氨甲环酸联合肾上腺素对全膝关节置换术失血量及膝关节功能恢复的影响

发布时间：2019-05-28 12:49

【摘要】：研究背景:1、人工全膝关节置换术后出血加重了膝关节置换术后肿胀和增加患者输血量,影响患者术后膝关节早期功能锻炼以及降低了患者满意度,且结合各种输血并发症及异体血血源紧张的背景,如何减少膝关节置换术后失血、促进膝关节的快速康复已引起了骨科医师的高度关注。2、氨甲环酸价格便宜,容易获得,有文献报道,氨甲环酸在人工膝关节置换术中应用能减少总失血量、术后引流量、隐性失血量,并降低术后输血率,且不增加深静脉血栓发生的风险。3、有研究表明,肾上腺素在人工膝关节置换术中局部应用有效减少术后失血量、术后引流量,降低术后输血率。4、氨甲环酸通过减少纤维蛋白溶解从而起到减少人工膝关节置换术失血的作用,而肾上腺素局部应用可以收缩血管,同时激活血小板上的α2受体,起到止血作用,两者机制不同,但在减少失血方面存在协同作用,在人工全膝关节置换术中,通过两者联合应用,来探讨其应用的价值以及安全性。目的:通过随机分组、对照研究,探讨静脉滴注氨甲环酸(tranexamicacidTXA)联合关节腔注入肾上腺素(Epinephrine EPI)对初次单侧人工全膝关节置换术(total knee arthroplasty,TKA)失血量及膝关节早期功能恢复的影响。方法:选取2015年2月-2016年12月昆明医科大学第一附属医院骨科收治的122例初次行单侧TKA治疗的患者为研究对象,按不同的给药方式采用随机数字表法分为四组。TXA+EPI组(n=31):静脉滴注氨甲环酸联合关节腔注入肾上腺素组;TXA组(n=31):静脉滴注氨甲环酸组;EPI组(n=30):关节腔注入肾上腺素组;对照组(n=30):空白对照组。TXA+EPI组于术中松止血带前10min给予氨甲环酸静滴(10mg/Kg),在缝合关节囊结束前向关节腔内注入肾上腺素稀释液50ml(1:200000),注射后夹闭引流管2h;TXA组在松止血带前1Omin给予氨甲环酸静滴(10mg/Kg),同时术后夹闭引流管2h;EPI组在缝合关节囊结束前向关节腔内注入肾上腺素稀释液50ml(1:200000),注射后夹闭引流管2h;对照组仅术后夹闭引流管2h,不静脉滴注氨甲环酸及关节腔注入肾上腺素。观察四组患者手术时间、总失血量、术后引流量、隐性失血量、术后输血率、术后24hD-二聚体水平、术后一周深静脉血栓(DVT)发生率、术后3～5d髌上及髌下10cm周径平均变化值、术后第1、3、5d膝关节活动度(rang of motion ROM)、术后7d膝关节HSS评分、术后随访3月,明确是否发生深静脉血栓。结果:四组患者中TXA+EPI组中有1例患者切口延期愈合,延长至3周拆线。其余三组患者伤口均一期愈合,2周左右拆线,均未发生切口皮肤坏死,未发生肺栓塞。(1)四组患者一般情况、手术时间、术前血红蛋白、术前血细胞比容、术前膝关节活动度、术前HSS评分无统计学意义(P0.05);经血管彩色多普勒超声证实,术后7d均未发现深静脉血栓患者。随访三月,未发现症状性深静脉血栓患者。(2)四组患者总失血量、术后引流量、隐性失血量上相比较,TXA+EPI组、TXA组、EPI组较对照组均显著降低(P0.05);而TXA+EPI较TXA组、EPI组在总失血量、术后引流量、隐性失血量上均显著降低(P0.05)。TXA与与EPI组相比较,TXA组较EPI组在总失血量上无显著差异(P0.05),但在术后引流量上,EPI组较TXA组减少更加明显,差异显著(P0.05),而在隐性失血量上,TXA组较EPI组减少更加明显,但两者无显著差异(P0.05);TXA+EPI组、TXA组、EPI组较对照组均降低了术后输血率,但三组患者之间无显著差异。四组患者术前D-二聚体相比较无显著差异,术后D-二聚体均升高,但对照组、EPI组较联合组、TXA组升高更明显。(3)TXA+EPI组在术后3～5d髌上及髌下10cm周径平均变化值上较TXA组、EPI组、对照组均显著降低(P0.05);TXA组、EPI组较对照组在术后3～5d髌上及髌下10cm周径平均变化值上均显著降低(P0.05);TXA组较EPI组在术后3～5d髌上及髌下10cm周径平均变化值上无显著差异(P0.05)。(4)TXA+EPI组在术后第1、3、5d膝关节活动度(rang of motion ROM)、术后7d膝关节HSS评分上较TXA组、EPI组、对照组均显著增高(P0.05);TXA组、EPI组较对照组在术后第1、3、5d膝关节活动度(rang of motion ROM)、术后7d膝关节HSS评分上均显著增高(P0.05);TXA组较EPI组在术后第1、3、5d膝关节活动度(rang of motion ROM)、术后7d膝关节HSS评分上无显著差异(P0.05)。结论:(1)静脉滴注氨甲环酸联合关节腔注入肾上腺素能明显减少了初次单侧TKA术后的失血量,且隐性失血减少更为明显,从而降低了术后输血率,但并不增加术后发生深静脉血栓的风险;(2)静脉滴注氨甲环酸联合关节腔注入肾上腺素明显减轻了术后早期的膝关节肿胀,增加了膝关节活动度,有效改善了术后早期的膝关节功能,增进了膝关节的快速康复,有一定的应用价值,但有可能造成伤口延迟愈合等并发症,临床应用需谨慎。
[Abstract]:Background:1. After the total knee replacement, the bleeding aggravated the swelling of the knee joint and the increase of the patient's blood transfusion, which affected the early functional exercise of the knee joint and reduced the patient's satisfaction, and combined with the various blood transfusion complications and the background of the blood source tension of the allogenic blood, How to reduce blood loss after knee replacement and to promote that rapid rehabilitation of the knee joint has cause the high attention of the orthopaedic surgeon. It is shown that the local application of epinephrine in the artificial knee replacement can effectively reduce the postoperative blood loss, post-operative drainage, and reduce the post-operative blood transfusion rate. The aminomethylcycloacid plays a role in reducing the blood loss of the artificial knee replacement by reducing the dissolution of the fibrin, and the epinephrine topical application can contract the blood vessel, and simultaneously activate the 2-2 receptor on the platelet to play a hemostatic effect, and the two mechanisms are different, However, there is a synergistic effect in reducing blood loss. In the total knee arthroplasty, the value and safety of its application are discussed by the combination of the two. Objective: To study the effect of epinephrine EPI on total knot total knee arthroplasty (TKA) blood loss and early function recovery of total knee arthroplasty (TKA) by a randomized, controlled study. Methods:122 patients who were treated with unilateral TKA in the first Affiliated Hospital of Kunming Medical University from February 2015 to December 2016 were selected as the subject of the study and divided into four groups according to the different methods of administration. TXA + EPI group (n = 31): the epinephrine group was injected into the combined joint cavity of the tranexamic acid by intravenous drip; the TXA group (n = 31): intravenous amipionate group; EPI group (n = 30): the joint cavity was injected into the epinephrine group; the control group (n = 30): the blank control group. The patients with TXA + EPI were given an intravenous injection of 50 ml (1:200000) of epinephrine in the anterior joint cavity before the end of the suture and the drainage tube was closed after injection for 2 h. The TXA group was given the intravenous drip (10 mg/ Kg) in 1 Omin before the relaxation of the tourniquet. At the same time, the drainage tube was closed for 2 h. The EPI group was injected with 50 ml of epinephrine diluent (1:200000) into the joint cavity after the end of the suture joint capsule, and the drainage tube was closed after injection for 2 h. The control group only had the drainage tube closed after operation for 2 h, and no epinephrine was injected into the urethane ring and the joint cavity. The operative time, total blood loss, postoperative drainage rate, hidden blood loss, postoperative blood transfusion rate, postoperative 24 hD-dimer level, postoperative week-week deep venous thrombosis (DVT) rate,3-5 days post-operation and the mean change value of 10 cm peripheral diameter were observed. The postoperative day 1,3, and 5 d knee motion (rang of motion ROM), the postoperative 7 d knee HSS score, follow-up for 3 months, to determine whether deep venous thrombosis occurred. Results: One patient in the TXA + EPI group had delayed healing and extended to 3 weeks. The wound of the remaining three groups was healed in the first stage and the left and right after 2 weeks, no incision and skin necrosis occurred, and no pulmonary embolism occurred. (1) The general conditions, operative time, pre-operative hemoglobin, preoperative hematocrit, pre-operative knee motion and pre-operative HSS score were not statistically significant (P0.05). No symptomatic deep vein thrombosis was noted for follow-up. (2) The total blood loss of the four groups was significantly lower than that of the control group (P0.05). The TXA + EPI group, the TXA group and the EPI group were significantly lower than those in the control group (P0.05). There was no significant difference in the total blood loss in the TXA group than in the EPI group (P0.05). However, in the postoperative drainage rate, the reduction of the group of the EPI group and the group of the TXA group was more obvious, the difference was significant (P0.05), and the TXA + EPI group and the TXA group were not significantly different (P0.05), and the TXA + EPI group and the TXA group were not significantly different (P0.05). The postoperative blood transfusion rate was reduced in the EPI group and the control group, but there was no significant difference between the three groups. There was no significant difference in the pre-operation of D-dimer in the four groups, and the D-dimer in the control group increased, but the level of TXA was higher in the control group and the EPI group. (3) The mean change value of TXA + EPI group was significantly lower than that of the control group (P0.05). There was no significant difference in the mean change of the mean change of the diameter of the group in the TXA group after 3-5 days after the operation and the mean change of the peripheral diameter of 10 cm (P0.05). (4) In the group of TXA + EPI, the first, third, and 5d knee-motion ROM in the group were significantly higher than that of the control group (P0.05). In the group of TXA and EPI, the first, third, and 5d knee-motion ROM in the group of TXA and EPI were significantly higher than those in the control group (P0.05). There was no significant difference in HSS (P0.05). Conclusion: (1) The injection of epinephrine in the combined joint cavity of the tranexamic acid can significantly reduce the blood loss after the primary unilateral TKA, and the decrease of the recessive blood loss is more obvious, and the postoperative blood transfusion rate is reduced, but the risk of deep vein thrombosis after operation is not increased; (2) The injection of the epinephrine in the combined joint cavity of the tranexamic acid in the intravenous drip obviously reduces the knee joint swelling in the early postoperative period, increases the motion of the knee joint, effectively improves the function of the knee joint in the early postoperative period, improves the rapid rehabilitation of the knee joint, and has certain application value, But it is possible to cause complications such as wound delay and the like, and the clinical application needs to be cautious.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.4

【参考文献】