發(fā)布時間：2018-01-21 00:37

  本文關鍵詞： 氨甲環(huán)酸 同期雙側全髖關節(jié)置換 失血量 深靜脈血栓　出處：《山東大學》2017年碩士論文　論文類型：學位論文

【摘要】：研究目的:隨著人工全髖關節(jié)置換(TotalHipArthroplasty,THA)技術的普及和持續(xù)發(fā)展、人工髖關節(jié)假體的不斷改良,人工全髖關節(jié)置換(THA)逐漸成為股骨頭壞死(Osteonecrosis of the Femeral Head,ONFH)、髖關節(jié)骨性關節(jié)炎(Osteoarthritis,OA)、發(fā)育性髖關節(jié)發(fā)育不良(Developmental Dysplasia Of the Hip,DDH)等終末期髖關節(jié)疾病的首選方法;對于累及髖關節(jié)的類風濕性關節(jié)炎(RheumatoidArthritis,RA)、強直性脊柱炎(Ankylosing Spondylitis,AS)等疾病而言,人工全髖關節(jié)置換(THA)術作為一種有效的治療方法而被廣泛應用于臨床。然而,ONFH、OA、RA及AS等疾患終末期可造成雙側髖關節(jié)病變,表現為雙側髖關節(jié)功能障礙,甚至發(fā)生髖關節(jié)強直,影響了患者的日常生活,從而導致生活質量嚴重下降。對于此類患者,雙側人工全髖關節(jié)置換術(Bilateral TotalHipArthroplasty,Bi-THA)作為一種有效的治療方法被應用于臨床,主要包括分期雙側全髖關節(jié)置換(Staged Bilateral Total Hip Arthroplasty)和同期雙側全髖關節(jié)置換(Simultaneous Bilateral Total Hip Arthroplasty,Sbi-THA)。顯而易見,同期置換(Sbi-THA)圍手術期的出血量較多,從而一定程度上增加了術中及術后輸血的比率、圍手術期的危險性,可能增加一定的經濟負擔。為此,臨床醫(yī)師及麻醉醫(yī)師等在圍手術期采取了多種措施來減少圍手術期失血量(隱形失血及顯性失血),包括術中仔細止血、自體血回輸(術中及術后)、術中應用止血藥物等。氨甲環(huán)酸(Tranexamic Acid,TXA)可減少圍手術期失血量,因而被逐漸應用于關節(jié)置換術等。雖然氨甲環(huán)酸(TXA)在單側全髖關節(jié)置換術及分期雙側全髖關節(jié)置換中應用較多,其安全性及有效性得到了一定程度上的印證。然而氨甲環(huán)酸(TXA)在同期雙側全髖關節(jié)置換(Sbi-THA)術中的應用鮮有報道。同期雙側全髖關節(jié)置換(Sbi-THA)應用氨甲環(huán)酸(TXA)的安全性及有效性尚無明確定論。本文旨在根據我院同期雙側全髖關節(jié)置換(Sbi-THA)中應用氨甲環(huán)酸(TXA)的經驗,探討氨甲環(huán)酸(TXA)在減少同期雙側全髖關節(jié)置換(Sbi-THA)圍手術期失血量的臨床療效及安全性,為氨甲環(huán)酸(TXA)在同期雙側全髖關節(jié)置換(Sbi-THA)中的應用提供理論參考信息。研究方法:收集山東大學齊魯醫(yī)院骨外科2012年5月～2016年6月收入院并行同期雙側人工全髖關節(jié)(Sbi-THA)的患者資料并進行回顧性分析研究,設定納入標準后共納入82例,其中男性48例,女性34例;年齡28～75歲,平均年齡54.43±10.53 歲;診斷為 ONFH 59 例,OA23 例;身高體重指數(Body Mass Index,BMI)21.97～32.18kg/m2,平均 BMI 26.28±4.36kg/m2;將 82 例分成 A、B 兩組,其中A組為單純靜脈應用TXA組,共42例;B組為對照組,不應用TXA組,共40例。A組患者于每側切皮前1Omin完成單次15mg/kgTXA靜脈滴注。收集各患者術前及術后1d、3d及7d的血紅蛋白(hemoglobin,Hb)值、紅細胞比容(hematocrit,HCT)值進行對比;根據Nadle及Gross方程計算各患者至術后第3天的失血總量;統(tǒng)計術后患者下靜脈血栓的發(fā)生率;統(tǒng)計術前、術后1月的髖關節(jié)Harris評分(HHS),統(tǒng)計所有患者圍手術期輸血情況、肺栓塞(Pulmonary Embolism,PE)的發(fā)生率、手術時間及其他并發(fā)癥(脫位、刀口感染、心腦血管事件等),應用SPSS19.0統(tǒng)計軟件進行統(tǒng)計分析,認為p0.05具有統(tǒng)計學差異。結果:入組的所有患者均獲得有效隨訪。兩組患者術前Hb值、HCT值、手術時間、術前HHS評分相比,無統(tǒng)計學差異(p0.05)。A組術后1dHb值、術后3dHb值、術后7d的Hb值、術后1dHCT值、術后3dHCT值、術后7d的HCT值分別與B組術后1d Hb值、術后3d Hb、術后7d的Hb值、術后1dHCT值、術后3dHCT值、術后7d的HCT值相比:術后1d、3d,A組各指標明顯高于B組,p值0.05,具有統(tǒng)計學差異;而術后7d,A組和B組各指標無明顯差異,P值0.05,無統(tǒng)計學差異。A組患者術后計算所得血液丟失總量為1546.08ml±258.54ml,B組術后計算所得血液丟失總量為1890.42ml土280.18ml,B組失血量明顯高于A組,p值0.05,具有統(tǒng)計學差異。兩組患者術后1月HHS評分分別較術前HHS評分有所升高;A、B兩組相比無明顯差異,p值0.05,差異無統(tǒng)計學意義。A組術后輸血患者10例,輸血率為23.81%;B組術后輸血患者21例,輸血率為52.50%。A組輸血率明顯低于B組,p值0.05,差異具有統(tǒng)計學意義;A組術后DVT為5例,全部為肌間靜脈血栓,DVT發(fā)生率為11.90%;B組術后DVT為4例,全部為肌間靜脈血栓,發(fā)生率為10.00%;p0.05,統(tǒng)計學無差異。DVT患者均為肌間靜脈血栓,且無明顯癥狀,經采取物理及藥物等預防措施,術后無生命危險。A組有2例患者出現胸悶、心慌等癥狀,診斷為急性冠脈綜合征(Acute coronary syndrome,ACS),經營養(yǎng)心肌等處理,胸悶、心慌等癥狀緩解,未出現心梗等不良結局。A患者均有1例患者發(fā)生術后脫位,脫位率為2.38%;B組無脫位患者,p值0.05,無統(tǒng)計學差異。兩組患者均無感染發(fā)生。結論:術前單純靜脈滴注應用15mg/kg TXA能減少同期雙側全髖置換圍手術期的失血量,且15mg/kg的劑量靜脈應用TXA并不增加圍手術期的血栓事件等并發(fā)癥;同期雙側全髖關節(jié)置換術靜脈滴注應用15mg/kg TXA是控制圍手術期失血量的一種安全、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?yōu)姣斿?

本文編號：1449916