     

Editorial Commentary: The Current Evidence in Support of Tranexamic Acid in Arthroscopic Surgery Is Poor

Tranexamic acid (TXA) has been used to treat severe bleeding events for nearly 60 years and is on the list of World Health Organization essential medicines. Initially, it was described to treat heavy menstrual bleeding, but it is now used for a variety of applications. In orthopedic surgery, TXA is commonly used to reduce bleeding after total joint arthroplasty and spine surgery. The use of TXA for joint arthroplasty has been principally endorsed by various orthopedic societies, but they have also criticized a lack of evidence for high-risk patients with a history of pulmonary embolus, vascular stents, stroke, transient ischemic attack, and other cardiac, respiratory, or vascular conditions. TXA may also reduce bleeding complications in arthroscopic surgery, and the findings of recent meta-analyses suggest that intravenous application reduced drainage output and the need for knee joint aspiration and reduced knee swelling. It also had a positive short-term effect on clinical and functional outcomes. However, high risk of bias, low-study quality, and heterogeneity substantially reduced the quality of evidence and the validity of the study conclusions. In my opinion, on the basis of the current evidence, the routine use of TXA in arthroscopic surgery is not recommended.     

Editorial Commentary: Tranexamic Acid Is Beneficial in the Very Early Postoperative Period in Anterior Cruciate Ligament Reconstruction Patients

Tranexamic acid (TXA) has been administrated in many orthopaedic surgical procedures to decrease perioperative and postsurgical bleeding. Relatively scant literature exists regarding the effect of TXA in patients after anterior cruciate ligament reconstruction. Currently, most evidence shows that within about 1 month after anterior cruciate ligament reconstruction, TXA can effectively reduce postoperative joint swelling and pain, as well as the aspiration rate. However, there are still controversies regarding the optimal dosage, timing, and route of administration of TXA in these patients. In addition, the potential chondrotoxic effect of TXA needs to be further clarified with longer clinical follow-up.     

Blood loss and perioperative transfusions related to surgery for spinal tumors. Relevance of tranexamic acid

IntroductionTranexamic acid (TXA) has been shown to reduce bleeding. Patients with spinal tumors are fragile and acute anemia may be harmful. Tumor excision surgery is reputed to be hemorrhagic and treatment may increase thromboembolic complications. The aim of this study was to compare blood loss with or without perioperative TXA injection. The transfusion-related and postoperative complications were documents.MethodThis retrospective analysis of prospectively collected data involved 83 patients with spinal tumors who underwent decompressive surgery associated with bone fixation. Tranexamic acid was used arbitrarily in 36 of them, while the other 47 did not receive TXA. The overall, intraoperative and postoperative blood loss was recorded. Blood loss was reported relative to the number of fixed levels and the number of levels decompressed by laminectomy. Transfusions were quantified in number of red blood cell packets and erythrocyte volume. Postoperative complications were documented.ResultsEpidemiological and morphological data were similar between groups. There were no significant differences between the two groups in the overall, intraoperative, and postoperative blood loss. A significant reduction in postoperative bleeding was found in the TXA group when the volume was related to the number of decompressed levels. A significant reduction (P < 0.05) in the volume of transfused blood was identified in the treated group. No predictor of blood loss was identified, and no additional complications occurred.ConclusionThe efficacy of TXA appears to be moderate during spinal tumor surgery since it does not lead to a reduction in perioperative bleeding. However, a significant reduction in transfusion volume was found without an increase in complications.     

Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized,controlled study

BACKGROUND: Extensive blood loss in total knee replacement (TKR) surgery is well known and is associated with a high transfusion rate of allogenic blood. Tranexamic acid (TXA) has been shown to reduce blood loss by 50% in this patient group, but only in cases with a perioperative loss of 1400-1800 ml. This study was performed to see if TXA offers any advantages in knee replacement surgery with blood loss at 800 ml. METHODS: Thirty consecutive patients scheduled for TKR in spinal anesthesia with the use of a tourniquet, were randomized to TXA or non-TXA. Tranexamic acid 10 mg kg-1 was given at conclusion of surgery and again 3 h later. Blood loss was registered. RESULTS: Total blood loss was at all times significantly lower in the TXA group compared to the non-TXA group (409.7+/-174.9 ml vs. 761.7+/-313.1 ml; P<0.001). There were no differences in coagulation parameters. No patients in the TXA group had a blood transfusion vs. 13% in the non-TXA group (NS). No complications were registered in the two groups. CONCLUSION: We conclude that TXA significantly reduces blood loss after total knee replacement surgery.     

Tranexamic acid in Neurosurgery: a controversy indication—review

Neurosurgical Review - Tranexamic acid (TXA) is one of the measures indicated to reduce bleeding and the need for volume replacement. However, data on risks and benefits are controversial. This...     

Größenprogrediente intrakranielle Blutungen nach Schädel-Hirn-Trauma

BACKGROUND: The aim of the study was to quantify the occurrence of progressive intracranial bleeding (PIB) and to identify concomitant parameters in patients suffering from traumatic brain injury (TBI). METHODS: TBI patients were included if initial and serial cranial computed tomography (CCT) scans were conducted within 24 h after trauma. A progression of > or =25% was considered as PIB. Patients with progression were compared to those with constant bleeding regarding clinical parameters, time lapse and coagulation status. RESULTS: A total of 98 patients with TBI and intracranial hemorrhaging were analyzed. PIB was detected in 45 patients showing significantly more intracerebral bleeding as well as fractures to the skull (p<0.05), compared to patients with constant bleeding. No significant differences between the groups regarding demographic and clinical parameters, time interval between trauma and initial CCT, and coagulation status were found. CONCLUSIONS: Early progression of intracranial hemorrhaging occurs in nearly every second TBI patient and is recognized frequently in cerebral contusions and after fractures to the skull. Hence, early repeated CT scanning is indicated in all TBI patients suffering from intracranial bleeding.     

氨甲环酸在全膝关节置换术中应用策略的研究进展

氨甲环酸作为一种抗纤维蛋白溶解药用于减少全膝关节置换术中术后失血量是近年来研究的热点问题,对全膝关节置换术后患者的失血量、血红蛋白含量、输血率等其他相关指标的影响被大量学者研究及探讨。但如何安全、有效地应用氨甲环酸,目前还没有一种金标准策略。根据不同的用药剂量,氨甲环酸可以按药物体重比例使用或直接1.5 g或3.0 g使用;根据不同的给药途径,氨甲环酸可以静脉滴注、局部应用以及口服用药;根据不同的使用时机,氨甲环酸可以术前、术中、术后或联合使用。在不增加全膝关节置换术后血栓形成概率的条件下,选择更为科学的使用方法来发挥氨甲环酸的最大效用,是近来研究的热点。     

Tranexamic Acid and Prothrombotic Complications Following Total Hip and Total Knee Arthroplasty: A Population-Wide Safety Analysis Accounting for Surgeon Selection Bias

BackgroundTranexamic acid (TXA) utilization during total joint arthroplasty (TJA) has become ubiquitous. However, concerns remain regarding the risk of thrombotic complications. The goal of this study was to examine the risk of prothrombotic complications in patients who received TXA during total knee (TKA) and total hip arthroplasty (THA).MethodsThe Premier Healthcare Database was queried for patients who underwent elective TJA. TXA utilization trends were described from 2008 to 2020. Two analyses were performed using ICD-10 codes from 2016 to 2020: (1) patients who received TXA compared to patients who did not receive TXA and, (2) to account for surgeon selection bias, patients whose surgeon utilized TXA consistently (≥90% of cases) compared to patients whose surgeons used TXA infrequently (≤30% of cases). Multivariate and instrumental variable analyses (IVA) were performed to assess outcomes while accounting for confounding factors. TXA utilization increased from 0.1% of cases in 2008 to 89.2% in 2020. From 2016 to 2020, 1,120,858 TJAs were identified (62.1% TKA, 27.9% THA), of which 874,627 (78.0%) received TXA.ResultsPatients who received TXA were at lower risk of prothrombotic (adjusted Odds Ratio (aOR) 0.82, P < .001), bleeding (aOR 0.75, P < .001), and infectious complications (aOR 0.91, P < 0.001). Furthermore, patients who underwent surgery from surgeons who utilized TXA consistently were at lower risk for prothrombotic (aOR 0.90, P < .001) and bleeding (aOR 0.72, P < .001) complications.ConclusionThe widespread utilization of TXA during elective TJA was not associated with increased rates of prothrombotic complications. These findings persisted after accounting for surgeon selection bias.Level of EvidenceLevel III.     

Tranexamic acid reduces blood loss in simultaneous bilateral total knee arthroplasty: a randomized control trial

Total knee arthroplasty (TKA) is a common procedure, and bilateral TKA ensures cost efficiency. Bilateral TKA is associated with increased requirement of blood transfusion (BT). BT is associated with hazards, therefore be avoided. Tranexamic acid (TXA) has been suggested to reduce the BT, and the use of TXA in bilateral TKA appears sparse in literature. This study aimed at assessing the effect of TXA in such patients. This prospective randomized controlled trial evaluated the use of TXA in bilateral TKA. Pre- and postoperative hemoglobin (Hb) and packed cell volume (PCV), blood loss and BT, hospital stay, and the cost of TXA compared to blood transfusion were the measured variables. 175 patients (n?=?88 TXA, n?=?87 CTRL) completed the study. The patients in the control (CTRL) group on an average received 0.3 units and 0.07 in TXA group. The average blood loss in the TXA group was significantly less than the CTRL (P?<?0.0001). There was no significant difference in the perioperative complications, hospital stay in the two groups. The use of TXA reduces the postoperative blood loss. The allogenic BT requirement in patients undergoing bilateral TKA is significantly decreased. The routine use of this drug is cost-effective and reduces postoperative blood loss.