氨甲环酸单次用药后持续输注在关节置换术中的作用
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Intravenous Tranexamic Acid Bolus plus Infusion Is Not More Effective than a Single Bolus in Primary Hip Arthroplasty
背景与目的
关节置换术患者术后第一天常存在大量的活化纤溶蛋白，术前使用抗纤溶药物氨甲环酸可减少出血。本研究探讨围术期额外剂量使用氨甲环酸是否会进一步减少出血。
方 法
本研究为随机、双盲、前瞻性的对照研究，共纳入168名一侧髋关节置换术患者。试验组术前静脉注射1g氨甲环酸后，1g氨甲环酸8h内持续输注完毕，对照组持续输注安慰剂。主要结果为术后5天内累积出血量，次要结果为需要红细胞输注的患者人数。
结 果
实验组出血量平均值为919±338ml，而对照组为888±366ml，平均差值30ml（95%CI：-77～137；P=0.58）；术后6周内，两组中均有3.6%的患者接受红细胞输注，试验组2名患者发生深静脉血栓；本实验数据结果与一项荟萃分析均显示围术期氨甲环酸的额外使用并不会产生增量效益。
结 论
术前氨甲环酸的使用及限制性输血策略的开展，减少了髋关节置换术患者围术期输血几率；但围术期额外剂量使用氨甲环酸并不会进一步减少患者出血量。
原始文献摘要
Zufferey P J, Lanoiselée J, Chapelle C, et al. Intravenous Tranexamic Acid Bolus plus Infusion Is Not More Effective than a Single Bolus in Primary Hip Arthroplasty: A Randomized Controlled Trial[J]. Anesthesiology, 2017:1.
Background: Preoperative administration of the antifibrinolytic agent tranexamic acid reduces bleeding in patients undergoing hip arthroplasty. Increased fibrinolytic activity is maintained throughout the first day postoperation. The objective of the
study was to determine whether additional perioperative administration of tranexamic acid would further reduce blood loss.
Methods: This prospective, double-blind, parallel-arm, randomized, superiority study was conducted in 168 patients undergoing unilateral primary hip arthroplasty. Patients received a preoperative intravenous bolus of 1 g of tranexamic acid followed by a continuous infusion of either tranexamic acid 1 g (bolus-plus-infusion group) or placebo (bolus group) for 8 h. The primary outcome was calculated perioperative blood loss up to day 5. Erythrocyte transfusion was implemented according to a restrictive transfusion trigger strategy.
Results: The mean perioperative blood loss was 919 ± 338 ml in the bolus-plus-infusion group (84 patients analyzed) and 888 ± 366 ml in the bolus group (83 patients analyzed); mean difference, 30 ml (95% CI, −77 to 137; P = 0.58). Within 6 weeks postsurgery, three patients in each group (3.6%) underwent erythrocyte transfusion and two patients in the bolus group experienced distal deep-vein thrombosis. A meta-analysis combining data from this study with those of five other trials showed no incremental efficacy of additional perioperative administration of tranexamic acid.
Conclusions: A preoperative bolus of tranexamic acid, associated with a restrictive transfusion trigger strategy, resulted in low erythrocyte transfusion rates in patients undergoing hip arthroplasty. Supplementary perioperative administration of tranexamic acid did not achieve any further reduction in blood loss.
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