氨甲环酸减少同期双侧全髋关节置换围手术期失血量的临床疗效分析

发布时间：2018-01-21 00:37

  本文关键词： 氨甲环酸 同期双侧全髋关节置换 失血量 深静脉血栓　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究目的:随着人工全髋关节置换(TotalHipArthroplasty,THA)技术的普及和持续发展、人工髋关节假体的不断改良,人工全髋关节置换(THA)逐渐成为股骨头坏死(Osteonecrosis of the Femeral Head,ONFH)、髋关节骨性关节炎(Osteoarthritis,OA)、发育性髋关节发育不良(Developmental Dysplasia Of the Hip,DDH)等终末期髋关节疾病的首选方法;对于累及髋关节的类风湿性关节炎(RheumatoidArthritis,RA)、强直性脊柱炎(Ankylosing Spondylitis,AS)等疾病而言,人工全髋关节置换(THA)术作为一种有效的治疗方法而被广泛应用于临床。然而,ONFH、OA、RA及AS等疾患终末期可造成双侧髋关节病变,表现为双侧髋关节功能障碍,甚至发生髋关节强直,影响了患者的日常生活,从而导致生活质量严重下降。对于此类患者,双侧人工全髋关节置换术(Bilateral TotalHipArthroplasty,Bi-THA)作为一种有效的治疗方法被应用于临床,主要包括分期双侧全髋关节置换(Staged Bilateral Total Hip Arthroplasty)和同期双侧全髋关节置换(Simultaneous Bilateral Total Hip Arthroplasty,Sbi-THA)。显而易见,同期置换(Sbi-THA)围手术期的出血量较多,从而一定程度上增加了术中及术后输血的比率、围手术期的危险性,可能增加一定的经济负担。为此,临床医师及麻醉医师等在围手术期采取了多种措施来减少围手术期失血量(隐形失血及显性失血),包括术中仔细止血、自体血回输(术中及术后)、术中应用止血药物等。氨甲环酸(Tranexamic Acid,TXA)可减少围手术期失血量,因而被逐渐应用于关节置换术等。虽然氨甲环酸(TXA)在单侧全髋关节置换术及分期双侧全髋关节置换中应用较多,其安全性及有效性得到了一定程度上的印证。然而氨甲环酸(TXA)在同期双侧全髋关节置换(Sbi-THA)术中的应用鲜有报道。同期双侧全髋关节置换(Sbi-THA)应用氨甲环酸(TXA)的安全性及有效性尚无明确定论。本文旨在根据我院同期双侧全髋关节置换(Sbi-THA)中应用氨甲环酸(TXA)的经验,探讨氨甲环酸(TXA)在减少同期双侧全髋关节置换(Sbi-THA)围手术期失血量的临床疗效及安全性,为氨甲环酸(TXA)在同期双侧全髋关节置换(Sbi-THA)中的应用提供理论参考信息。研究方法:收集山东大学齐鲁医院骨外科2012年5月～2016年6月收入院并行同期双侧人工全髋关节(Sbi-THA)的患者资料并进行回顾性分析研究,设定纳入标准后共纳入82例,其中男性48例,女性34例;年龄28～75岁,平均年龄54.43±10.53 岁;诊断为 ONFH 59 例,OA23 例;身高体重指数(Body Mass Index,BMI)21.97～32.18kg/m2,平均 BMI 26.28±4.36kg/m2;将 82 例分成 A、B 两组,其中A组为单纯静脉应用TXA组,共42例;B组为对照组,不应用TXA组,共40例。A组患者于每侧切皮前1Omin完成单次15mg/kgTXA静脉滴注。收集各患者术前及术后1d、3d及7d的血红蛋白(hemoglobin,Hb)值、红细胞比容(hematocrit,HCT)值进行对比;根据Nadle及Gross方程计算各患者至术后第3天的失血总量;统计术后患者下静脉血栓的发生率;统计术前、术后1月的髋关节Harris评分(HHS),统计所有患者围手术期输血情况、肺栓塞(Pulmonary Embolism,PE)的发生率、手术时间及其他并发症(脱位、刀口感染、心脑血管事件等),应用SPSS19.0统计软件进行统计分析,认为p0.05具有统计学差异。结果:入组的所有患者均获得有效随访。两组患者术前Hb值、HCT值、手术时间、术前HHS评分相比,无统计学差异(p0.05)。A组术后1dHb值、术后3dHb值、术后7d的Hb值、术后1dHCT值、术后3dHCT值、术后7d的HCT值分别与B组术后1d Hb值、术后3d Hb、术后7d的Hb值、术后1dHCT值、术后3dHCT值、术后7d的HCT值相比:术后1d、3d,A组各指标明显高于B组,p值0.05,具有统计学差异;而术后7d,A组和B组各指标无明显差异,P值0.05,无统计学差异。A组患者术后计算所得血液丢失总量为1546.08ml±258.54ml,B组术后计算所得血液丢失总量为1890.42ml土280.18ml,B组失血量明显高于A组,p值0.05,具有统计学差异。两组患者术后1月HHS评分分别较术前HHS评分有所升高;A、B两组相比无明显差异,p值0.05,差异无统计学意义。A组术后输血患者10例,输血率为23.81%;B组术后输血患者21例,输血率为52.50%。A组输血率明显低于B组,p值0.05,差异具有统计学意义;A组术后DVT为5例,全部为肌间静脉血栓,DVT发生率为11.90%;B组术后DVT为4例,全部为肌间静脉血栓,发生率为10.00%;p0.05,统计学无差异。DVT患者均为肌间静脉血栓,且无明显症状,经采取物理及药物等预防措施,术后无生命危险。A组有2例患者出现胸闷、心慌等症状,诊断为急性冠脉综合征(Acute coronary syndrome,ACS),经营养心肌等处理,胸闷、心慌等症状缓解,未出现心梗等不良结局。A患者均有1例患者发生术后脱位,脱位率为2.38%;B组无脱位患者,p值0.05,无统计学差异。两组患者均无感染发生。结论:术前单纯静脉滴注应用15mg/kg TXA能减少同期双侧全髋置换围手术期的失血量,且15mg/kg的剂量静脉应用TXA并不增加围手术期的血栓事件等并发症;同期双侧全髋关节置换术静脉滴注应用15mg/kg TXA是控制围手术期失血量的一种安全、有效的方法。
[Abstract]:Objective: with the total hip arthroplasty (TotalHipArthroplasty, THA) and the continuous development of technology, continuous improvement of artificial hip prosthesis, total hip arthroplasty (THA) has gradually become the avascular necrosis of the femoral head (Osteonecrosis of the Femeral Head, ONFH), hip osteoarthritis (Osteoarthritis, OA), developmental dysplasia of the hip Hip Dysplasia (Developmental Dysplasia Of the Hip, DDH) preferred method of end-stage hip disease; for rheumatoid arthritis involving the hip joint (RheumatoidArthritis, RA), ankylosing spondylitis (Ankylosing Spondylitis, AS) and other diseases, the artificial hip joint replacement (THA) surgery as an effective treatment the method has been widely applied in clinic. However, ONFH, OA, RA and AS and other diseases can cause end-stage bilateral hip lesions showed bilateral hip joint dysfunction, even hip strong Direct impact on the patient's daily life, resulting in a serious decline in quality of life. For these patients, bilateral total hip arthroplasty (Bilateral TotalHipArthroplasty Bi-THA) is a kind of effective treatment method has been applied to clinical staging, including bilateral total hip arthroplasty (Staged Bilateral Total Hip Arthroplasty) and simultaneous bilateral total hip arthroplasty (Simultaneous Bilateral Total Hip Arthroplasty, Sbi-THA). Obviously, replacement (Sbi-THA) perioperative bleeding more rate to a certain extent increase the intraoperative and postoperative blood transfusion, perioperative risk, may increase the economic burden. Therefore, clinicians and anesthesiologists in perioperative take a variety of measures to reduce perioperative blood loss (invisible blood loss and dominant blood loss), including careful intraoperative hemostasis, autologous blood transfusion (surgery During and after operation), intraoperative application of hemostatic drugs. Tranexamic acid (Tranexamic, Acid, TXA) can reduce perioperative blood loss, so it has been gradually applied in the joint replacement. Although the tranexamic acid (TXA) used in unilateral total hip arthroplasty and staged bilateral total hip arthroplasty, the the safety and effectiveness of a certain degree of proof. However, tranexamic acid (TXA) in simultaneous bilateral total hip arthroplasty (Sbi-THA) application is rarely reported in operation. Simultaneous bilateral total hip arthroplasty (Sbi-THA) application of tranexamic acid (TXA) the safety and effectiveness of no definite conclusion. This paper aims at according to our hospital in the same period of bilateral total hip arthroplasty (Sbi-THA) in the application of tranexamic acid (TXA) to investigate the experience of tranexamic acid (TXA) in reducing the simultaneous bilateral total hip replacement (Sbi-THA) clinical efficacy and safety of perioperative blood loss, as tranexamic acid (TXA) in Simultaneous bilateral total hip arthroplasty (Sbi-THA) provides a theoretical reference for information application. Methods: collected bone surgery in Qilu Hospital from May 2012 to June 2016 in Shandong University hospital parallel simultaneous bilateral artificial total hip (Sbi-THA) patients were retrospectively analyzed and divided into research, setting standards included a total of 82 cases, including 48 cases of male, 34 women; age ranged from 28 to 75 years old, mean age 54.43 + 10.53 years old; 59 patients with ONFH diagnosed OA23 cases; body mass index (Body Mass, Index, BMI) 21.97 ~ 32.18kg/m2, average BMI 26.28 + 4.36kg/ m2; 82 cases were divided into two groups including A, B, A group with intravenous application of TXA group, 42 cases; group B was the control group, without TXA group, a total of 40 cases of.A patients were on each side before skin incision 1Omin 15mg/kgTXA single intravenous infusion. The patients with preoperative and postoperative 1D, 3D and 7d (hemoglobin, Hb) value of hemoglobin, red blood cells 鑳炴瘮瀹，

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