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HERALD OF MEDICINE, 2018, 37(6): 715-717
doi: 10.3870/j.issn.1004-0781.2018.06.015
低分子肝素钙不同时间用于老年半髋关节置换对出血量的影响
董艳龙1,, 何亮2,

摘要:

目的 观察低分子肝素钙术前术后使用时机对老年半髋关节置换者围手术期失血量的影响。方法 将67例老年股骨颈骨折患者随机分为A组34例和B组33例。A组术后使用低分子肝素钙抗凝剂,B组术前术后均使用低分子肝素钙抗凝。术后第1,3天,记录两组围术期总失血量(TBL)、显性失血量(ABL)和隐性失血量(HBL)。结果 两组间男女患者术后第1和第3天TBL、ABL、HBL比较均差异无统计学意义(均P>0.05)。结论 低分子肝素钙术前术后抗凝对股骨颈骨折半髋置换的老年患者出血量未见明显影响。

关键词: 低分子肝素钙 ; 半髋关节置换 ; 老年 ; 抗凝作用 ; 失血量

Abstract:

我国人口平均寿命逐年增加,我国逐步进入老龄化社会。由于老年人神经肌肉协调能力下降,运动缓慢,加之有不同程度的骨质疏松,跌倒后易导致骨折。特别是股骨颈骨折发生率逐年增高。保守治疗需要长期牵引卧床,如预防不当极易引起静脉血栓栓塞(venous thrombus embolism,VTE),导致较高病死率[1]。目前,多主张积极手术治疗[2]。近年来,髋部骨折围手术期常规抗凝成为共识。但是,不合理使用抗凝药物可能带来出血风险的增加。笔者通过观察2012年1月—2015年12月因股骨颈骨折行半髋置换患者,统计分析比较抗凝时机对出血量的影响。

1 资料与方法
1.1 临床资料

选择2012年1月—2015年12月在西安医学院第一附属医院骨科因新鲜股骨颈骨折行半髋置换患者67例,排除复合伤、多发伤、活动性消化道溃疡或胃肠道出血、凝血功能障碍、明显重要脏器功能不全、重度心肺及脑血管疾病史、肝肾功能不全、血栓性疾病和正在服用抗凝药物的患者。本研究经西安医学院第一附属医院伦理委员会批准。所有患者及家属均签署知情同意书。

1.2 方法

1.2.1 分组方法 按前瞻、随机、双盲、单中心临床研究方法设计。将患者分为术后抗凝(A组)34例和术前术后均抗凝(B组)33例。A组男18例,女16例,平均年龄(80.56±6.04)岁,体质量(56.35±3.64) kg;B组男16例,女17例,平均年龄(82.01±3.25)岁,体质量(57.12±2.07) kg。两组男女患者身高、年龄、体质量、入院Hb比较均差异无统计学意义(均P>0.05)。见表1。

表1 两组患者一般资料 x¯±s
组别与性别 例数 身高/cm 年龄/岁 体质量/kg 入院Hb/(g·L-1)
A组 34
18 172.17±6.46 81.06±3.04 60.12±2.54 114.17±10.20
16 160.17±4.46 79.41±10.05 55.26±9.52 107.92±23.74
B组 33
16 171.23±7.62 82.23±4.32 58.54±3.07 111.02±16.52
17 159.23±6.46 81.03±8.07 56.34±6.58 102.45±34.12

表1 两组患者一般资料 x¯±s

1.2.2 围手术期处理 ①患者入院后完善术前准备,行各项常规检查,包括血常规,尿常规,生化系列(肝肾功能、电解质、血糖),血凝系列,胸部X线片,心电图,心脏超声,肺功能等检查,评估各器官功能,对合并有糖尿病、心脑肺部疾病患者,请内科专家会诊,协助对症治疗;对糖尿病、高血压患者,术前将血糖、血压调整至稳定水平[空腹血糖7~9 mmol·L-1,血压(90~160)/(60~90) mmHg(1 mmHg=0.133 kPa)]。所有患者骨折行术前X线检查,包括骨盆正位及患肢股骨近端;术前24 h双侧下肢静脉B超,均未发现血栓形成。对近期不能手术,有内科疾病需要治疗的患者,行股骨髁上骨牵引。依据两组患者体质量均使用低分子肝素钙(海南通用同盟药业有限公司,批准文号:国药准字H20010300,规格:1 mL:5 000 U)1 mL预防剂量。A组患者仅在术后12 h后开始皮下注射。B组患者在入院后凝血功能检查提示正常后开始皮下注射,至术前24 h停药,术后12 h后继续皮下注射低分子肝素钙1 mL抗凝至术后14 d。②手术方式:所有患者术前0.5 h常规应用抗菌药物预防感染。所有患者均由我科同一组医生采取标准髋部后外侧入行生物型半髋置换术治疗。术毕放置引流管一根。③术后处理:术后预防性使用抗菌药物48 h,同时予镇痛、抑酸、营养支持等对症治疗;术后记录24 h引流量并拔除引流管。术后第1和第3天患者行血常规检查,对血红蛋白(Hb)<80 g·L-1患者输注红细胞悬液;嘱患者术后第2天开始行股四头肌功能训练,同时使用下肢气压泵治疗,术后第3天行下肢功能锻炼。

1.2.3 主要观察指标 ①Hb及红细胞压积(hematocrit,Hct):患者于入院后、术后第1天、术后第3天均进行血常规检验,根据血常规结果,记录这3个时间点的Hb、Hct值。②显性失血量 (apparent blood loss,ABL):ABL=术中吸引瓶液体量-冲洗液量+血纱布增加质量+术后引流量。血纱布增加质量(1.05 g=1 mL)[3]。③总血容量 (blood volume,BV),应用Nadler方程[4]计算,BV(男)=0.366 9×[身高(m)3]+0.032 19×体质量(kg)+0.604 1,BV(女)=0.356 1×[身高(m)3]+0.033 08×体质量(kg)+0.183 3。④失血量(volume of blood loss,VL)、总失血量(total blood loss,TBL)、输血量(blood transfusion volume,BTV)。VL=BV×(术前红细胞压积-术后红细胞压积),TBL=VL+ BTV,输血指征为Hb<80 g·L-1,输红细胞悬液1 U相当于全血200 mL,含血红蛋白55 g[5]。术中及术后均为异体输血。⑤隐性失血量 (hidden blood loss,HBL),HBL=TBL-ABL。

1.3 统计学方法

所有数据采用SPSS19.0版统计软件进行分析处理,计量资料采用均数±标准差( x ¯ ±s)表示,组间比较采用两独立样本t检验,男女分开比较,以P<0.05为差异有统计学意义。

2 结果

两组男女患者术后第1天、第3天TBL、ABL、HBL比较结果见表2。两组间男女患者术后第1和第3天TBL、ABL、HBL比较均差异无统计学意义(均P>0.05)。

表2 两组患者术后第1和第3天TBL、ABL、HBL检测值 mL,x¯±s
组别与性别 例数 TBL ABL HBL
第1天 第3天 第1天 第3天 第1天 第3天
A组 34
18 812.17±235.46 1 054.17±329.06 79.41±22.05 79.41±22.05 731.26±100.52 956.42±215.92
16 752.36±198.43 842.17±235.46 84.52±29.15 84.52±29.15 665.46±215.23 755.26±425.19
B组 33
16 778.23±332.28 1 011.23±425.28 81.03±21.07 81.03±21.07 682.34±201.58 874.31±326.08
17 731.89±232.04 798.23±332.28 94.46±26.27 94.46±26.27 646.754±422.58 712.56±346.28

表2 两组患者术后第1和第3天TBL、ABL、HBL检测值 mL,x¯±s

3 讨论

高龄老人股骨颈骨折多由于走跌倒时大转子着地,髋部直接遭受外力撞击引起骨折[6,7]。由于牵引等保守治疗患者卧床时间长,老年骨折患者会发生各种并发症,特别VTE病死率较高,故主张早期手术治疗[8]。Virchow描述静脉血栓栓塞形成三要素是:血液淤滞、血管内皮损伤和血液高凝状态[9]。髋部骨折后,由于疼痛等原因,患者肢体活动减少,常常需要卧床牵引制动,导致血流缓慢,可发生血液淤滞;骨折发生和手术过程中均可发生血管内皮损伤,可激活内源性和外源性凝血途径;骨折导致的组织因子释放则会导致血液高凝状态[10]。因此老年髋部骨折的患者最易发生静脉血栓栓塞。一旦形成深静脉血栓,栓子脱落极易导致肺栓塞,严重威胁患者生命安全。所以对于老年股骨颈骨折患者,围术期预防深静脉血栓非常重要。目前临床上常见预防血栓的药物有肝素、低分子肝素、凝血因子抑制药等[11]

低分子肝素可由普通肝素直接分离或降解后再分离得到。它具有很高的抗凝血因子Xa活性,较低的抗凝血因子Ⅱa或抗凝血酶活性。同时不影响血小板的聚集和纤维蛋白原与血小板的结合,引起出血的风险较低,也不延长出血时间。使用预防剂量,不显著改变APTT,其抗血栓作用与致出血作用分离,保持抗血栓作用的同时,降低了出血风险。2012年第9版美国胸科医师学会(ACCP)抗栓治疗与血栓预防临床实践指南已把低分子肝素作为围术期髋部骨折抗凝的首选用药[12]。GILLESPIE等[13]发现髋部骨折患者隐性失血是显性失血的6倍。本次研究统计数据可以看出,隐性失血占总失血量的80%以上,故隐性失血是患者围手术期主要的失血方式。隐性失血的原因和发生机制主要有溶血、血液转移外渗和高龄[14,15]

低分子肝素钙的不良反应之一是引起血小板减少,会增加出血风险[16]。何时使用低分子肝素钙抗凝,减少出血风险目前仍然存在争议。在欧洲,术前12 h及术后12 h均按预防剂量每日皮下注射1次。在北美洲和我国,一般在术后12 h按预防剂量开始使用。本次研究观察患者术后第1天、第3天失血量。统计数据结果表明,男女患者体质量身高差异,术后使用ABL与术前术后使用低分子肝素钙在TBL、ABL和HBL之间差异无统计学意义(均P>0.05)。说明术前术后应用低分子肝素钙在有效预防血栓形成的基础上,并不会造成失血量的增加。股骨颈骨折失血主要是骨折创伤、手术对血液生理环境的刺激,导致早期凝血因子消耗,血液渗出。低分子肝素钙对失血量未见明显影响。

综上所述,高龄股骨颈骨折患者,一方面,疼痛、卧床、手术等增加血栓形成的风险;另一方面,也造成了失血量的增加。围手术期即存在血栓形成又存在失血的风险。本研究发现,使用低分子肝素钙可有效抑制血栓的形成,且对围手术期出血量未见明显影响,所以,为了减少骨折术前术后深静脉血栓形成,临床上对老年股骨颈骨折患者应术前术后常规使用低分子肝素钙预防剂量抗凝。

The authors have declared that no competing interests exist.

参考文献

[1] 梁昌详,詹世强,肖丹,.老年骨质疏松性股骨转子间骨折的治疗策略[J].中国矫形外科杂志,2013,21(12) :1247-1248.
[本文引用:1]
[2] 张长青. 关于老年股骨转子间骨折的当代观点[J].中华骨科杂志,2012,32(7) :611-613.
老年股骨转子间骨折是下肢最常见的骨折之一, 也是骨科医生在日常工作及学术会议上经常讨论的话题。当前, 转子间骨折临床研究着重关注于合理治疗技术的选择、并发症和死亡率控制等方面。随着老龄化人口数量和期望治疗结果的提高, 股骨转子间骨折带来了一系列新的议题。第一, 疾病治疗模式从以野骨折冶为中心演变为以野高龄患者冶为中心, 需要骨科医生对老年病医学有更深入地理解;第二, 骨折治疗的期望结果是能够使得患者尽早离床活动, 降低致死性并发症的产生;第三, 转子间骨折患者数量的增多和骨折复杂程度加剧要求治疗医生必须根据自身经验, 提供最佳治疗策略。以股骨转子间骨折为代表的老年性骨折将挑战整体骨科医生的智慧, 现今医疗与护理条件也将面临其考验。
DOI:10.3760/cma.j.issn.0253-2352.2012.07.001      Magsci     URL    
[本文引用:1]
[3] 杜哲,刘培来,张元凯,.人工全膝关节置换术中止血带应用对围手术期失血量及近期疗效的影响研究[J].中国修复重建外科杂志,2013,27(11):1318-1323.
目的探讨初次人工全膝关节置换术(total knee arthroplasty,TKA)中,止血带应用对围手术期失血量及术后近期疗效的影响。方法回顾分析2010年9月-2011年12月接受初次TKA治疗且符合选择标准的94例94膝骨关节炎患者临床资料,其中51例术中使用止血带(A组),43例未使用止血带(B组)。两组患者性别、年龄、侧别、体重指数、术前血红蛋白(hemoglobin,Hb)水平、患肢膝上10 cm周径、关节活动度、疼痛视觉模拟评分(VAS)、美国特种外科医院(HSS)评分、美国西部Ontario与McMaster大学骨关节炎指数评分(WOMAC)比较,差异均无统计学意义(P0.05),具有可比性。记录并比较两组患者术后红细胞压积(hematocrit,Hct)、Hb、隐性失血量、显性失血量及理论总失血量,以及两组手术时间、住院时间、患肢膝上10 cm周径增加率、VAS评分、关节活动度、HSS评分、WOMAC评分。结果术后A组4例(7.84%)、B组1例(2.33%)输血,术后输血率比较差异无统计学意义(χ2=1.410,P=0.235)。术后2 d,两组Hb及Hct比较,差异均无统计学意义(P0.05)。A组术中显性失血量少于B组,隐性失血量多于B组,差异有统计学意义(P0.05);但两组理论总失血量比较差异无统计学意义(t=0.662,P=0.510)。A、B组手术时间、住院时间及术后3 d VAS评分比较,差异均无统计学意义(P0.05)。患者术后切口均Ⅰ期愈合,无相关并发症发生。术后3 d A组膝上10 cm周径增加率高于B组(t=9.435,P=0.000),7 d时差异无统计学意义(t=0.462,P=0.645);术后3、5 d,B组关节活动度优于A组(P0.05),7 d时两组比较差异无统计学意义(t=—1.279,P=0.204)。患者均获随访,随访时间12~18个月,平均14.3个月。两组术后1年HSS评分差异无统计学意义(t=0.952,P=0.344),WOMAC评分比较差异有统计学意义(t=—2.488,P=0.015)。X线片复查示,假体位置良好,无松动及下沉,无骨溶解。结论 TKA术中应用止血带增加隐性失血量,与未使用止血带相比在降低输血率上无明显优势,建议对于有血栓栓塞高风险患者减少止血带使用时间及压力。
URL    
[本文引用:1]
[4] PATAL D A,LAVIE C J,GILLILAND Y E,et al.Prediction of all-cause mortality by the left atrial volume index in patients with normal left ventricular filling pressure and preserved ejection fraction[J].Mayo Clin Proc,2015,90(11):1499-1505.
To describe the prevalence of left atrial (LA) enlargement (LAE) and its association with all-cause mortality in 10,719 patients with an early diastolic transmitral flow velocity (E) to early diastolic mitral annular velocity (e′) ratio–determined normal left ventricular (LV) filling pressure and preserved LV ejection fraction (LVEF). We evaluated 10,719 patients (deceased patients: n=479; mean [SD] age, 65 [14] years; 60% male; surviving patients: n=10,240; mean (SD) age, 54 (16) years; 48% male) with estimated normal LV filling pressure (E/e′ ratio ≤8) and preserved LVEF (≥50%) to determine the impact of LA volume index (LAVi) on all-cause mortality during a mean (SD) follow-up of 2.2 (1.0) years. In the univariate analysis, with every milliliter per square meter increase in LAVi, all-cause mortality risk increased by 3% (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04;P<.001). After adjusting for covariates, LAVi (as a continuous variable) was an independent predictor of all-cause mortality (HR, 1.015; 95% CI, 1.005-1.026;P=.01). When LAVi was assessed as a categorical variable with normal LAVi (≤28 mL/m2) as the reference group, moderate LAVi (34-39 mL/m2) and severe LAVi (≥40 mL/m2) were independent predictors of all-cause mortality (HR, 1.34; 95% CI, 1.01-1.79;P=.04; and HR, 1.65; 95% CI, 1.18-2.29;P=.003, respectively). LAE was independently associated with an increased risk of all-cause mortality in our large cohort of 10,719 patients with normal LV filling pressure and preserved LVEF.
DOI:10.1016/j.mayocp.2015.07.021      PMID:26455887      URL    
[本文引用:1]
[5] IZUMI M,MIGITA K,NAKAMURA M,et al.Risk of venous thromboembolism after total knee arthroplasty in patients with rheumatoid arthritis[J].J Rheumatol,2015,42(6):928-934.
To compare the incidence of venous thromboembolism (VTE) following total knee arthroplasty (TKA) between patients with rheumatoid arthritis (RA) and those with osteoarthritis (OA).The subjects were composed of 1084 Japanese patients with OA and 204 with RA. Primary effectiveness outcomes were any deep vein thrombosis (DVT) as detected by bilateral ultrasonography up to postoperative Day 10 (POD10) and pulmonary embolism (PE) up to POD28. The main safety outcomes were bleeding and death from any cause up to POD28. Plasma D-dimer levels were measured before and at POD10 after TKA.The study cohort was composed of 1288 patients from 34 hospitals. There was no death up to POD28. PE occurred in 2 patients with OA and in no patients with RA. The incidence of primary effectiveness outcome was 24.3% and 24.0% in patients with OA and RA, respectively. The incidence of major bleeding up to POD28 was 1.3% and 0.5% in patients with OA and RA, respectively. No differences in the incidence of VTE (symptomatic/asymptomatic DVT plus PE) or bleeding were noted between patients with RA and OA. D-dimer levels on POD10 were significantly higher in patients with OA compared with those with RA. Also, D-dimer levels on POD10 were significantly lower in patients receiving fondaparinux than in patients without pharmacological prophylaxis.Despite some differences in demographic data, patients with RA and OA have equivalent risks of VTE and bleeding following TKA.
DOI:10.3899/jrheum.140768      PMID:25877506      URL    
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[6] 代恒茂,陈罡,许巧巧,.髋关节置换手术患者实施超声定位神经阻滞麻醉的护理[J].护理学杂志,2017,32(18):61-63.
对37例全髋关节置换手术患者实施超声定位神经阻滞麻醉,麻醉科护士对患者进行术前访视与宣教,提前准备麻醉所需仪器、药品和物品,熟悉神经阻滞麻醉的过程,主动配合麻醉医生操作,手术过程中严密监测患者生命体征,协助麻醉医生做好患者呼吸道管理和液体管理,阻滞麻醉后苏醒期观察与评估患者出入液量、疼痛情况、感觉阻滞平面、运动阻滞平面等。结果所有患者神经阻滞效果良好,均顺利完成手术。提出麻醉科护士在超声定位神经阻滞麻醉过程中发挥重要作用,提高了麻醉质量和效率。
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[7] 赵丽,吴清,叶旭春.关节置换术患者参与健康照护的研究进展[J].护理学杂志,2016,31(18):106-110.
介绍了国内外关节置换术患者参与健康照护的内容,主要包括决策性参与、照护性参与及信息互动性参与3个方面;探讨了关节置换术患者参与健康照护的影响因素,主要包括性别、年龄、种族、患者的认知、疾病状态、信任、社会支持、医生的角色、医生的态度、医患沟通等方面;总结了国内外现有的患者参与健康照护的促进策略,如决策帮助、患者教育,以期为促进关节置换术患者参与实践提供借鉴。
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[8] BJORNARA B T,GUDMUNDSEN T E,DAHL O E.Fre-quency and timing of clinical venous thromboembolism after major joint surgery[J].J Bone Joint Surg,2006,88(3):386-391.
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[9] WASSILEW G I,PERKA C,JANZ V,et al.Tranexamic acid reduces the blood loss and blood transfusion requirements following peri-acetabular osteotomy[J].J Bone Joint Surg,2015,97(12):1604-1607.
72 Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.72 A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.72 Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.72 Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.72 The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.
DOI:10.2106/JBJS.O.00071      PMID:26446969      URL    
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[10] 周卫征,徐向红,张金庆.糖尿病髋关节骨折患者术后关节功能恢复及影响因素调查[J].护理学杂志,2016,31(10): 22-25.
目的了解糖尿病髋关节骨折患者术后髋关节功能恢复情况及其影响因素。方法采用横断面调查方法,应用Harris髋关节功能评价表、心理弹性量表及一般资料调查表对110例符合纳入标准的2型糖尿病髋关节骨折患者进行问卷调查。结果 2型糖尿病髋关节骨折患者术后3个月Harris功能评分为(78.29±16.61)分;患者髋关节功能评分与心理弹性总评分及各维度得分呈显著正相关(均P〈0.01);术后规律康复锻炼、糖化血红蛋白水平、心理弹性显著影响患者的Harris功能评分(均P〈0.01),共解释33.5%的总变异。结论 2型糖尿病髋关节骨折患者术后关节功能康复情况不甚理想,需加强血糖管理、术后规律康复锻炼指导,提高患者心理弹性等,以促进患者髋关节功能康复。
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[11] 中华医学会骨科学分会.中国骨科大手术静脉血栓栓塞症预防指南[J].中华骨科杂志,2016,36(2):65-71.
骨科大手术后静脉血栓栓塞(venous thromboembolism,VTE)发生率较高,是患者围手术期死亡的主要原因之一,也是医院内非预期死亡的重要原因。本文介绍了骨科大手术后静脉 血栓栓塞的概况,分析了静脉血栓栓塞症的危险因素,提出预防骨科大手术深静脉血栓形成的措施和具体方案。
DOI:10.3760/cma.j.issn.0253-2352.2009.06.023      Magsci     URL    
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[12] NAJAFZADEH M,KIM S C,PATTERSON C,et al.Patients' perception about risks and benefits of antithrombotic treatment for theprevention of venous thromboembolism (VTE) after orthopedic surgery[J].BMC Musculoskelet Disord,2015,26(16):319-321.
The 9th edition of the American College of Chest Physicians’ Antithrombotic Therapy and Prevention of Thrombosis guidelines emphasize the importance of considering the risk–benefit ratio of “patient-important” outcomes. However, little is known about patients’ perception and understanding regarding the different outcomes of antithrombotic treatment after orthopedic surgery, and the factors that influence their decision to use these treatments. Using a series of semi-structured interviews, we explored patients’ understanding and perception concerning the benefits and risks of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after joint replacement surgery. A series of semi-structured interviews were conducted with patients who had undergone knee or hip replacement surgery at a tertiary care hospital (Brigham and Women’s Hospital, Boston, MA) in 2014. Discussions were recorded and transcribed. Two investigators independently coded and analyzed the data to identify important themes and concepts using the constant comparative method. Of 64 patients who were invited, 12 patients (1902%) completed the interviews. The majority of patients (9202%) were aware of the benefits of antithrombotic therapy for reducing the risk of blood clots, while less than half of them had a clear understanding of deep vein thrombosis and pulmonary embolism. While all patients were aware of risk of minor bleeding, only 6 patients (5002%) considered the risk of major bleeding as a possible side effect of antithrombotic treatment. Overall, patients perceived bleeding as a less important outcome than a thrombotic event. The lack of awareness about the risk of major bleeding, the assumption that a short-term exposure would not meaningfully affect bleeding risk, and the assumption that bleeding is a controllable event influenced their perception. Most patients (8302%) stated that their decision to use antithrombotic medications was mainly based on the trust in their physician’s expertise. Patients perceived thrombotic events as more important outcomes than bleeding events. Patients’ understanding of thrombotic and bleeding events varies and may play a key role in their preferences. The majority of patients stated that trust in their physician’s expertise had a large influence on their decision to use antithrombotic medications.
DOI:10.1186/s12891-015-0777-x      PMID:4624375      URL    
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[13] GILLESPIE R,SHISHANI Y,JOSEPH S,et al.Neer award 2015:a randomized,prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty[J].J Shoulder Elbow Surg,2015,24(11):1679-1684.
Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. The purpose of this study was to evaluate the effect of TXA on postoperative blood loss after shoulder arthroplasty. A total of 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application into the wound at the completion of the case. All patients received a postoperative drain. Drain output representing postoperative blood loss, transfusion requirements, and change in hemoglobin level were recorded. All postoperative complications were noted. The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P = .017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group. In this cohort of patients, those treated with TXA experienced a significantly lower amount of postoperative blood loss and a significantly smaller change in hemoglobin level compared with those treated with placebo. Further work is required to determine the effectiveness and clinical significance of TXA in reducing transfusion requirements in shoulder arthroplasty and, more specifically, shoulder arthroplasty performed for complicated patients or for trauma and fracture patients.
DOI:10.1016/j.jse.2015.05.009      PMID:26480877      URL    
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[14] CARVALHO L H J,FROIS TEMPONI E,MACHADO SOARES L F,et al.Bleeding reduction after topical application of tranexamic acid together with betadine solution in total knee arthroplasty[J].Orthop Traumatol Surg Res,2015,101(1):83-87.
Topical application of tranexamic acid to the knee joint before closure in total knee arthroplasty reduces postoperative bleeding without increase in complication. However, it is unknown the effectiveness of topic TXA performed with other topical medications, like povidone-iodine solution.One hundred and twenty-five patients were randomized to receive 100mL of povidone-iodine solution (control: group A) or 1.5 (group B) and 3.0g (group C) of topical TXA in povidone-iodine solution applied into the knee before closure in total knee arthroplasty.The patients in the TXA groups had higher mean postoperative hemoglobin levels (P=0.01 and P=0.03 in groups B and C, respectively) and a reduced postoperative blood loss in the TXA groups (P=0.07 and P=0.09 in groups B and C, respectively). No significant complications were observed.In this study, topical application of tranexamic acid after total knee arthroplasty together with povidone-iodine solution results in higher postoperative hemoglobin levels and lower blood loss compared with those in the control group without other complications.I-I: high-powered prospective randomized trial.
DOI:10.1016/j.otsr.2014.10.013      PMID:25541338      URL    
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[15] ZHAOHUI L,WANSHOU G,QIDONG Z,et al.Topical hemostatic procedures control blood loss in bilateral cemented single-stage total knee arthroplasty[J].J Orthop Sci,2014,19(6):948-953.
BackgroundBlood management is critical in total knee arthroplasty (TKA). In bilateral, single stage TKA, blood loss seems more prominent. We believe it is important to control all potential bleeding within the wound tissue. PurposeThe purpose of the study was to evaluate a series of topical procedures used to reduce blood loss and transfusion in single-stage bilateral cemented total knee arthroplasty: antifibrinolysis with tranexamic acid, vasoconstriction with epinephrine, sealing of the bone section intraoperatively, and closure of the drainage tube within the first 402h postoperatively. Materials and methodsPatients with osteoarthritis of the knees were randomly divided into two groups. In group A, 502ml (2502mg/ml) tranexamic acid (TXA) and 502ml analgesic containing epinephrine (302μg/ml) solution were injected at several points into the posterior capsule before installation of the prosthesis. The femoral medullar canal was closed with autograft bone and then sealed compressively with cement. Before the tourniquet was released, 1002ml TXA solution and 1002ml analgesic containing epinephrine were injected at several points into the periosteum, synovium, joint capsule, tendons, and deep fascia tissue (injection of analgesic containing epinephrine into subcutaneous fat and dermis was avoided). The residual nail holes in the bone and the uncovered bone section were covered with bone wax. The tourniquet was then removed, and active bleeding points were stanched. TXA solution (2002ml) was injected into the articular cavity after wound closure. The drainage tube was clamped for 402h, then opened. In group B, injection of analgesic containing epinephrine into soft tissue, control of active bleeding, and clamping of the drainage tube for 4-h, only, were performed. ResultsNinety patients were enrolled in the study. Compared with those in group B, intraoperative blood loss, drainage volume, total postoperative blood loss, and number of patients requiring allogenic blood transfusion were significantly reduced in group A. There was no significant difference between the incidence of complications in the groups. ConclusionsOur topical procedures enable effective and safe reduction of blood loss and the number of patients requiring transfusion in single-stage bilateral osteoarthritic TKA.
DOI:10.1007/s00776-014-0621-4      PMID:25158897      URL    
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[16] 蒋媛,史桂玲,张惠娟,.1例低分子肝素钙诱导血小板减少症的药学监护[J].医药导报, 2017,36(4):406-409.
目的 为临床药师参与低分子肝素钙诱导的血小板减少症患者的药物治疗提供参考。方法 临床药师对1例使用低分子肝素钙过程中出现进行性血小板减少的慢性喘息性支气管炎急性加重伴慢性肺源性心脏病患者进行药学监护,协助临床医生进行不良反应处理及治疗药物选择。结果 医生采纳临床药师建议,患者血小板逐渐恢复,未出现血栓事件。结论 临床药师参与低分子肝素钙诱导血小板减少的管理,能有效改善患者预后,保障患者的用药安全。
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关键词(key words)
低分子肝素钙
半髋关节置换
老年
抗凝作用
失血量


作者
董艳龙
何亮