抗纤溶序贯抗凝专家共识指导下用与不用止血带初次全膝关节置换术的疗效及安全性比较  

Comparison of efficacy and safety between with and without tourniquet under the program of expert consensus statement on anti-coagulation sequential anti-fibrinolysis during primary total knee arthroplasty

作　　者：马俊[1] 黄泽宇[1] 王端[1] 谢锦伟[1] 徐彬[1] 裴福兴[1] 沈彬[1] 

机构地区：[1]四川大学华西医院骨科,成都610041

出　　处：《中华骨与关节外科杂志》2017年第5期391-395,399,共6页Chinese Journal of Bone and Joint Surgery

基　　金：国家卫生公益性行业科研专项基金(201302007)

摘　　要：背景:止血带能够减少术中显性失血,保持手术创面相对干净。在使用氨甲环酸控制出血情况下,止血带是否还有使用的必要性值得探讨。目的:评价初次全膝关节置换术中,在抗纤溶序贯抗凝专家共识方案下不使用止血带的安全性及有效性。方法:选取63例于我院就诊的全膝关节置换患者,随机分为无止血带组32例与止血带组31例。无止血带组切皮前静脉给予每公斤体重氨甲环酸(tranexamic acid,TXA)20 mg;止血带组切皮前止血带充气,压力设定为高于当时收缩压100 mm Hg。两组术后按照抗纤溶及序贯抗凝专家共识,在手术结束关闭关节囊后通过引流管灌注TXA 1 g,距麻醉诱导3、6、12、24 h分别再次追加TXA每公斤体重10 mg。术后6 h给予依诺肝素0.2 ml抗凝,以后每日0.4 ml至出院,出院后每日1次口服利伐沙班10 mg 2周。主要评价指标包括围术期失血量、术后血红蛋白水平、疼痛评分、肢体肿胀程度及关节活动度。结果:无止血带组手术时间、术中失血量均多于止血带组(P<0.05),但止血带组引流量更高,显性失血量两组比较差异无统计学意义。通过Gross方程计算总失血量及隐性失血量,无止血带组均低于止血带组(P<0.05)。术后血红蛋白水平及肿胀程度无止血带组均优于止血带组,手术当日和术后第2日患者VAS评分无止血带组低于止血带组,而术后第1日和第3日,两组VAS评分、术后关节活动度、并发症发生率均无统计学差异。结论:在抗纤溶序贯抗凝专家共识方案下,初次全膝关节置换不使用止血带不增加显性失血量,隐性失血及总失血量更少,可以改善患者术后血红蛋白水平并减轻术后疼痛和肢体肿胀。Background： The role of a tourniquet during primary total knee arthroplasty is regarded as reducing intraoperative blood loss and improving visibility. Our goal is to investigate whether the tourniquet is still necessary for controlling intraoperative blood loss when alternatives such as TXA are available. Objective： To evaluate the efficacy and safety of primary total knee arthroplasty without a tourniquet under the program of expert consensus statement on anti coagulation sequential anti fibrinolysis. Methods： A total of 63 patients admitted in our hospital to undergo total knee arthroplasty were randomized to two groups： non tourniquet group（n=32） and tourniquet group（n=31）. Patients in non tourniquet group received intravenously a dose of 20 mg/kg tranexamic acid（TXA） before skin incision and patients in tourniquet group were treated with tourniquet during operation, air inflation before skin incision and pressure set 100 mm Hg higher than current systolic pressure. All patients were infused with TXA 1 g at joint capsule closure when the operation was completed and TXA at a dose of 10 mg/kg additionally at 3, 6, 12, 24 h after anesthesia induction in accordance with expert consensus statement on anti coagulation sequential anti fibrinolysis. Enoxaparin of 0.2 ml was administered to all patients for anticoagulation at 6 h after operation and then every day 0.4 ml until hospital discharge. After discharge the patients took orally 10 mg Rivaroxaban once daily for two weeks. The main evaluation indicators included perioperative blood loss, postoperative hemoglobin,VAS score, swelling rate and range of motion. Results： Compared with the tourniquet group, operation duration and intraoperative blood loss in non tourniquet increased（P〈0.05）. Drainage volume was higher in tourniquet group than in non tourniquet group. The difference in dominant blood loss between the two groups was not statistically significant. Total blood loss and hidden blood loss calculated through Gross equation in non

关 键 词：抗纤溶 氨甲环酸 全膝关节置换术 止血带 

分 类 号：R687.4[医药卫生—骨科学]