联合氨甲环酸和肾上腺素对全膝关节置换术失血的研究

doi:10.3877/cma.j.issn.1674-134X.2019.03.012

目的

评价联合使用氨甲环酸(TXA)和稀释的肾上腺素(DEP)对初次全膝关节置换术(TKA)围术期失血量等指标的影响及其安全性。

方法

检索电子数据库包括PubMed，荷兰医学文摘数据库(EMBASE)，Cochrane对照研究注册中心，Web of Science，万方数据库和中国知网，根据纳入排除标准，包括初次TKA患者的随机对照研究，干预措施实验组为TXA＋DEP，对照组为TXA。采用RevMan 5.2软件进行Meta分析。

结果

经过全面严格筛选，共纳入高质量随机对照研究6篇。Meta分析结果显示，使用TXA＋DEP可以减少病人平均总失血量[MD ＝－184.32，95%CI(－251.11，－117.52), P<0.01]；平均减少隐性失血量[MD ＝－150.89，95%CI(－179.83，－121.95), P<0.00001]；平均减少引流量[MD ＝－63.16，95%CI(－116.29，－10.02), P＝0.02]。联合TXA＋DEP可以显著降低输血率[RR ＝0.51, 95%CI(0.28，0.93), P＝0. 03]；两组间深静脉血栓发生率差异无统计学意义(P＝1.00)。

结论

联合TXA＋DEP能有效减少初次TKA的失血量和降低输血率，并不增加术后DVT的发生率。

关键词: 氨甲环酸, 肾上腺素, 关节成形术，置换，膝, Meta分析

Objective

To evaluate the effect and safety of combination of tranexamic acid (TXA) and diluted-epinephrine (DEP) on blood loss during the primary total knee arthroplasty (TKA).

Methods

The electronic databases of PubMed, Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials, Web of Science, Wanfang and China National Knowledge Infrastructure (CNKI) were searched. TXA+ DEP were initially searched of the high-quality randomized controlled trials (RCTs) in TKA by the inclusion criteria, the intervention measures were as follows: the experimental group was TXA DEP, the control group was TXA. Meta-analysis was performed using RevMan 5.2 software.

Results

A total of six RCTs were included. The results of meta analysis showed that using TXA+ DEP could reduce the average total blood loss [MD =-184.32, 95%CI(-251.11, -117.52), P<0.01], reduce the average amount of hidden blood loss [MD =-150.89, 95%CI(-179.83, -121.95), P<0.00001], and reduce the average amount of drainage [MD =-63.16, 95%CI(-116.29, -10.02), P=0.02]. The combination application of TXA+ DEP could significantly reduce the blood transfusion rate [RR =0.51, 95%CI(0.28, 0.93), P=0. 03]. There was no significant difference in the incidence of DVT between the two groups (P=1.00).

Conclusion

Combination application of TXA+ DEP can effectively reduce the blood loss and transfusion rate in primary TKA, without increasing the incidence of DVT.

Key words: Tranexamic acid, Epinephrine, Arthroplasty, replacement, knee, Meta-analysis

表1 纳入研究的基本情况

作者	出版时间	样本量(例)		年龄(岁)		干预措施		血栓预防	输血标准	随访时间	改良 Jadad
作者	出版时间	TXA＋DEP组	TXA组	TXA＋DEP组	TXA组	TXA＋DEP组	TXA组	血栓预防	输血标准	随访时间	改良 Jadad
Gao et al ^[14]	2015	50	50	68.5	67.4	局部TXA 1 g ＋ DEP 0.25 mg	局部TXA 1 g	利伐沙班	Hb<80 g/L	90 d	7
Zeng et al ^[15]	2018	59	59	59.66	61.54	静脉10 mg/kg＋局部3 g TXA＋ DEP 0.25 mg	静脉10 mg/kg＋局部3 g TXA	低分子肝素	Hb<70 g/L	90 d	6
魏国^[16]	2016	48	48	68.6	67	局部TXA 1 g＋ DEP 0.25 mg	局部TXA 1 g	低分子肝素	Hb<80 g/L	90 d	6
吴宏扬 ^[19]	2017	56	56	69.7	68.9	局部TXA 1 g＋ DEP 0.25 mg	局部TXA 1 g	低分子肝素	Hb<70 g/L	90 d	5
彭中鸿 ^[20]	2017	31	31	68.5	67.17	静脉TXA 10 mg/kg＋DEP 50 ml	静脉TXA 10 mg/kg	－	Hb<70 g/L	90 d	5
李海锋^[21]	2017	32	32	66.21	66.21	局部TXA 3 g＋ DEP 0.25 mg	局部TXA 3 g	－	－	1 d	4

表1 纳入研究的基本情况

作者	出版时间	样本量(例)		年龄(岁)		干预措施		血栓预防	输血标准	随访时间	改良 Jadad
作者	出版时间	TXA＋DEP组	TXA组	TXA＋DEP组	TXA组	TXA＋DEP组	TXA组	血栓预防	输血标准	随访时间	改良 Jadad
Gao et al ^[14]	2015	50	50	68.5	67.4	局部TXA 1 g ＋ DEP 0.25 mg	局部TXA 1 g	利伐沙班	Hb<80 g/L	90 d	7
Zeng et al ^[15]	2018	59	59	59.66	61.54	静脉10 mg/kg＋局部3 g TXA＋ DEP 0.25 mg	静脉10 mg/kg＋局部3 g TXA	低分子肝素	Hb<70 g/L	90 d	6
魏国^[16]	2016	48	48	68.6	67	局部TXA 1 g＋ DEP 0.25 mg	局部TXA 1 g	低分子肝素	Hb<80 g/L	90 d	6
吴宏扬 ^[19]	2017	56	56	69.7	68.9	局部TXA 1 g＋ DEP 0.25 mg	局部TXA 1 g	低分子肝素	Hb<70 g/L	90 d	5
彭中鸿 ^[20]	2017	31	31	68.5	67.17	静脉TXA 10 mg/kg＋DEP 50 ml	静脉TXA 10 mg/kg	－	Hb<70 g/L	90 d	5
李海锋^[21]	2017	32	32	66.21	66.21	局部TXA 3 g＋ DEP 0.25 mg	局部TXA 3 g	－	－	1 d	4

图1 总的失血量评估的出版偏倚

图2 总的失血量比较森林图

图3 隐性失血量比较森林图

图4 引流量比较森林图

图5 输血率比较森林图

图6 DVT(深静脉血栓)发生率比较森林图

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Combined tranexamic acid and diluted epinephrine reduces blood loss following primary total knee arthroplasty

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Combined tranexamic acid and diluted epinephrine reduces blood loss following primary total knee arthroplasty