氨甲环酸与血凝酶关节腔内注射在全膝关节置换术中的应用研究

目的比较分析氨甲环酸(TXA)与血凝酶(HCA)关节腔注射对减少人工全膝关节置换(TKA)术后出血的有效性及安全性。 方法2012年1月至2015年6月福建医科大学附属闽东医院关节科共纳入120例老年膝关节骨关节炎终末期患者行单侧初次TKA;排除术前血红蛋白(Hb)<95 g/L、血液系统疾病患者、合并心肌梗塞病史、心房颤动、安装起搏器患者、静脉血栓形成、肾功能不全者。入组病例按随机数表法分为3组：TXA组40例(TXA 2 g溶于100 ml生理盐水,关节囊缝合后经引流管逆行注入关节腔); HCA组40例(HCA 4 U溶于100 ml生理盐水同法注入关节腔);NS组40例(100 ml生理盐水同法注入关节腔)。术后第1、3、5天查血常规、凝血象及D二聚体,记录术后引流量、总失血量、术后第1、3、5天Hb变化值、输血率、深静脉血栓生率及切口感染率,引流量、总失血量、隐性失血量、血红蛋白变化的组间比较采用组间两两比较F检验;输血患者比例、下肢静脉血栓和肺栓塞发生率等计数资料采用χ²检验。 结果TXA组输血2例,HCA组输血3例,NS组输血12例,TXA组、HCA组分别与NS组比较差异有统计学意义(F＝12.33、13.45,P<0.01);TXA组与HCA组比较差异无统计学意义(F＝ 1.08,P>0.05)。HCA组、TXA组与NS组3组比较,术后6 h(F＝9.320)、24 h引流量(F＝12.15)、术后1、3、5 d隐性失血量(F＝9.450,F＝8.650,F＝7.885)及总失血量(F＝6.334,F＝7.898,F＝6.167)差异有统计学意义(P<0.05);其中HCA组与TXA组比较差异无统计学意义(P>0.05)。HCA组、TXA组与NS组3组比较术后1、3、5 d的Hb(F＝6.300,F＝8.470,F＝10.56)及△Hb值(F＝13.35,F＝17.76,F＝16.33),差异有统计学意义(P<0.05);其中HCA组与TXA组比较差异无统计学意义(P>0.05)。TXA组出现2例小腿肌间静脉血栓,HCA组3例小腿肌间静脉血栓,NS组1例小腿肌间静脉血栓,所有患者住院期间均未出现心梗、脑梗、肺梗等严重并发症,3组患者血栓发生率比较差异无统计学意义(F＝ 1.4,P>0.05)。伤口愈合情况,3组患者均有出现手术切口脂肪液化情况,TXA组3例,HCA组2例,NS组4例,均换药后愈合。 结论TKA术后关节腔内注射HCA或TXA并夹闭引流管3 h均能有效减少术后引流量、术后第1天隐性失血量及总失血量,不增加深静脉血栓发生率及切口愈合不良率。     

Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds — A double blind randomised controlled trial

IntroductionThis study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns.MethodsThis was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15?55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH).ResultsThirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm²; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups.ConclusionTXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.     

老年股骨粗隆间骨折髓内钉固定围手术期中隐性失血现象的病例对照研究

目的:分析髓内钉固定治疗老年股骨粗隆间骨折易被忽略的隐性失血现象,通过改善围手术期的治疗方式来保障临床疗效。方法:回顾性分析2010年1月至2014年1月采取髓内钉固定治疗的99例老年性股骨粗隆间骨折患者(男47例,女52例),其中围手术期采取输血支持47例(输血组),未输血患者52例(未输血组),根据Gross方程,用患者围手术期平均血红蛋白(Hb)、平均红细胞压积(HCT)来分析围手术期失血量,评估该类患者围手术期隐性失血情况。结果:未输血组(男22例,女30例)手术时间为(62.13±4.01) min,术中显性失血及术后引流量共215 ml;术前Hb(103.22±9.01) g /L,术后(81.13±6.20) g /L;术前HCT(96.93±3.38) I/L,术后(308.00±11.81) I/L.输血组(男25例,女22例)手术时间为(60.12±3.27) min,术中显性失血及术后引流量共196 ml,平均输血量621 ml;术前Hb(92.15±5.46) g /L,术后(95.20±8.93) g /L;术前HCT(96.52±3.63) I/L,术后(392.70±14.03) I/L.按Gross方程计算,未输血组和输血组围手术期失血总量分别为(937.29±63.04) ml和(706.43±35.02) ml,其中隐性失血量占较大比例。术后1、3个月,髋关节Harris评分输血组优于未输血组,术后12个月两组差异无统计学意义。结论:股骨粗隆间骨折髓内钉固定手术围手术期的隐性失血现象需引起足够重视,避免因贫血导致的围手术期并发症,影响患者预后。     

股骨髓腔注射氨甲环酸对股骨粗隆间骨折围术期失血的影响

目的探究股骨髓腔注射氨甲环酸（TXA）对股骨粗隆间骨折患者围术期失血的影响。 方法前瞻性选取我院收治的108例股骨粗隆间骨折患者,按随机数字表法将其分为对照组（n=54）和观察组（n=54）。对照组在扩髓前静脉滴注TXA,观察组在对照组的基础上于开髓后髓腔内注射TXA。比较两组手术中的输血量、输血率;隐性、显性及围术期总失血量;术前及术后5 d凝血指标;术后24 h引流量。 结果两组均随访2～6个月,统计随访期间两组下肢深静脉血栓、肺栓塞等并发症发生情况。观察组术中输血量、输血率、术后24 h引流量、隐性、显性及围术期总失血量[（0.31±0.09）U、11.11%、（198±101）ml、（528±157）ml、（375±103）ml、（892±232）ml]均少于对照组[（0.49±0.13）U、29.63%、（495±123）ml、（843±237）ml、（469±144）ml、（1 309±372）ml]（P<0.05）;与术前相比,两组术后5 d APTT水平均升高,且观察组APTT水平[（32.64±5.96）s]低于对照组[（37.52±6.17）s]（P<0.05）;术后5 d对照组的PT水平[（12.87±2.32）s]较术前升高[（15.49±2.82）s],且观察组[（12.87±2.32）s]显著低于对照组（P<0.05）;两组术前及术后3 d的INR差异无统计学意义（P>0.05）;随访期间,两组患者下肢深静脉血栓发生率差异无统计学意义（P>0.05）,均未发生肺栓塞。 结论股骨髓腔注射TXA可有效减少股骨粗隆间骨折患者PFNA内固定术围手术期失血量,且不增加术后下肢深静脉血栓及肺栓塞形成的风险。     

氨甲环酸局部应用并不放置引流对高龄人工股骨头置换术失血量的影响

目的探讨氨甲环酸局部应用并不放置引流对高龄人工股骨头置换术患者失血量的影响。 方法回顾性收集济宁医学院附属医院骨关节科收治的50例因股骨颈骨折行人工股骨头置换术的高龄患者,随机分为试验组和对照组,每组各25例。试验组在缝合阔筋膜张肌后关节腔注射2 g氨甲环酸,并加入生理盐水稀释至50 ml;对照组则关节腔注射50 ml生理盐水,2组术后均不放置引流。比较两组患者术中显性失血量、术后隐性失血量、总失血量、输血率、术后第1、3、5天血红蛋白以及下肢深静脉血栓、肺栓塞、切口感染等并发症的发生率。 结果试验组第1、3、5天血红蛋白浓度高于对照组（t=7.473, t=7.226, t=7.572, P<0.05）,其总失血量、显性失血量、隐性失血量及输血率低于对照组,差异有统计学意义（t=7.881, t=15.353, t=7.225, t=5.781,P<0.05）。两组患者术中出血量差异比较无统计学意义（t=1.382,P>0.05）。两组患者均无下肢深静脉血栓形成及肺栓塞发生。两组患者均有1例发生下肢肌间静脉血栓,无统计学差异。两组患者术后3 h相关凝血指标比较差异无统计学意义（t=1.483, t=1.352, t=1.466,P>0.05）。 结论人工股骨头置换术中关节腔注射氨甲环酸并不放置引流,能有效减少术后失血和输血,不增加下肢深静脉血栓形成和肺栓塞的发生,对凝血无影响。     

氨甲环酸减少全髋关节翻修术围手术期失血的安全性及有效性研究

目的探讨氨甲环酸减少全髋关节翻修术围手术期失血的有效性及安全性。方法将60例拟行单侧全髋关节翻修手术的患者随机分为氨甲环酸组与对照组,每组30例。术前所有患者均进行血常规、凝血常规、双下肢静脉彩超等检查,氨甲环酸组患者于切皮前10min静脉单次使用10mg／kg的氨甲环酸,对照组予以相当剂量的生理盐水。记录术中出血量、术后引流量,术后第1天、第3天复查血常规并记录患者血红蛋白水平和红细胞压积,术后第5天复查双下肢静脉彩超。如患者术后血红蛋白水平低于80g／L或患者有贫血表现时予以输入同型红细胞悬液。通过公式计算并比较患者血容量、总失血量、隐性失血量等指标。记录患者术后输血量和深静脉血栓的发生率。结果氨甲环酸组患者术中出血、术后引流、总失血量及隐形失血量均低于对照组,差异有统计学意义。氨甲环酸组患者术后14例（46．7％,14／30）,对照组26例（86．7％,26／30）需要输血,差异有统计学意义。两组患者术后深静脉血栓发生率及术后住院Et比较差异无统计学意义。结论以10mg／kg氨甲环酸术前静脉单次用药为主的多模式控制血液丢失方案可以有效减少髋关节翻修手术围手术期的血液丢失且不增加下肢深静脉血栓和肺栓塞的发生风险,该方案是髋关节翻修术围手术期控制血液丢失的安全、有效的方法。     

长短髓内钉治疗老年股骨反转子间骨折的疗效比较

目的通过分析比较短髓内钉与长髓内钉治疗老年股骨反转子间骨折的效果，为反转子间骨折内植物的选择提供临床参考。 方法回顾性分析2012年12月至2016年11月在枣庄市山亭诚德骨科医院治疗的47例老年股骨反转子间骨折的患者，根据内固定物的绝对长度与相对比例以及远端锁定器械不同分为短髓内钉（240 mm）与长髓内钉（300 mm以上）两组，其中短髓内钉组26例（55.3%），长髓内钉组21例（44.7%），观察两组患者的手术时间、术中出血量、输血量、术后负重时间、骨折愈合时间、术后并发症发生情况、髋关节功能恢复情况，日常生活能力评分按照Harris标准对患者功能进行评分。 结果术后1年内有5例患者因意外及心血管疾病等其它的原因死亡，其中短髓内钉组3例，长髓内钉组2例，均与骨折无关，40例纳入研究的患者均完成了1年的随访，随访率（85.1%）。在手术时间、出血量、输血量方面，短髓内钉组患者手术时间为（33.5±1.0）min、出血量为（192±5）ml、输血量为（192±116）ml，明显少于长髓内钉组[（68.7±12.3）min、（313±37）ml、（370±122）ml]，差异具有统计学意义（t=0.018，t=0.004，t=0.001，P<0.05）。短髓内钉组患者的术后负重时间[（8.3±2.8）d]、术后1年Harris评分[（81±3）分]、骨折愈合时间[（14.5±2.1）w]方面与长髓内钉组[（8.4±2.2）d、（80±4）分、（14.8±2.7）w）]比较，差异无统计学意义；两组术后均未发生切口不愈合或者感染、骨折延迟愈合或不愈合、下肢深静脉血栓形成、髋内翻、内固定松动及内固定周围骨折等情况。 结论短髓内钉治疗老年股骨反转子间骨折的手术时间、出血量、输血量要优于长髓内钉，并不存在"中裤效应"，建议使用短髓内钉进行固定。     

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。     

A comparative study of the therapeutic effect between long and short intramedullary nails in the treatment of intertrochanteric femur fractures in the elderly

Purpose: To compare the clinical effects of long vs. short intramedullary nails in the treatment of intertrochanteric fractures in old patients more than 65 years old. Methods: A retrospective analysis of 178 cases of intertrochanteric fractures of the femur (AO type A1 and A2) in the elderly was conducted from January 2008 to December 2013. There were 85 males (47.8%) and 93 females (52.2%) with the age of 65e89 (70.2±10.8) years. The patients were treated by closed reduction and long or short intramedullary nail (Gamma 3) fixation. The length of short nail was 180 mm and that for long nail was 320e360 mm. The general data of patients, operation time, intraoperative blood loss, length of hospital stay, preoperative hemoglobin level, blood transfusion rate, postoperative periprosthetic fractures, infections, complications, etc were carefully recorded. Results: There were 76 cases (42.7%) in the long intramedullary nail group and 102 cases (57.3%) in the short nail group. All the cases were followed up for 12-48 (21.3±6.8) months, during which there were 21 deaths (11.8%), mean (13.8±6.9) months after operation. The intraoperative blood loss was (90.7±50.6) ml in short nail group, greatly less than that in long nail group (127.8±85.9) ml (p=0.004). The short nail group also had a significantly shorter operation time (43.5 min±12.3 min vs. 58.5 min±20.3 min, p=0.002) and lower rate of postoperative transfusion (42.3% vs. 56.7%, p=0.041). But the length of hospital stay showed no big differences. After operation, in each group there was 1 case of periprosthetic fracture with a total incidence of 1.1%, 1.3% in long nail group and 0.9% in short nail group. At the end of the follow-up, all patients achieved bony union. The average healing time of the long nail group was (6.5±3.1) months, and the short nail group was (6.8±3.7) months, revealing no significant differences (p=0.09). Postoperative complications showed no great differences either. Conclusion: Both the intramedullary long and short nail fixation has a good clinical effect in treating intertrochanteric femur fractures in the elderly. They showed no significant difference in terms of therapeutic effect, hospital stay and postoperative complications. The incidence of periprosthetic fractures treated by either length of nails was low. But short intramedullary nailing can obviously decrease the intraoperative blood loss, operation time and postoperative blood transfusion.     

口服和静脉注射氨甲环酸对于腰椎椎管减压融合术的围手术期失血量影响

目的 ：探讨氨甲环酸（tranexamic acid,TXA）不同给药方式对腰椎椎管减压融合术围手术期失血量、隐性出血量、输血率,以及不良反应等各方面的影响。方法：对2019年7月至2020年7月接受腰椎椎管减压融合术的60例患者进行回顾性分析,根据TXA不同给药方式分为观察组和对照组,每组30例。观察组术前2 h口服2 g TXA;对照组在切皮前5～10 min予以1 g TXA静脉输注,术后6 h予以1 g TXA静脉输注1次。分别记录两组患者术中出血量、术后引流量、总失血量、隐性失血量、引流管拔除时间、输血率、静脉血栓形成率、不良事件发生率,观察术前和术后1、3 d血红蛋白（hemoglobin,Hb）,红细胞比容（hematocrit,HCT）的变化情况。结果：术后1、3 d的Hb及HCT均较术前有明显改善（P<0.01）,但组间比较差异无统计学意义（P>0.05）。两组术中出血量、术后引流量、总失血量、术中失血量、隐性失血量、拔管时间、输血率比较差异无统计学意义（P>0.05）。两组患者均未见静脉血栓形成和不良事件发生。结论：在腰椎椎管减压融合术围手术期口服...     

氨甲环酸对全膝关节置换术失血量的影响

目的：探讨氨甲环酸静脉重复剂量给药对全膝关节置换术失血量的影响及安全性评估。方法：对2011年4月-2012年4月90例初次行单侧全膝关节置换术的患者资料进行回顾性分析,其中男性32例,女性58例。90例患者被随机分为3组,（A组）对照组30例：（B组）单次剂量组30例：术中松止血带前10min1000mg氨甲环酸静脉滴注;（C组）双次剂量组30例：分别于术中松止血带前10min、术后3h各1000mg氨甲环酸静脉滴注。记录术后48h引流量、隐性失血量、术后12h血红蛋白减少量、输血量,术后14天观察患者是否出现下肢深静脉栓塞症状。结果：术后引流量、隐性失血量单次剂量组及双次剂量组明显低于对照组（P〈0．05）,其中双次剂量组最低。术后12h血红蛋白保持水平单次剂量组及双次剂量组明显高于对照组（P〈0．05）,术后输血量双次剂量组明显低于单次剂量组和对照组（P〈0．05）,所有患者术后14天彩色多普勒检查未发现下肢深静脉血栓形成。结论：氨甲环酸重复剂量给药可以显著减少全膝关节置换术后失血量,氨甲环酸并没有增加术后下肢深静脉血栓及肺栓塞的风险,另外,重复剂量给药可以显著减少全膝关节置换术患者的输血量。     

3种内固定方法治疗老年股骨粗隆间骨折的病例对照研究

目的:比较3种不同内固定方式治疗老年股骨粗隆间骨折的临床疗效。方法:对2004年至2008年筛选的股骨粗隆间骨折患者112例进行回顾性分析,男63例,女49例;年龄60～80岁,平均66.2岁。112例患者分别采用动力髋螺钉(DHS组,40例),股骨近端解剖型钢板(解剖型钢板组,36例)和股骨近端髓内钉(PFN组,36例)3种手术方式治疗。分析比较3组患者手术时间、术中出血量、骨折愈合时间、术后并发症以及髋关节功能评分(Harris评分)。结果:112例患者均获随访,时间20～24个月,平均22.6个月。3组患者手术时间、术中出血量差异无统计学意义,但骨折愈合时间、Harris评分及术后并发症方面差异有统计学意义(P<0.05)。愈合时间:PFN组明显低于其他两组(P=0.001),但DHS组和解剖型钢板组差异无统计学意义。Harris评分:PFN组明显高于其他两组(P=0.001),但DHS组和解剖型钢板组比较则差异无统计学意义。并发症:DHS组出现2例髋内翻,1例内固定松动,1例深静脉血栓;PFN组出现2例下肢深静脉血栓;解剖型钢板组出现2例髋内翻和1例内固定松动,3组比较差异有统计学意义(P=0.001)。结论:股骨粗隆间骨折的治疗应以PFN为首选,适应证广、愈合快,并发症低,效果确切。     

Use of Topical Tranexamic Acid Reduces Direct and Indirect Blood Loss and Transfusion Rates in Revision Total Hip Arthroplasty

Background

In primary total hip arthroplasty (THA), evidence supports the use of tranexamic acid (TXA) as an effective strategy for reducing blood loss, but scant evidence supports its use in revision THA.

Questions/Purposes

We aimed to evaluate whether the use of topical TXA in revision THA is associated with less blood loss and lower transfusion rates and to assess its safety, specifically as it relates to thromboembolic complications.

Methods

In this retrospective comparative study, two groups who underwent revision THA between 2005 and 2017 were defined: 98 patients who received 3 g of topical TXA (study group) and 475 patients who did not receive TXA (control group). Subjects were divided into subgroups according to the type of revision. Hemoglobin and hematocrit levels, blood loss, and transfusions were recorded. The follow-up period was 6 weeks.

Results

Median estimated blood loss, hidden blood loss, hemoglobin drop, and transfusion rates were significantly lower in the study group. The rates of post-operative thromboembolism were similar in the two groups. According to subgroup analysis, patients with revision of the femoral component, both components, and staged exchange revisions showed significantly lower rates of transfusion.

Conclusion

Topical TXA administration during revision THA effectively reduced direct and indirect blood loss, including hidden losses, without increasing the rates of thromboembolic events. This effect appeared to be enhanced when the femoral component was revised.

     

氨甲环酸对全髋关节置换术的止血及安全分析

目的探讨氨甲环酸(TXA)对初次单侧全髋关节置换术(THA)围手术期的输血率及术后并发症的影响。 方法回顾性分析2010年1月至2018年12月在中山大学附属第一医院关节外科行过初次单侧THA患者的病历资料。纳入标准：行初次单侧非骨水泥THA患者;术前凝血正常;髋关节疾病类型为髋关节骨关节炎、股骨头缺血性或无菌性坏死、发育性髋关节发育不良、股骨颈骨折、类风湿性关节炎以及强直性脊柱炎;术前切皮前按体重15 mg/kg给予TXA。排除标准：行髋关节翻修患者,同时有合并除单侧THA其他手术患者;凝血功能异常;合并恶性肿瘤;既往有心肌梗死或下肢血栓史;使用骨水泥假体;其他髋关节疾病类型;术前切皮前不是按体重15 mg/kg给予TXA等。根据术后使用抗凝药与未使用抗凝药两种情况,初次单侧THA术后使用抗凝药的患者,使用TXA实验组共556例,未使用TXA对照组共244例;初次单侧THA术后未使用抗凝药的患者,使用TXA实验组共248例,未使用TXA对照组共130例。本研究采用独立样本t检验、Wilcoxon秩和检验及卡方检验统计学方法,比较两种情况下两组输血率、输悬浮红细胞(RBC)量、血红蛋白(HB)最大丢失量、并发症及术后住院时间等。 结果对于行初次单侧THA患者,在术后使用抗凝药物情况下,实验组输血率14.4%,对照组48.4%,差异有统计学意义(χ²＝105.085,P<0.001);实验组中输悬浮RBC量低于对照组(2.0 U vs 2.5 U,Z＝-2.600,P<0.01)(1 U＝200 ml);实验组HB最大丢失量低于对照组(32.0 g/L vs 36.3 g/L,Z＝-4.402,P<0.001)。实验组伤口周围瘀斑(0例)低于对照组(5例)(P<0.05);伤口其他并发症及发生血栓事件差异无统计学意义(P>0.05);实验组与对照组术后住院时间差异无统计学意义(P>0.05)。在术后未使用抗凝药情况下,实验组输血率低于对照组(9.7% vs 53.8%,χ²＝89.058,P<0.001),实验组输入悬浮RBC量与对照组差异无统计学意义(3.5 U vs 4.0 U,Z ＝-0.303,P>0.05),实验组HB最大丢失量低于对照组(29.8 g/L vs 39.5 g/L,Z ＝-6.285,P<0.001)。实验组出现伤口感染低于对照组(1例vs 5例,P<0.05);伤口其他并发症及血栓事件差异无统计学意义(P>0.05);实验组术后住院时间低于对照组(7.0 d vs 8.0 d,Z＝-6.165,P<0.001)。 结论TXA对行初次单侧THA患者,在使用抗凝药与未使用抗凝药两种情况下,均能降低输血率、HB最大丢失量,具有明显的止血效果,且不增加术后伤口及发生血栓并发症,具有一定的安全性。     

The effect of multiple-dose oral versus intravenous tranexamic acid in reducing postoperative blood loss and transfusion rate after adolescent scoliosis surgery: a randomized controlled trial

BACKGROUND CONTEXTTranexamic acid (TXA) is widely used in surgery for adolescent idiopathic scoliosis (AIS) and has been proved to be efficacious in reducing intraoperative blood loss (IBL) and the transfusion rate. However, the routine TXA regimen was intraoperative administration alone, in which the concentration of TXA could not cover the whole process of hyperfibrinolysis. And, its ability to control the massive postoperative blood loss (PBL) may be insufficient. Thus, we promoted a multiple-dose regimen of TXA for patients with AIS who underwent surgical correction.PURPOSEThe primary aims were (1) to determine whether the multiple-dose regimen of TXA could reduce PBL and the postoperative transfusion rate, and (2) to compare the efficacy of oral administration with intravenous administration. The secondary aims were (3) to evaluate whether this regimen could alleviate inflammatory response, and (4) to assess the occurrence of drug-related side effects.STUDY DESIGNProspective, double-blinded, randomized controlled trial.PATIENT SAMPLEA total of 108 patients with AIS who underwent posterior scoliosis correction and spinal fusion (PSS) were enrolled in this study.OUTCOME MEASURESThe primary parameters were PBL and postoperative transfusion rate. Other parameters such as total blood loss (TBL), maximum hemoglobin (Hb) decrease, volume of drainage, inflammation markers (interleukin-6 [IL-6] and C-reactive protein [CRP]), and occurrence of complications were also collected and compared. Multiple regression analysis was used to examine the variables that affected PBL.METHODSPatients were randomized into three groups. All patients received intravenous TXA 50 mg/kg loading dose and 10 mg/kg/h maintenance dose during surgery. Group A received 1 g oral TXA at 4 hours, 10 hours, and 16 hours postoperatively; group B received 0.5 g intravenous TXA at 6 hours, 12 hours, and 18 hours postoperatively; group C received placebo.RESULTSThe mean PBL and postoperative transfusion rate in group A (957.8±378.9 mL, 13.89%) and B (980.3±491.8 mL, 11.11%) were significantly lower than those in group C [1,495.9±449.6 mL, mean differences=538.1 mL, 95% confidence interval (CI), 290.1–786.1 mL, p<0.001; 515.6 mL, 95% CI, 267.6–763.6 mL, p<.001]; (36.11%, p=.029, p=.013). Meanwhile, the mean TBL, maximum Hb decrease, and volume of drainage were also significantly lower in group A and B than in group C. IL-6 and CRP in group A and B were significantly lower than in group C from postoperative days 1 to 3. All these differences were not significant between groups A and B. No drug-related complications were observed in any patient. Multiple regression showed that the application of postoperative TXA and number of screws were significant parameters affecting PBL.CONCLUSIONSA multiple-dose regimen of TXA, either by oral or intravenous application, could be a safe and effective means of controlling PBL and decreasing the postoperative transfusion rate in patients with AIS who underwent scoliosis surgery. In addition, it could inhibit postoperative inflammatory response.     

全膝关节置换围手术期氨甲环酸不同使用方法的有效性和安全性

 目的 探讨在全膝关节置换围手术期氨甲环酸不同使用方法的有效性和安全性。方法 2013年2至5月150例行初次单侧全膝关节置换的女性骨关节炎患者随机分为三组,每组50例。分别在关闭切口前静脉滴注氨甲环酸10 mg/kg（单次使用组）;关闭切口前静脉滴注氨甲环酸10 mg/kg、术后3 h再次按该剂量重复使用（重复使用组）;不使用氨甲环酸（对照组）。比较三组引流量、总失血量、隐性失血量、术后不同时间血红蛋白、输血患者比例、深静脉血栓和肺栓塞发生率。结果 对照组引流量（447.2±101.9） ml,大于单次使用组（273.6±99.6） ml和重复使用组（168.5±80.8） ml,差异有统计学意义。对照组总失血量（1 100.8±288.3） ml,大于单次使用组（959.1±291.7） ml和重复使用组（818.7±206.9） ml,差异有统计学意义。三组隐性失血量的差异无统计学意义。对照组术后第1、3、5天的血红蛋白均低于单次使用组和重复使用组,重复使用组均高于单次使用组,差异有统计学意义。三组输血患者比例分别为8.0%（4/50）、6.0%（3/50）和22.0%（11/50）,对照组高于单次使用组和重复使用组,差异有统计学意义。术后90 d内均未出现症状性深静脉血栓和肺栓塞。结论 全膝关节置换术中关闭切口前静脉滴注氨甲环酸10 mg/kg能有效减少围手术期失血量和降低输血患者比例,术后3 h重复使用能进一步减少失血量,但不能进一步降低输血患者比例。使用氨甲环酸不增加深静脉血栓和肺栓塞发生的风险。     

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。     

The role of tranexamic acid in reducing blood loss in total knee replacement

BackgroundTotal knee arthroplasty is associated with significant perioperative blood loss which may necessitate blood transfusion. In this prospective randomised case control study we analysed the efficacy and safety of tranexamic acid in reducing perioperative blood loss and requirement of blood transfusion in total knee arthroplasty.MethodsFourteen patients (group A) undergoing total knee replacement were given intravenous tranexamic acid twice, once ten minutes before tourniquet deflation and once after four hours. Thirteen patients (group B) were observed as a separate group without the administration of the drug. Total perioperative blood loss, need of blood transfusion and D-dimer assay were analysed subsequently.ResultsThe average blood loss in the first group was 266.2 ml and in the second group was 667.5 ml (p < 0.001). average requirement of transfusion in both the groups were 0.54 and 1.6 units of blood respectively (p < 0.001). There was no case of deep vein thrombosis or any other untoward effects.ConclusionHence from these evidences it was concluded that administration of tranexamic acid during total knee replacement helps to reduce blood loss without increasing the risk of deep vein thrombosis.     

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial

IntroductionTopical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.MethodsA total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.ResultsThere was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760–1.795) in the TXA group and 1.078 L (IQR: 0.797–1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40–140) in the TXA group and 70 mL (IQR: 30–168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).ConclusionA 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.     

氨甲环酸不同静脉给药方式对青少年特发性脊柱侧凸后路矫形术中出血量的影响

目的 对比氨甲环酸(TXA)不同静脉给药方式对青少年特发性脊柱侧凸(AIS)后路矫形术中出血量的影响及安全性.方法 2017年1月—2020年3月,廊坊市第四人民医院采用脊柱后路矫形术治疗AIS患者120例,按照随机数字表法分为3组,每组40例.A组切开皮肤前15 min静脉滴注TXA 30 mg/kg;B组切开皮肤前15 min静脉滴注TXA 15 mg/kg,术中给予TXA 10 mg/(kg·h)维持至术毕;C组围手术期不使用TXA.比较3组手术时间、术中出血量、异体血输注量、晶体输注量、胶体输注量、术后输血率、术后引流量及手术前后血红蛋白(Hb)水平、D-二聚体(D-D)水平等指标,并记录并发症发生情况.结果 所有手术顺利完成.A、B组术中出血量、异体血输注量、胶体输注量、术后输血率、术后1 d引流量低于C组,术后各时间点Hb水平高于C组,差异均有统计学意义(P<0.05);以上指标A、B组组间比较,差异无统计学意义(P>0.05).3组术后各时间点D-D水平均较术前明显升高,术后1 d达到最高值,之后逐渐下降;术后各时间点A、B组D-D水平低于C组,差异均有统计学意义(P<0.05);A、B组组间比较,差异无统计学意义(P>0.05).所有患者切口愈合良好,术后双下肢血管超声检查未见深静脉血栓形成.术后电话随访均未出现相关并发症.结论 术前TXA足够剂量静脉滴注可取得与首次负荷量联合术中维持量静脉滴注相同的止血效果,无安全隐患,术前单剂量静脉滴注在操作上更为简便,值得推广应用.