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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2021, Vol. 15 ›› Issue (04) : 404 -410. doi: 10.3877/cma.j.issn.1674-134X.2021.04.003

临床论著

止血带对全膝关节置换术后凝血状态的血栓弹力图评估
黄超然1, 郭开今1, 吴继彬1, 潘盛1, 阮如昕1, 庞勇1, 张星晨1, 郑欣1,†()   
  1. 1. 221006　徐州医科大学附属医院骨科
  • 收稿日期:2020-11-08 出版日期:2021-09-29
  • 通信作者: 郑欣
  • 基金资助:
    国家自然科学基金项目(81902244); 江苏省卫生计生委面上项目(H201528); 徐州市科技局项目(KC19063，KC16SH095)

Thrombelastographic analysis of effects of tourniquets on postoperative coagulation status in total knee arthroplasty

Chaoran Huang1, Kaijin Guo1, Jibin Wu1, Sheng Pan1, Ruxin Ruan1, Yong Pang1, Xingchen Zhang1, Xin Zheng1,†()   

  1. 1. Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221006, China
  • Received:2020-11-08 Published:2021-09-29
  • Corresponding author: Xin Zheng
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引用本文：

黄超然, 郭开今, 吴继彬, 潘盛, 阮如昕, 庞勇, 张星晨, 郑欣. 止血带对全膝关节置换术后凝血状态的血栓弹力图评估[J]. 中华关节外科杂志(电子版), 2021, 15(04): 404-410.

Chaoran Huang, Kaijin Guo, Jibin Wu, Sheng Pan, Ruxin Ruan, Yong Pang, Xingchen Zhang, Xin Zheng. Thrombelastographic analysis of effects of tourniquets on postoperative coagulation status in total knee arthroplasty[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2021, 15(04): 404-410.

目的

通过血栓弹力图(TEG)评估止血带应用与否对全膝关节置换术(TKA)后早期凝血状态的影响。

方法

纳入徐州医科大学附属医院骨科2019年1月至2020年5月拟行初次单侧TKA的160例膝关节骨关节炎患者；排除合并严重内科疾病、既往血栓病史或术前下肢动静脉彩超示DVT阳性、术前凝血功能异常或存在抗凝禁忌、围术期输注凝血因子或血小板的患者。随机分成止血带组和无止血带组，每组80例。分别于术前和术后7 d检查下肢动静脉彩超，术前、术后1 d和术后7 d检测常规凝血指标和TEG，对比两组患者的总失血量、血栓发生情况及常规凝血指标和TEG参数变化。输血率、静脉血栓发生情况等，使用卡方检验；常规凝血指标如纤维蛋白降解产物(FDP)和凝血酶时间(TT)及TEG各值如凝血反应时间(R)、血块形成时间(K)、凝固角(Alpha)、最大振幅(MA)、凝血指数(CI)比较使用t检验，不同时间点的参数比较使用重复测量方差分析。

结果

通过Gross方程计算患者的预计总失血量，得出止血带组总失血量(1 036±238)ml大于无止血带组(852±220)ml (t ＝4.713，P<0.001)。两组输血率和血栓发生率差异无统计学意义(χ2＝0.538，0.132，P>0.05)。止血带组内不同时间点FDP、D-二聚体和TEG的R、MA和CI差异均有统计学意义，无止血带组内不同时间点FDP、D-二聚体、K、Alpha和CI差异均有统计学意义(均为P<0.05)，术后7 d止血带组TT显著低于无止血带组(F＝15.818，P<0.05)，FDP和D-二聚体高于无止血带组(F＝18.795、U＝1 314，均为P<0.05)。术后7 d止血带组R低于无止血带组(F＝4.438)，MA(F＝87.088)和CI(F＝5.282)显著高于无止血带组(均为P<0.05)。

结论

在TKA术中，全程使用止血带不影响输血率和血栓发生率，但会增加预计总失血量，并且加剧术后早期血液高凝状态。

关键词: 血栓弹力描记术, 止血带, 关节成形术, 置换, 膝, 血栓形成倾向
Objective

To investigate the influence of tourniquets on the earlypostoperative coagulation status in total knee arthroplasty (TKA) evaluated by thrombelastography (TEG).

Methods

From January 2019 to May 2020, 160 patients with knee osteoarthritis undergoing primary unilateral TKA in Department of Orthopaedics of the Affiliated Hospital of Xuzhou Medical University were randomly assigned to the tourniquet group and the non-tourniquet group with 80 patients in each group. The patients with serious medical comorbidities, history of thrombosis, positive ultrasound results for preoperative DVT, preoperative coagulant function abnormality, anticoagulant therapy contraindications and perioperative transfusion of blood coagulation factors or platelets were excluded. Lower extremity doppler ultrasonography was performed before operation and seven days after the operation, conventional coagulation tests and TEG were performed before operation, one day after operation and seven days after operation. The calculated blood loss, the occurrence of venous thrombosis, the parameters of conventional coagulation tests and TEG were compared between the two groups. The chi-square test was used to compared the transfusion rate and the incidence of thrombosis, etc. The conventional coagulation test and TEG variables, including fibrin degradation products (FDP), thrombin time(TT), reaction time (R), clotting time (K), α-angle (alpha), maximum amplitude (MA), coagulation index (CI), between the two groups were analyzed by t test, and repeated measurement analysis of variance was used for comparison at different time points.

Results

The tourniquet group had significant higher blood loss [(1 036±238)ml vs. (852±220)ml, t=4.713, P<0.001], which were calculated by the Formula of Gross. There was no statistically significant difference in the transfusion rate and the incidence of thrombosis between the two groups (χ2=0.538, 0.132, both P>0.05). There was a significant difference in terms of FDP, D-dimer, R, MA and CI among the three time points in the tourniquet group, while in the non-tourniquet group, statistically significant differences were observed with regard to FDP, D-dimer, K, Alpha and CI(all P<0.05). At seven days after operation, the level of TT in the tourniquet group was lower than that of the non-tourniquet group(F=15.818, P<0.05), and the levels of FDP and D-dimer of the tourniquet group were higher than those of the non-tourniquet (F=18.795, U=1 314, both P<0.05). At seven days after operation, with regard to TEG, R value of the tourniquet group was significantly lower than that of the non-tourniquet group(F=4.438), whereas MA(F=87.088) and CI(F=5.282)in the tourniquet group was significantly higher than those in the non-tourniquet group (both P<0.05).

Conclusion

The use of a tourniquet during the whole TKA does not affect the transfusion rate and the incidence of thrombosis, but it may increase calculated total blood loss, and exacerbate the early postoperative blood hypercoagulability.

Key words: Thrombelastography, Tourniquets, Arthroplasty, replacement, knee, Thrombophilia
表1 两组患者一般资料比较
组别 例数 性别(男/女) 年龄[岁，(±s)] 身体质量指数[kg/m2, (±s)] 合并高血压(有/无) 合并糖尿病(有/无)
止血带组 80 20/60 67±6 26±4 14/66 7/73
无止血带组 80 23/57 66±5 26±3 18/62 5/75
统计值   χ2＝0.286 t＝0.973 t＝1.251 χ2＝0.625 χ2＝0.360
P值   >0.05 >0.05 >0.05 >0.05 >0.05
表2 两组患者手术时间、失血量、输血率及血栓发生率比较
组别 手术时间[min, (±s)] 预计总失血量[ml, (±s)] 围术期输血率[例(%)] 血栓发生率[例(%)]
止血带组 77±14 1036±238 11/80(14) 5/80(6)
无止血带组 82±14 852±220 8/80(10) 3/80(4)
统计值 t＝-1.782 t＝4.713 χ2＝0.538 χ2＝0.132
P值 >0.05 <0.001 >0.05 >0.05
表3 两组多个时间点传统凝血指标比较
分组 例数 APTT[s，(±s)] F值 P值
术前 术后1 d 术后7 d
止血带组 80 28.9±3.5 28.3±5.6 27.8±4.0 1.116 >0.05
无止血带组 80 28.1±3.3 32.5±6.0 29.1±3.9 20.389 <0.001
F值   1.711 22.299 4.886    
P值   >0.05 <0.001 0.030    
分组 例数 PT[s，(±s)] F值 P值
术前 术后1 d 术后7 d
止血带组 80 10.9±0.6 11.6±1.4 11.5±1.1 10.556 <0.001
无止血带组 80 10.7±0.7 12.0±1.5 11.8±1.0 45.469 <0.001
F值   2.877 3.934 2.276    
P值   >0.05 >0.05 >0.05    
分组 例数 TT[s，(±s)] F值 P值
术前 术后1 d 术后7 d
止血带组 80 17.6±1.6 15.7±1.4 15.2±1.3 66.710 <0.001
无止血带组 80 17.3±1.4 16.1±1.3 15.9±1.4 27.747 <0.001
F值   1.895 5.736 15.818    
P值   >0.05 0.019 <0.001    
指标 例数 FDP[mg/L，(±s)] F值 P值
术前 术后1 d 术后7 d
止血带组 80 3.4±4.0 15.9±12.9 15.0±6.3 56.491 <0.001
无止血带组 80 3.2±3.1 12.5±10.2 10.9±5.3 45.933 <0.001
F值   0.080 3.352 18.795    
P值   >0.05 >0.05 <0.001    
分组 例数 DD[ng/ml, M(P25，P75)] H值 P值
术前 术后1 d 术后7 d
止血带组 80 0.4(0.3, 0.8) 3.4(2.4, 5.7) 4.2(3.0, 6.0) 125.177 <0.001
无止血带组 80 0.5(0.3, 0.9) 2.8(1.4, 3.9) 2.3(1.5, 3.5) 105.550 <0.001
U值   2 195.5 2 309 1 314    
P值   >0.05 <0.01 <0.001    
表4 两组多个时间点TEG参数比较(±s)
分组 例数 R(min) F值 P值
术前 术后1 d 术后7 d
止血带组 80 5.2±1.1 4.4±1.1 4.9±1.4 8.704 <0.001
无止血带组 80 5.0±1.1 5.3±1.2 5.3±1.0 2.519 >0.05
F值   1.805 25.578 4.438    
P值   >0.05 <0.001 0.038    
分组 例数 K(min) F值 P值
术前 术后1 d 术后7 d
止血带组 80 2.1±1.1 1.8±1.0 1.9±1.4 1.884 >0.05
无止血带组 80 2.5±1.6 2.7±1.4 1.7±0.9 14.904 <0.001
F值   2.143 21.721 2.238    
P值   >0.05 <0.001 >0.05    
分组 例数 Alpha(°) F值 P值
术前 术后1 d 术后7 d
止血带组 80 60.3±10.9 66.4±9.4 65.1±9.1 9.839 <0.001
无止血带组 80 58.3±10.0 61.2±10.3 65.4±11.1 10.331 <0.001
F值   1.609 10.824 0.053    
P值   >0.05 0.001 >0.05    
分组 例数 MA(mm) F值 P值
术前 术后1 d 术后7 d
止血带组 80 57.2±6.6 56.1±7.3 68.6±7.0 75.956 <0.001
无止血带组 80 55.0±9.9 56.5±8.6 56.8±9.4 1.016 >0.05
F值   3.343 0.071 87.088    
P值   >0.05 >0.05 <0.001    
分组 例数 CI F值 P值
术前 术后1 d 术后7 d
止血带组 80 -0.7±2.2 -1.0±2.9 1.0±2.1 21.561 <0.001
无止血带组 80 -0.6±2.8 0.6±2.1 0.2±2.8 4.525 0.014
F值   0.131 15.566 5.282    
P值   >0.05 <0.001 0.024    
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