氨甲环酸在全膝关节置换术中的应用与疗效分析

发布时间：2018-02-16 15:31

  本文关键词： 人工膝关节置换 出血 氨甲环酸　出处：《苏州大学》2015年硕士论文　论文类型：学位论文

【摘要】：背景:膝骨性关节炎是一种在中老年人群中较为常见的慢性退行性疾病。目前人工膝关节置换术(TKA)作为一种成熟的技术已经广泛应用于中晚期膝骨性关节炎的治疗,其疗效也己经被证实确切可靠。TKA术后截骨面及髓腔内的出血量较大,部分患者术后不可避免需要进行异体输血。但目前临床上出现的用血紧张现象及难以避免的输血窗口期感染疾病的风险,一直对患者及临床医生造成困扰。因此临床上一直希望能够找到一种新的方法来减少手术创伤带来的失血,降低术后的输血概率及相应带来的输血风险。目前国内外有多篇报道于TKA术中静脉或局部使用氨甲环酸均可降低术后失血量。但目前术中氨甲环酸如何使用可取得最佳的效果并无统一意见。对于氨甲环酸用于局部关节腔内使用与静脉使用的效果孰优孰劣也一直有不少争议。国内外虽然对该此有不少相关研究及报道,但目前并没有统一的结论。局部关节腔内使用氨甲环酸需在手术结束后大部分都会对负压引流管夹闭一段时间,其目的是减少局部的氨甲环酸的流失,并尽可能的产生最大的药物效应。故本研究夹闭引流管3小时的情况下采用关节腔内局部注射氨甲环酸,以尽量延长药物的作用时间。目的:比较全膝关节置换术中关节腔内局部氨甲环酸使用方法的临床疗效。方法:将2013.4-2014.11期间苏州大学附属常熟市第一人民医院骨科66例患膝关节骨性关节炎拟行单侧人工全膝关节置换术的患者,其中男性为18例,女性为48例,采用随机的方法分为三组,A组21例,B组23例,C组22例,A组患者术中使用局部浸润氨甲环酸治疗,在安装假体结束后,缝合表面支持带后,夹闭负压引流,将1g氨甲环酸注射液直接注射于关节腔内。术后引流管保持夹闭3小时。B组患者于松开止血带前10分钟静滴氨甲环酸1g,术后同样夹闭负压引流3小时。C组不使用氨甲环酸,术后同样夹闭负压引流3小时。术中根据出血量,患者心跳,血压等一般情况综合考虑是否输血。三组患者均于术后24小时拔除负压引流管。患者术后当血常规Hb小于70g/L予输红悬纠正贫血,70至80g/L之间时,根据患者当时一般情况以及是否存在明显的贫血症状决定是否进行输血治疗。记录的数据如下:术中失血量,患者术前及术后96h时Hb及HCT,术后24h内负压管血性液引流量,术前及术后3小时后凝血功能指标变化(含D2聚体,纤维蛋白原、活化部分凝血活酶时间以及凝血酶原时间),术后患肢肿胀程度变化(髌上10cm周径变化),术后患肢疼痛评分变化,术后需要输血患者例数及输血量,术后2周时膝关节Hss评分,下肢静脉血栓或肺栓塞情况。使用SPSS19.0(社会科学统计软件包)对以上采集的临床数据进行统计学数据分析,计量资料如经过检验符合正态分布的标准,则采用(χ±S)表示。组间数据两两比较采用单因素分析的方法。如检验后不符合正态分布的标准,则采用四分位数表达。三组患者性别,输血比例采用卡方检验,如最小理论频数小于5,则使用Fisher确切概率法对所得的数据进行分析,如P0.05则考虑有显著性的差异。结果:①术后24h内负压管血性液引流量比较结果:A组B组C组三组间术后24h内血性液引流量比较结果,P值均0.05,有统计学意义。②术后96h时隐性失血量比较结果:A组和B组术后隐性失血量比较结果,P0.05,无统计学意义。A组B组分别与C组比较,P值均0.05,有统计学意义。③术后96h时总体失血量比较结果:A组B组C组三组间术后总失血比较结果,P值均0.05,有统计学意义。④A组B组C组三组间术后FDPS,PT,APTT比较结果,P值均0.05,无统计学意义。A组和B组术后D二聚体比较结果,P0.05,无统计学意义。A组B组D二聚体结果分别与C组比较,P值均0.05,有统计学意义。⑤术后患肢1天及4天时肿胀程度变化比较结果:A组和B组术后患肢髌上10cm周径程度变化比较结果,P0.05,无统计学意义。A组B组分别与C组比较,P值均0.05,有统计学意义。⑥术后患肢24h,48h,96 h静息疼痛评分变化比较结果:A组B组C组三组间术后患肢疼痛评分比较结果,P值均0.05,无统计学意义。⑦术后2周时膝关节Hss评分比较结果:A组B组C组三组间术后2周Hss评分比较结果,P值均0.05,无统计学意义。⑧需要输血患者比例比较结果:A组和B组术后需要输血患者比例比较结果,P0.05,无统计学意义。A组B组分别与C组比较,P值均0.05,有统计学意义。结论:全膝关节置换术中关节腔内局部使用氨甲环酸可以减低术后出血量及输血的概率。且并不会增加术后发生静脉栓塞的概率。
[Abstract]:Background: knee osteoarthritis is more common in the elderly population of chronic degenerative diseases. The total knee arthroplasty (TKA) as a kind of advanced technology has been widely used in the treatment of knee osteoarthritis, its curative effect has been proved to be exact and reliable bleeding after.TKA the surface of the osteotomy and intramedullary greatly, some patients need blood transfusion. But the inevitable risk of current clinical use of blood and nervous phenomena appear difficult to avoid blood transfusion infection in window period of the disease, has been caused by the troubled patients and clinicians. So we always hope to be able to find a new method to reduce surgical trauma caused by blood loss, reduce the probability of postoperative blood transfusion and bring the risk of blood transfusion. There are several reports on intravenous TKA operation or topical use of tranexamic acid can reduce the postoperative loss But the current volume. Intraoperative tranexamic acid can be used to obtain the best effect. There is no unified opinion for tranexamic acid for local intra-articular and intravenous use of the effect of the merits has also been a lot of controversy. Although many of the related studies and reports, but there is no unified conclusion local intra-articular use of tranexamic acid in the end of the operation are mostly on negative pressure drainage pipe clamp for a period of time, the purpose is to reduce the partial loss of tranexamic acid, and as far as possible to produce the biggest effect of drugs. Therefore, the study of closed drainage for 3 hours under the condition of the use of intra-articular local injection of tranexamic acid, so as to prolong the time of drug action. Objective: To compare the clinical effect of total knee arthroplasty in intra-articular local tranexamic acid use. Methods: during the period of 2013.4-2014.11 in Suzhou Department of orthopedics, the first people's Hospital of Changshou City affiliated to study 66 patients with knee osteoarthritis underwent unilateral total knee arthroplasty patients, including 18 cases of male, female 48 cases, were randomly divided into three groups and 21 cases in A group, 23 cases in B group, C group of 22 cases, the use of local the infiltration of tranexamic acid in the treatment of patients in the A group, in the installation of prosthesis after suture with support surface after clamping the negative pressure drainage, Tranexamic Acid Injection 1g will directly injected into the articular cavity. Keep the tube clamping 3 hour.B patients on tourniquet release 10 minutes before the intravenous drip of tranexamic acid 1g postoperative drainage, postoperative the same clamping drainage for 3 hours in group.C without the use of tranexamic acid, after the same clamping drainage for 3 hours. According to the intraoperative bleeding, blood pressure in patients with heart, generally considered whether blood transfusion. Three groups of patients in the 24 hours after removal of negative pressure drainage tube. When the blood of patients after operation The conventional Hb is less than 70g/L to lose the red suspension for correction of anemia, between 70 and 80g/L, according to the patient at the time the general situation and the existence of obvious symptoms of anemia, determine whether blood transfusion treatment. The data recorded are as follows: the intraoperative blood loss, Hb and HCT in patients with preoperative and postoperative 96h, negative pressure drainage tube bloody 24h after the operation, preoperative and postoperative 3 hours after the change of coagulation index (including D2 dimer, fibrinogen, activated partial thromboplastin time and prothrombin time), changes of postoperative limb swelling (10cm patellar circumference), postoperative limb pain score changes, postoperative blood transfusion and the number of patients, 2 weeks after operation Hss knee score, lower extremity venous thrombosis or pulmonary embolism. Using SPSS19.0 (statistical package for Social Science) for statistical data analysis of the clinical data collected over the measurement data, such as through the test are consistent with the 鎬佸垎甯冪殑鏍囧噯,鍒欓噰鐢，

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