氨甲環(huán)酸聯(lián)合腎上腺素對全膝關(guān)節(jié)置換術(shù)失血量及膝關(guān)節(jié)功能恢復的影響
發(fā)布時間：2019-05-28 12:49
【摘要】：研究背景:1、人工全膝關(guān)節(jié)置換術(shù)后出血加重了膝關(guān)節(jié)置換術(shù)后腫脹和增加患者輸血量,影響患者術(shù)后膝關(guān)節(jié)早期功能鍛煉以及降低了患者滿意度,且結(jié)合各種輸血并發(fā)癥及異體血血源緊張的背景,如何減少膝關(guān)節(jié)置換術(shù)后失血、促進膝關(guān)節(jié)的快速康復已引起了骨科醫(yī)師的高度關(guān)注。2、氨甲環(huán)酸價格便宜,容易獲得,有文獻報道,氨甲環(huán)酸在人工膝關(guān)節(jié)置換術(shù)中應用能減少總失血量、術(shù)后引流量、隱性失血量,并降低術(shù)后輸血率,且不增加深靜脈血栓發(fā)生的風險。3、有研究表明,腎上腺素在人工膝關(guān)節(jié)置換術(shù)中局部應用有效減少術(shù)后失血量、術(shù)后引流量,降低術(shù)后輸血率。4、氨甲環(huán)酸通過減少纖維蛋白溶解從而起到減少人工膝關(guān)節(jié)置換術(shù)失血的作用,而腎上腺素局部應用可以收縮血管,同時激活血小板上的α2受體,起到止血作用,兩者機制不同,但在減少失血方面存在協(xié)同作用,在人工全膝關(guān)節(jié)置換術(shù)中,通過兩者聯(lián)合應用,來探討其應用的價值以及安全性。目的:通過隨機分組、對照研究,探討靜脈滴注氨甲環(huán)酸(tranexamicacidTXA)聯(lián)合關(guān)節(jié)腔注入腎上腺素(Epinephrine EPI)對初次單側(cè)人工全膝關(guān)節(jié)置換術(shù)(total knee arthroplasty,TKA)失血量及膝關(guān)節(jié)早期功能恢復的影響。方法:選取2015年2月-2016年12月昆明醫(yī)科大學第一附屬醫(yī)院骨科收治的122例初次行單側(cè)TKA治療的患者為研究對象,按不同的給藥方式采用隨機數(shù)字表法分為四組。TXA+EPI組(n=31):靜脈滴注氨甲環(huán)酸聯(lián)合關(guān)節(jié)腔注入腎上腺素組;TXA組(n=31):靜脈滴注氨甲環(huán)酸組;EPI組(n=30):關(guān)節(jié)腔注入腎上腺素組;對照組(n=30):空白對照組。TXA+EPI組于術(shù)中松止血帶前10min給予氨甲環(huán)酸靜滴(10mg/Kg),在縫合關(guān)節(jié)囊結(jié)束前向關(guān)節(jié)腔內(nèi)注入腎上腺素稀釋液50ml(1:200000),注射后夾閉引流管2h;TXA組在松止血帶前1Omin給予氨甲環(huán)酸靜滴(10mg/Kg),同時術(shù)后夾閉引流管2h;EPI組在縫合關(guān)節(jié)囊結(jié)束前向關(guān)節(jié)腔內(nèi)注入腎上腺素稀釋液50ml(1:200000),注射后夾閉引流管2h;對照組僅術(shù)后夾閉引流管2h,不靜脈滴注氨甲環(huán)酸及關(guān)節(jié)腔注入腎上腺素。觀察四組患者手術(shù)時間、總失血量、術(shù)后引流量、隱性失血量、術(shù)后輸血率、術(shù)后24hD-二聚體水平、術(shù)后一周深靜脈血栓(DVT)發(fā)生率、術(shù)后3～5d髕上及髕下10cm周徑平均變化值、術(shù)后第1、3、5d膝關(guān)節(jié)活動度(rang of motion ROM)、術(shù)后7d膝關(guān)節(jié)HSS評分、術(shù)后隨訪3月,明確是否發(fā)生深靜脈血栓。結(jié)果:四組患者中TXA+EPI組中有1例患者切口延期愈合,延長至3周拆線。其余三組患者傷口均一期愈合,2周左右拆線,均未發(fā)生切口皮膚壞死,未發(fā)生肺栓塞。(1)四組患者一般情況、手術(shù)時間、術(shù)前血紅蛋白、術(shù)前血細胞比容、術(shù)前膝關(guān)節(jié)活動度、術(shù)前HSS評分無統(tǒng)計學意義(P0.05);經(jīng)血管彩色多普勒超聲證實,術(shù)后7d均未發(fā)現(xiàn)深靜脈血栓患者。隨訪三月,未發(fā)現(xiàn)癥狀性深靜脈血栓患者。(2)四組患者總失血量、術(shù)后引流量、隱性失血量上相比較,TXA+EPI組、TXA組、EPI組較對照組均顯著降低(P0.05);而TXA+EPI較TXA組、EPI組在總失血量、術(shù)后引流量、隱性失血量上均顯著降低(P0.05)。TXA與與EPI組相比較,TXA組較EPI組在總失血量上無顯著差異(P0.05),但在術(shù)后引流量上,EPI組較TXA組減少更加明顯,差異顯著(P0.05),而在隱性失血量上,TXA組較EPI組減少更加明顯,但兩者無顯著差異(P0.05);TXA+EPI組、TXA組、EPI組較對照組均降低了術(shù)后輸血率,但三組患者之間無顯著差異。四組患者術(shù)前D-二聚體相比較無顯著差異,術(shù)后D-二聚體均升高,但對照組、EPI組較聯(lián)合組、TXA組升高更明顯。(3)TXA+EPI組在術(shù)后3～5d髕上及髕下10cm周徑平均變化值上較TXA組、EPI組、對照組均顯著降低(P0.05);TXA組、EPI組較對照組在術(shù)后3～5d髕上及髕下10cm周徑平均變化值上均顯著降低(P0.05);TXA組較EPI組在術(shù)后3～5d髕上及髕下10cm周徑平均變化值上無顯著差異(P0.05)。(4)TXA+EPI組在術(shù)后第1、3、5d膝關(guān)節(jié)活動度(rang of motion ROM)、術(shù)后7d膝關(guān)節(jié)HSS評分上較TXA組、EPI組、對照組均顯著增高(P0.05);TXA組、EPI組較對照組在術(shù)后第1、3、5d膝關(guān)節(jié)活動度(rang of motion ROM)、術(shù)后7d膝關(guān)節(jié)HSS評分上均顯著增高(P0.05);TXA組較EPI組在術(shù)后第1、3、5d膝關(guān)節(jié)活動度(rang of motion ROM)、術(shù)后7d膝關(guān)節(jié)HSS評分上無顯著差異(P0.05)。結(jié)論:(1)靜脈滴注氨甲環(huán)酸聯(lián)合關(guān)節(jié)腔注入腎上腺素能明顯減少了初次單側(cè)TKA術(shù)后的失血量,且隱性失血減少更為明顯,從而降低了術(shù)后輸血率,但并不增加術(shù)后發(fā)生深靜脈血栓的風險;(2)靜脈滴注氨甲環(huán)酸聯(lián)合關(guān)節(jié)腔注入腎上腺素明顯減輕了術(shù)后早期的膝關(guān)節(jié)腫脹,增加了膝關(guān)節(jié)活動度,有效改善了術(shù)后早期的膝關(guān)節(jié)功能,增進了膝關(guān)節(jié)的快速康復,有一定的應用價值,但有可能造成傷口延遲愈合等并發(fā)癥,臨床應用需謹慎。
[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.
【學位授予單位】：昆明醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R687.4
本文編號：2487076
[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.
【學位授予單位】：昆明醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R687.4
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