本文關(guān)鍵詞： 人工膝關(guān)節(jié)置換 出血 氨甲環(huán)酸　出處：《蘇州大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：背景:膝骨性關(guān)節(jié)炎是一種在中老年人群中較為常見的慢性退行性疾病。目前人工膝關(guān)節(jié)置換術(shù)(TKA)作為一種成熟的技術(shù)已經(jīng)廣泛應(yīng)用于中晚期膝骨性關(guān)節(jié)炎的治療,其療效也己經(jīng)被證實(shí)確切可靠。TKA術(shù)后截骨面及髓腔內(nèi)的出血量較大,部分患者術(shù)后不可避免需要進(jìn)行異體輸血。但目前臨床上出現(xiàn)的用血緊張現(xiàn)象及難以避免的輸血窗口期感染疾病的風(fēng)險(xiǎn),一直對患者及臨床醫(yī)生造成困擾。因此臨床上一直希望能夠找到一種新的方法來減少手術(shù)創(chuàng)傷帶來的失血,降低術(shù)后的輸血概率及相應(yīng)帶來的輸血風(fēng)險(xiǎn)。目前國內(nèi)外有多篇報(bào)道于TKA術(shù)中靜脈或局部使用氨甲環(huán)酸均可降低術(shù)后失血量。但目前術(shù)中氨甲環(huán)酸如何使用可取得最佳的效果并無統(tǒng)一意見。對于氨甲環(huán)酸用于局部關(guān)節(jié)腔內(nèi)使用與靜脈使用的效果孰優(yōu)孰劣也一直有不少爭議。國內(nèi)外雖然對該此有不少相關(guān)研究及報(bào)道,但目前并沒有統(tǒng)一的結(jié)論。局部關(guān)節(jié)腔內(nèi)使用氨甲環(huán)酸需在手術(shù)結(jié)束后大部分都會(huì)對負(fù)壓引流管夾閉一段時(shí)間,其目的是減少局部的氨甲環(huán)酸的流失,并盡可能的產(chǎn)生最大的藥物效應(yīng)。故本研究夾閉引流管3小時(shí)的情況下采用關(guān)節(jié)腔內(nèi)局部注射氨甲環(huán)酸,以盡量延長藥物的作用時(shí)間。目的:比較全膝關(guān)節(jié)置換術(shù)中關(guān)節(jié)腔內(nèi)局部氨甲環(huán)酸使用方法的臨床療效。方法:將2013.4-2014.11期間蘇州大學(xué)附屬常熟市第一人民醫(yī)院骨科66例患膝關(guān)節(jié)骨性關(guān)節(jié)炎擬行單側(cè)人工全膝關(guān)節(jié)置換術(shù)的患者,其中男性為18例,女性為48例,采用隨機(jī)的方法分為三組,A組21例,B組23例,C組22例,A組患者術(shù)中使用局部浸潤氨甲環(huán)酸治療,在安裝假體結(jié)束后,縫合表面支持帶后,夾閉負(fù)壓引流,將1g氨甲環(huán)酸注射液直接注射于關(guān)節(jié)腔內(nèi)。術(shù)后引流管保持夾閉3小時(shí)。B組患者于松開止血帶前10分鐘靜滴氨甲環(huán)酸1g,術(shù)后同樣夾閉負(fù)壓引流3小時(shí)。C組不使用氨甲環(huán)酸,術(shù)后同樣夾閉負(fù)壓引流3小時(shí)。術(shù)中根據(jù)出血量,患者心跳,血壓等一般情況綜合考慮是否輸血。三組患者均于術(shù)后24小時(shí)拔除負(fù)壓引流管。患者術(shù)后當(dāng)血常規(guī)Hb小于70g/L予輸紅懸糾正貧血,70至80g/L之間時(shí),根據(jù)患者當(dāng)時(shí)一般情況以及是否存在明顯的貧血癥狀決定是否進(jìn)行輸血治療。記錄的數(shù)據(jù)如下:術(shù)中失血量,患者術(shù)前及術(shù)后96h時(shí)Hb及HCT,術(shù)后24h內(nèi)負(fù)壓管血性液引流量,術(shù)前及術(shù)后3小時(shí)后凝血功能指標(biāo)變化(含D2聚體,纖維蛋白原、活化部分凝血活酶時(shí)間以及凝血酶原時(shí)間),術(shù)后患肢腫脹程度變化(髕上10cm周徑變化),術(shù)后患肢疼痛評分變化,術(shù)后需要輸血患者例數(shù)及輸血量,術(shù)后2周時(shí)膝關(guān)節(jié)Hss評分,下肢靜脈血栓或肺栓塞情況。使用SPSS19.0(社會(huì)科學(xué)統(tǒng)計(jì)軟件包)對以上采集的臨床數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)數(shù)據(jù)分析,計(jì)量資料如經(jīng)過檢驗(yàn)符合正態(tài)分布的標(biāo)準(zhǔn),則采用(χ±S)表示。組間數(shù)據(jù)兩兩比較采用單因素分析的方法。如檢驗(yàn)后不符合正態(tài)分布的標(biāo)準(zhǔn),則采用四分位數(shù)表達(dá)。三組患者性別,輸血比例采用卡方檢驗(yàn),如最小理論頻數(shù)小于5,則使用Fisher確切概率法對所得的數(shù)據(jù)進(jìn)行分析,如P0.05則考慮有顯著性的差異。結(jié)果:①術(shù)后24h內(nèi)負(fù)壓管血性液引流量比較結(jié)果:A組B組C組三組間術(shù)后24h內(nèi)血性液引流量比較結(jié)果,P值均0.05,有統(tǒng)計(jì)學(xué)意義。②術(shù)后96h時(shí)隱性失血量比較結(jié)果:A組和B組術(shù)后隱性失血量比較結(jié)果,P0.05,無統(tǒng)計(jì)學(xué)意義。A組B組分別與C組比較,P值均0.05,有統(tǒng)計(jì)學(xué)意義。③術(shù)后96h時(shí)總體失血量比較結(jié)果:A組B組C組三組間術(shù)后總失血比較結(jié)果,P值均0.05,有統(tǒng)計(jì)學(xué)意義。④A組B組C組三組間術(shù)后FDPS,PT,APTT比較結(jié)果,P值均0.05,無統(tǒng)計(jì)學(xué)意義。A組和B組術(shù)后D二聚體比較結(jié)果,P0.05,無統(tǒng)計(jì)學(xué)意義。A組B組D二聚體結(jié)果分別與C組比較,P值均0.05,有統(tǒng)計(jì)學(xué)意義。⑤術(shù)后患肢1天及4天時(shí)腫脹程度變化比較結(jié)果:A組和B組術(shù)后患肢髕上10cm周徑程度變化比較結(jié)果,P0.05,無統(tǒng)計(jì)學(xué)意義。A組B組分別與C組比較,P值均0.05,有統(tǒng)計(jì)學(xué)意義。⑥術(shù)后患肢24h,48h,96 h靜息疼痛評分變化比較結(jié)果:A組B組C組三組間術(shù)后患肢疼痛評分比較結(jié)果,P值均0.05,無統(tǒng)計(jì)學(xué)意義。⑦術(shù)后2周時(shí)膝關(guān)節(jié)Hss評分比較結(jié)果:A組B組C組三組間術(shù)后2周Hss評分比較結(jié)果,P值均0.05,無統(tǒng)計(jì)學(xué)意義。⑧需要輸血患者比例比較結(jié)果:A組和B組術(shù)后需要輸血患者比例比較結(jié)果,P0.05,無統(tǒng)計(jì)學(xué)意義。A組B組分別與C組比較,P值均0.05,有統(tǒng)計(jì)學(xué)意義。結(jié)論:全膝關(guān)節(jié)置換術(shù)中關(guān)節(jié)腔內(nèi)局部使用氨甲環(huán)酸可以減低術(shù)后出血量及輸血的概率。且并不會(huì)增加術(shù)后發(fā)生靜脈栓塞的概率。
[Abstract]:Background: knee osteoarthritis is more common in the elderly population of chronic degenerative diseases. The total knee arthroplasty (TKA) as a kind of advanced technology has been widely used in the treatment of knee osteoarthritis, its curative effect has been proved to be exact and reliable bleeding after.TKA the surface of the osteotomy and intramedullary greatly, some patients need blood transfusion. But the inevitable risk of current clinical use of blood and nervous phenomena appear difficult to avoid blood transfusion infection in window period of the disease, has been caused by the troubled patients and clinicians. So we always hope to be able to find a new method to reduce surgical trauma caused by blood loss, reduce the probability of postoperative blood transfusion and bring the risk of blood transfusion. There are several reports on intravenous TKA operation or topical use of tranexamic acid can reduce the postoperative loss But the current volume. Intraoperative tranexamic acid can be used to obtain the best effect. There is no unified opinion for tranexamic acid for local intra-articular and intravenous use of the effect of the merits has also been a lot of controversy. Although many of the related studies and reports, but there is no unified conclusion local intra-articular use of tranexamic acid in the end of the operation are mostly on negative pressure drainage pipe clamp for a period of time, the purpose is to reduce the partial loss of tranexamic acid, and as far as possible to produce the biggest effect of drugs. Therefore, the study of closed drainage for 3 hours under the condition of the use of intra-articular local injection of tranexamic acid, so as to prolong the time of drug action. Objective: To compare the clinical effect of total knee arthroplasty in intra-articular local tranexamic acid use. Methods: during the period of 2013.4-2014.11 in Suzhou Department of orthopedics, the first people's Hospital of Changshou City affiliated to study 66 patients with knee osteoarthritis underwent unilateral total knee arthroplasty patients, including 18 cases of male, female 48 cases, were randomly divided into three groups and 21 cases in A group, 23 cases in B group, C group of 22 cases, the use of local the infiltration of tranexamic acid in the treatment of patients in the A group, in the installation of prosthesis after suture with support surface after clamping the negative pressure drainage, Tranexamic Acid Injection 1g will directly injected into the articular cavity. Keep the tube clamping 3 hour.B patients on tourniquet release 10 minutes before the intravenous drip of tranexamic acid 1g postoperative drainage, postoperative the same clamping drainage for 3 hours in group.C without the use of tranexamic acid, after the same clamping drainage for 3 hours. According to the intraoperative bleeding, blood pressure in patients with heart, generally considered whether blood transfusion. Three groups of patients in the 24 hours after removal of negative pressure drainage tube. When the blood of patients after operation The conventional Hb is less than 70g/L to lose the red suspension for correction of anemia, between 70 and 80g/L, according to the patient at the time the general situation and the existence of obvious symptoms of anemia, determine whether blood transfusion treatment. The data recorded are as follows: the intraoperative blood loss, Hb and HCT in patients with preoperative and postoperative 96h, negative pressure drainage tube bloody 24h after the operation, preoperative and postoperative 3 hours after the change of coagulation index (including D2 dimer, fibrinogen, activated partial thromboplastin time and prothrombin time), changes of postoperative limb swelling (10cm patellar circumference), postoperative limb pain score changes, postoperative blood transfusion and the number of patients, 2 weeks after operation Hss knee score, lower extremity venous thrombosis or pulmonary embolism. Using SPSS19.0 (statistical package for Social Science) for statistical data analysis of the clinical data collected over the measurement data, such as through the test are consistent with the 鎬佸垎甯冪殑鏍囧噯,鍒欓噰鐢，

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