术后追加应用氨甲环酸对类风湿性关节炎全膝关节置换术后失血量的影响
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摘要
目的探讨术后追加应用氨甲环酸(TXA)对类风湿性关节炎(RA)全膝关节置换术(TKA)后失血量的影响。方法将初次行TKA治疗的100例RA患者随机分组为常规剂量组和术后追加剂量组,每组50例。常规剂量组于手术切皮前30 min静脉滴注及关闭关节腔后关节腔内注射TXA,追加剂量组在常规剂量组基础上于术后4 h静脉滴注TXA。记录两组患者术后第7天的RBC计数、Hb、红细胞压积、凝血功能、D-二聚体水平及膝关节疼痛视觉模拟量表(VAS)评分、美国特种外科医院(HSS)膝关节评分、下肢深静脉血栓(DVT)发生率,比较两组患者术后失血量。结果术后第7天,追加剂量组Hb水平高于常规剂量组(P<0.05),而两组PLT、凝血酶原时间、国际标准化比值、部分凝血活酶时间、D-二聚体水平及VAS评分、HSS评分、DVT发生率比较,差异均无统计学意义(均P>0.05)。追加剂量组总失血量、围术期总失血量、隐形失血量及术后需输血率均低于常规剂量组(均P<0.05)。结论术后追加应用TXA可进一步减少RA患者TKA后失血量,且不增加DVT的发生。
Objective To investigate the effect of postoperative tranexamic acid( TXA) on blood loss after total knee arthroplasty( TKA) for rheumatoid arthritis( RA). Methods A total of 100 patients with RA undergoing first TKA were randomly divided into conventional dose group and postoperative additional dose group,with 50 cases in each group. The conventional dose group was given intravenous drip of TXA at 30 minutes before skin incision as well as intra-articular injection of TXA after closing articular cavity,and the postoperative additional dose group was given intravenous drip of TXA at 4 hours after surgery on the basis of the therapy performed in the conventional dose group. On the 7 th day after operation,the levels of RBC count,Hb,hematocrit,coagulation function and D-dimer,as well as the knee Visual Analogue Scale( VAS) score,Hospital for Special Surgery( HSS) knee score and incidence of lower extremity deep vein thrombosis( DVT),were recorded,and the postoperative blood loss was compared between the two groups. Results On the 7 th day after operation,the level of Hb in the additional dose group was higher than that in the conventional dose group( P < 0. 05),and there was no significant difference between the two groups in the PLT,prothrombin time,international normalized ratio,activated partial thromboplastin time,D-dimer level,VAS score,HSS score,or incidence rate of DVT( all P > 0. 05). The total blood loss,total blood loss during the perioperative period,hidden blood loss,and the rate of postoperative blood transfusion in the additional dose group were lower than those in the conventional dose group( all P < 0. 05). Conclusion Additional dose of TXA used after operation can further reduce the blood loss after TKA in RA patients,which does not increase the incidence of DVT.
Objective To investigate the effect of postoperative tranexamic acid( TXA) on blood loss after total knee arthroplasty( TKA) for rheumatoid arthritis( RA). Methods A total of 100 patients with RA undergoing first TKA were randomly divided into conventional dose group and postoperative additional dose group,with 50 cases in each group. The conventional dose group was given intravenous drip of TXA at 30 minutes before skin incision as well as intra-articular injection of TXA after closing articular cavity,and the postoperative additional dose group was given intravenous drip of TXA at 4 hours after surgery on the basis of the therapy performed in the conventional dose group. On the 7 th day after operation,the levels of RBC count,Hb,hematocrit,coagulation function and D-dimer,as well as the knee Visual Analogue Scale( VAS) score,Hospital for Special Surgery( HSS) knee score and incidence of lower extremity deep vein thrombosis( DVT),were recorded,and the postoperative blood loss was compared between the two groups. Results On the 7 th day after operation,the level of Hb in the additional dose group was higher than that in the conventional dose group( P < 0. 05),and there was no significant difference between the two groups in the PLT,prothrombin time,international normalized ratio,activated partial thromboplastin time,D-dimer level,VAS score,HSS score,or incidence rate of DVT( all P > 0. 05). The total blood loss,total blood loss during the perioperative period,hidden blood loss,and the rate of postoperative blood transfusion in the additional dose group were lower than those in the conventional dose group( all P < 0. 05). Conclusion Additional dose of TXA used after operation can further reduce the blood loss after TKA in RA patients,which does not increase the incidence of DVT.
引文
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[5]Ker K,Edwards P,Perel P,et al.Effect of tranexamic acid on surgical bleeding:systematic review and cumulative metaanalysis[J].BMJ,2012,334:e3 054.
[6]Ishida K,Tsumura N,Kitagawa A,et al.Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty[J].Int Orthop,2011,35(11):1 639-1 645.
[7]Yang ZG,Chen WP,Wu LD.Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty:a meta-amalysis[J].J Bone Joint Surg Am,2012,94(13):1 153-1 159.
[8]Gandhi R,Evans HM,Mahomed SR,et al.Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty:a meta-analysis[J].BMC Res Notes,2013,6:184.
[9]徐闯,刘明廷,尚义美,等.氨甲环酸对全膝关节置换术安全性及有效性的Meta分析[J].中国运动医学杂志,2016,35(7):690-696.
[10]Amett FC,Edworth S,Bllk DA,et al.The 1987 revised ARA criteria for rheumatoid arthritis[J].Arthritis Rheum,1987,30:17.
[11]Britsemmer K,Ursum J,Gerritsen M,et al.Validation of the2010 ACR/EULAR classification criteria for rheumatoid arthritis:slight improvement over the 1987 ACR criteria[J].Ann Rheum Dis,2011,70(8):1 468-1 470.
[12]陈乐锋,莫颖倩,戴冽.关节X线检查在类风湿关节炎诊断及影像学评估中的应用[J].中华临床医师杂志(电子版),2013,7(10):4 489-4 492.
[13]马剑达,郑东辉,朱浪静,等.病情活动性评分在类风湿关节炎患者治疗中的应用[J].中华关节外科杂志(电子版),2014,8(1):83-86.
[14]中华医学会骨科学分会.中国骨科大手术静脉血栓栓塞预防指南[J].中华关节外科杂志(电子版),2009,3(3):70-72.
[15]Nadler SB,Hidalgo JU,Bloch T.Prediction of blood volume in normal human adults[J].Surgery,1962,51(2):224-232.
[16]Knight JL,Sherer D,Guo J.Blood transfusion strategies for total knee arthroplasty:minimizing autologous blood wastage,risk of homologous blood transfusion and transfusion cost[J].J Arthroplasty,1998,13(1):70-76.
[17]Good L,Peterson E,Lisander B.Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement[J].Br J Anaesth,2003,90(5):596-599.
[18]Zhang H,Chen J,Chen F,et al.The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty:a meta-analysis[J].Knee Surg Sports Traumatol Arthrosc,2012,20(9):1 742-1 752.
[19]Howes JP,Sharma V,Cohen AT.Tranexamic acid reduces blood loss after knee athroplasty[J].J Bone Joint Surg Br,2012,78(6):995-996.
[20]Endo Y,Nishimura S,Miura A.Deep-vein thrombosis induced by tranexamic acid in idiopathic thrombocytopenic purpura[J].JAMA,1988,259(24):3 561-3 562.
[21]Upadhyay SP,Mallick PN,Jagia M,et al.Acute arterial thrombosis associated with inadvertent high dose of tranexamic acid[J].Indian J Crit Care Med,2013,17(4):237-239.
[22]Francesco M,Federica R,Matteo B,et al.Use of tranexamic acid in total knee arthroplasty[J].Joints,2016,4(4):202-213.
[23]Benoni G,Bjorkman S,Fredin H.Application of pharmacokinetics data from healthy volunteers for the prediction of plasma comcentrations of tranexamic acid in surgical patients[J].Clin Drug Invest,1995,10(5):280-287.
[24]Macgillivray RG,Tarabichi SB,Hawari MF,et al.Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty:a prospective,randomized double blind study[J].J Arthroplasty,2011,26(1):24-28.
[25]Maniar RN,Kumar G,Singhi T,et al.Most effective regimen of tranexamic acid in knee arthroplasty:a prospective randomized controlled study in 240 patients[J].Clin Orthop Relat Res,2012,470(9):2 005-2 012.
[26]Ishii Y,Noguchi H,Sato J,et al.Effect of a single injection of tranexamic acid on blood loss after primary hybrid TKA[J].Knee,2015,22(3):197-200.
[27]Lee SH,Cho KY,Khurana S,et al.Less blood loss under concomitant administration of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty:a prospective randomized controlled trial[J].Knee Surg Sports Traumatol Arthrosc,2013,21(11):2 611-2 617.
[28]Patel JN,Spanyer JM,Smith LS,et al.Comparison of intravenous versus topical tranexamic acid in total knee arthroplasty:a prospective randomized study[J].J Arthroplasty,2014,29(8):1 528-1 531.
[29]Chen SB,Wu KZ,Kong GB,et al.The efficacy of topical tranexamic acid in total hip arthroplasty:a meta-analysis[J].BMC Musculoskelet Disord,2016,17(1):81-88.
[30]Mutsuzaki H,Ikeda K.Intra-articular injection of tranexamic acid via a drain plus drain-clamping to reduce blood loss in cementless total knee arthroplasty[J].J Orthop Surg Res,2012,7(2):32.
[31]Prasad N,Padmanabhan V,Mullaji A.Comparison between two methods of drain clamping after total knee replacement[J].Arch Oethop Trauma Surg,2005,125(6):381-384.
[2]Mylod AJ,France MP,Muser DE,et al.Perioperative blood loss associated with total knee arthropalsty.A comparison of procedures performed with and without cementing[J].J Bone Joint Surg Am,1990,72(7):1 010-1 012.
[3]Panteli M,Papakostidis C,Dahabreh Z,et al.Topical tranexamic acid in total knee arthroplasty:a systematic review and meta-analysis[J].Knee,2013,20(5):300-309.
[4]张阳,钱齐荣,吴海山,等.氨甲环酸减少全膝关节置换术失血量的Meta分析[J].中华骨科杂志,2009,29(6):524-529.
[5]Ker K,Edwards P,Perel P,et al.Effect of tranexamic acid on surgical bleeding:systematic review and cumulative metaanalysis[J].BMJ,2012,334:e3 054.
[6]Ishida K,Tsumura N,Kitagawa A,et al.Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty[J].Int Orthop,2011,35(11):1 639-1 645.
[7]Yang ZG,Chen WP,Wu LD.Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty:a meta-amalysis[J].J Bone Joint Surg Am,2012,94(13):1 153-1 159.
[8]Gandhi R,Evans HM,Mahomed SR,et al.Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty:a meta-analysis[J].BMC Res Notes,2013,6:184.
[9]徐闯,刘明廷,尚义美,等.氨甲环酸对全膝关节置换术安全性及有效性的Meta分析[J].中国运动医学杂志,2016,35(7):690-696.
[10]Amett FC,Edworth S,Bllk DA,et al.The 1987 revised ARA criteria for rheumatoid arthritis[J].Arthritis Rheum,1987,30:17.
[11]Britsemmer K,Ursum J,Gerritsen M,et al.Validation of the2010 ACR/EULAR classification criteria for rheumatoid arthritis:slight improvement over the 1987 ACR criteria[J].Ann Rheum Dis,2011,70(8):1 468-1 470.
[12]陈乐锋,莫颖倩,戴冽.关节X线检查在类风湿关节炎诊断及影像学评估中的应用[J].中华临床医师杂志(电子版),2013,7(10):4 489-4 492.
[13]马剑达,郑东辉,朱浪静,等.病情活动性评分在类风湿关节炎患者治疗中的应用[J].中华关节外科杂志(电子版),2014,8(1):83-86.
[14]中华医学会骨科学分会.中国骨科大手术静脉血栓栓塞预防指南[J].中华关节外科杂志(电子版),2009,3(3):70-72.
[15]Nadler SB,Hidalgo JU,Bloch T.Prediction of blood volume in normal human adults[J].Surgery,1962,51(2):224-232.
[16]Knight JL,Sherer D,Guo J.Blood transfusion strategies for total knee arthroplasty:minimizing autologous blood wastage,risk of homologous blood transfusion and transfusion cost[J].J Arthroplasty,1998,13(1):70-76.
[17]Good L,Peterson E,Lisander B.Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement[J].Br J Anaesth,2003,90(5):596-599.
[18]Zhang H,Chen J,Chen F,et al.The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty:a meta-analysis[J].Knee Surg Sports Traumatol Arthrosc,2012,20(9):1 742-1 752.
[19]Howes JP,Sharma V,Cohen AT.Tranexamic acid reduces blood loss after knee athroplasty[J].J Bone Joint Surg Br,2012,78(6):995-996.
[20]Endo Y,Nishimura S,Miura A.Deep-vein thrombosis induced by tranexamic acid in idiopathic thrombocytopenic purpura[J].JAMA,1988,259(24):3 561-3 562.
[21]Upadhyay SP,Mallick PN,Jagia M,et al.Acute arterial thrombosis associated with inadvertent high dose of tranexamic acid[J].Indian J Crit Care Med,2013,17(4):237-239.
[22]Francesco M,Federica R,Matteo B,et al.Use of tranexamic acid in total knee arthroplasty[J].Joints,2016,4(4):202-213.
[23]Benoni G,Bjorkman S,Fredin H.Application of pharmacokinetics data from healthy volunteers for the prediction of plasma comcentrations of tranexamic acid in surgical patients[J].Clin Drug Invest,1995,10(5):280-287.
[24]Macgillivray RG,Tarabichi SB,Hawari MF,et al.Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty:a prospective,randomized double blind study[J].J Arthroplasty,2011,26(1):24-28.
[25]Maniar RN,Kumar G,Singhi T,et al.Most effective regimen of tranexamic acid in knee arthroplasty:a prospective randomized controlled study in 240 patients[J].Clin Orthop Relat Res,2012,470(9):2 005-2 012.
[26]Ishii Y,Noguchi H,Sato J,et al.Effect of a single injection of tranexamic acid on blood loss after primary hybrid TKA[J].Knee,2015,22(3):197-200.
[27]Lee SH,Cho KY,Khurana S,et al.Less blood loss under concomitant administration of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty:a prospective randomized controlled trial[J].Knee Surg Sports Traumatol Arthrosc,2013,21(11):2 611-2 617.
[28]Patel JN,Spanyer JM,Smith LS,et al.Comparison of intravenous versus topical tranexamic acid in total knee arthroplasty:a prospective randomized study[J].J Arthroplasty,2014,29(8):1 528-1 531.
[29]Chen SB,Wu KZ,Kong GB,et al.The efficacy of topical tranexamic acid in total hip arthroplasty:a meta-analysis[J].BMC Musculoskelet Disord,2016,17(1):81-88.
[30]Mutsuzaki H,Ikeda K.Intra-articular injection of tranexamic acid via a drain plus drain-clamping to reduce blood loss in cementless total knee arthroplasty[J].J Orthop Surg Res,2012,7(2):32.
[31]Prasad N,Padmanabhan V,Mullaji A.Comparison between two methods of drain clamping after total knee replacement[J].Arch Oethop Trauma Surg,2005,125(6):381-384.