人工全髋关节置换术后的隐性失血

自从1938年Wiles用不锈钢研制,并应用全髋关节以来,人工全髋关节置换术有了很大的发展,但是临床疗效仍然不是很令人满意。近年来,随着外科手术技术的不断发展,手术过程中的显性失血量显著减少,但隐性失血问题并未引起足够重视,患者术后血红蛋白水平急剧下降,这种血红蛋白量下降与显性失血不符的现象,即被认为是隐性失血,它     

全膝关节置换术后隐性失血危险因素的分析

目的探讨全膝关节置换术后的隐性失血量,并分析影响隐性失血的相关因素。方法收集48例行初次单侧全膝关节置换术的患者,其中女42例,男6例;年龄29～79岁,平均年龄65岁。通过Gross方程,根据患者身高、体重和手术前后的红细胞压积(Hct)计算患者的总失血量,减去显性失血量后得隐性失血量。分析年龄、性别、诊断、身高、体重、BMI、术中出血量、术后引流量、术者以及止血带时间、手术时间与隐性失血的相关性。结果术中出血量为(541±271)mL(200～1700mL),术后引流量为(479±249)mL(50～1010mL),显性出血量为(1020±327)mL(440～2 220 mL),总失血量为(1 963±734)mL(92～3 926 mL),隐性失血量为(942±692)mL(-502～2 716 mL)。因此,隐性失血占总失血的48.0%。隐性失血与身高、体重都有明显正相关,但与BMI没有明显相关性,另外,隐性失血还与术后引流量呈明显负相关。结论全膝关节置换术后隐性失血量约占总失血量的一半,应引起我们足够的重视,并且术后引流量少时更不能忽视隐性失血的存在。     

全膝关节置换术隐性失血的初步研究

目的研究人工全膝关节置换术(totalkneearthroplasty,TKA)的隐性失血。方法对73例TKA患者进行回顾性分析,通过Gross方程推算术后平均隐性失血量。结果TKA组中使用自体血回输患者的总失血量为1625ml,隐性失血量为774ml(48%);未使用自体血回输患者的总失血量是1345ml,隐性失血量是783ml(58%);实际上两组的隐性失血相差不大。结论TKA隐性失血量占总失血量的比例为52%,且使用自体血回输不能完全满足机体恢复体循环的需要,在围手术期要特别注意及时补充血容量。     

全膝关节置换术后隐性失血的研究进展

全膝关节置换术后患者血红蛋白的下降程度与观察到的出血明显不符,这是由于隐性失血存在的缘故。隐性失血影响患者伤口的愈合,增加了感染的机会,延长了康复锻炼的时间,严重影响术后疗效。因此,有效地预防隐性失血就显得格外重要。本文分析了性别、年龄、身高与体重、止血带、手术时间与手术创伤、术后抗凝、单双膝置换、自体血回输等因素对隐性失血的影响,为全膝关节置换术隐性失血的预防提供一定的帮助。     

体位对初次人工膝关节置换术后隐性失血的影响

[目的]探讨术后患肢体位对初次人工膝关节置换术后隐性失血的影响.[方法]北大人民医院骨关节中心自2012年3月～2012年5月共实施单侧初次人工全膝关节置换术60例,患者随机分为2组,每组30例.A组:术后6 h髋、膝关节均完全伸直位.B组:术后6h患肢屈髋30°、屈膝70°,计算所有患者的术后隐性失血量.[结果]A组术后平均隐性失血量为(480.23±57.64) ml,占总失血量的48.3％.B组术后平均隐性失血量为(315.23±56.32) ml,占总失血量的31.4％.两组之间比较,P＜0.05,差异有统计学意义.[结论]术后体位不同可以明显影响全膝关节置换术后的隐性失血量,术后6h患肢屈髋30°、屈膝70°位可有效减少关节置换术后的引流量,有助于术后康复.     

隐性失血对双侧人工全膝关节同期置换手术的影响

[目的]研究双侧人工全膝关节同期置换术术后隐性失血的相关因素。[方法]对2005年2月～2007年2月44例双侧人工全膝关节同期置换术患者进行回顾性分析，通过Gross方程，根据身高、体重及手术前后的红细胞压积推算术后平均显性失血量及平均隐性失血量。[结果]平均总失血量2065ml，其中显性失血量1198ml，隐性失血量867ml，使用自体血回输患者总失血量为2180ml，隐性失血量为937ml（42％）；未使用自体血回输患者的总失血量是1950ml，隐性失血量是799ml（41％）；两组的隐性失血相比差异无统计学意义。[结论]双侧人工全膝关节同期置换术术后隐性失血量占总失血量的比例较高，且使用自体血回输不能完全满足机体恢复体循环的需要，在围手术期要特别注意及时补充血容量。     

全膝关节置换术围手术期隐性失血的危险因素研究

目的探讨影响人工全膝关节置换术（TKA）术后隐性失血的危险因素及发生机制。方法选取2008年5月至2011年5月136位患者192例TKA,患者平均年龄67．5岁,其中单侧膝关节置换80例,双膝关节同期置换56例,同组医师采用同种术式完成,术后24h补液总量不超过2000ml。利用Gross方程,计算患者的术后总失血量,隐性失血量以及血红蛋白降低情况,记录年龄、性别、术侧、BMI、输血等危险因素,通过SPSS13．0进行统计学分析,比较各组之间隐性失血量有无差别,分析影响TKA围手术期隐性失血的危险因素。结果单侧TKA总失血量1650ml,隐性失血830ml;双膝同期置换者总失血量2864ml,隐性失血1487ml。无论是单侧还是双侧TKA,男性及应用自体血回输患者的围手术期失血量多于对照组（P〈0．01）,双膝同期置换隐性失血量比例较大（X^2=6．836,P〈0．01）,高龄肥胖患者隐性失血量明显多于对照组（单膝）X^2=21．587,P〈0．01,双膝X^2=29．233,P〈0．01）。结论TKA术后失血量较高,其中隐性失血比例占50％以上。男性双膝同期置换的患者,年龄〉70且BMI〉27．0,使用自体血回输均是增加围手术期隐性失血的危险因素。     

髋膝关节置换及髋部骨折内固定术后隐性失血

老年人髋膝部手术显性失血明显减少,但大量隐性失血依然存在,隐性失血是髋膝关节置换术与髋部骨折内固定术后贫血的主要原因.目前认为创伤和手术引起的红细胞进入组织间隙和积留在关节腔内,溶血以及其他途径所致血细胞丢失是造成隐性失血的重要因素.隐性失血量与病人年龄、性别、体重、基础疾病、骨折类型、止血带、手术部位和手术方案等有关...     

髋膝关节置换及髋部骨折内固定术后隐性失血

老年人髋膝部手术显性失血明显减少,但大量隐性失血依然存在,隐性失血是髋膝关节置换术与髋部骨折内固定术后贫血的主要原因。目前认为创伤和手术引起的红细胞进入组织间隙和积留在关节腔内,溶血以及其他途径所致血细胞丢失是造成隐性失血的重要因素。隐性失血量与病人年龄、性别、体重、基础疾病、骨折类型、止血带、手术部位和手术方案等有关,根据这些临床资料综合评估隐性失血量对术后贫血的防治有重要意义。该文就髋膝部手术隐性失血机制、隐性失血量及其影响因素、隐性失血预防和治疗等作一综述,以提高对隐性失血的认识,使髋膝部手术达到更佳治疗效果。     

初次全膝关节置换术后肢体肿胀程度与隐性失血量的相关性研究

[目的]膝关节置换术后下肢肢体肿胀是术后常见现象,隐性失血为其可能的原因之一.本研究旨在分析初次全膝关节置换术后隐性失血对肢体肿胀程度的影响.[方法]对2007年10月～2009年8月接受全膝关节置换术的286例患者进行回顾性分析,按照术后有无下肢深静脉血栓形成分为血栓组(65例)和无血栓组(221例),通过围手术期血红蛋白变化值来推算隐性失血量(Hbl),还计算出术后第2～5 d的术侧下肢膝上10 cm及膝下10 cm周径较术前相比周径增加的平均值D-up及D-down.[结果]在无血栓组,隐性失血量对术侧下肢膝上膝下肢体周径变化均造成影响,具有统计学意义(P＜0.001),分别建立线性回归方程,在血栓组,隐性失血量对术侧下肢膝上膝下肢体周径变化影响不大,两者Pearson相关分析不具有统汁学意义(P=0.110,P=0.066),有无血栓组间经两独立样本t检验,发现两组间D-up、D-down和Hhl的差异均没有统计学意义,P值分别为0.334,0.156,0.180.[结论]初次全膝关节置换术后,特别是3～5 d内,应持续关注患者血色素的变化,隐性失血量与下肢的肿胀程度呈相关性,在一定程度上形成并加重了肢体肿胀.TKA术后下肢肌间静脉丛血栓形成对远端肢体肿胀程度影响不大,考虑后者主要还是与隐性失血有关.     

Hidden blood loss after total hip arthroplasty

A prospective study was carried out to analyze the characteristics of hidden blood loss after total hip arthroplasty (THA) in a series of 1232 patients. The method of deducting the observed perioperative blood loss from the calculated total blood loss based on hematocrit changes was used to calculate the hidden blood loss of each patient. The reinfused and transfused bloods were also considered. We found that the amount of hidden blood loss after THA was much larger than we observed perioperatively and significantly different between differently diagnosed patients. We concluded that THA can cause a large amount of hidden blood loss, which should be monitored carefully. Retaining and repairing the articular capsule is recommended during the operation, which can significantly decrease hidden blood loss.     

Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement

Background. Total knee arthroplasty (TKA) is often carried outusing a tourniquet and shed blood is collected in drains. Tranexamicacid decreases the external blood loss. Some blood loss maybe concealed, and the overall effect of tranexamic acid on thehaemoglobin (Hb) balance is not known. Methods. Patients with osteoarthrosis had unilateral cementedTKA using spinal anaesthesia. In a double-blind fashion, theyreceived either placebo (n=24) or tranexamic acid 10 mg kg^–1(n=27) i.v. just before tourniquet release and 3 h later. Thedecrease in circulating Hb on the fifth day after surgery, aftercorrection for Hb transfused, was used to calculate the lossof Hb in grams. This value was then expressed as ml of bloodloss. Results. The groups had similar characteristics. The medianvolume of drainage fluid after placebo was 845 (interquartilerange 523–990) ml and after tranexamic acid was 385 (331–586)ml (P<0.001). Placebo patients received 2 (0–2) unitsand tranexamic acid patients 0 (0–0) units of packed redcells (P<0.001). The estimated blood loss was 1426 (1135–1977)ml and 1045 (792–1292) ml, respectively (P<0.001).The hidden loss of blood (calculated as loss minus drainagevolume) was 618 (330–1347) ml and 524 (330–9620)ml, respectively (P=0.41). Two patients in each group developeddeep vein thrombosis. Conclusions. Tranexamic acid decreased total blood loss by nearly30%, drainage volume by     

不同止血带使用方法对TKA围手术期失血量影响的临床研究

目的研究人工全膝关节置换术（TKA）中两种不同止血带使用方法对围手术失血总量的影响。方法选取2009年1月至2010年6月60例60～75岁单侧TKA患者进行研究,随机分成A组（30例,术中采用截骨完成后使用止血带至手术结束）和B组（30例,术中采用全程在止血带下完成手术）,所有手术均由同一组医师完成,比较A、B两组患者围手术期总失血量、显性出血量、隐性失血量、输血比例、输血量及手术时间的差异。结果 A组在显性失血量、手术时间较B组明显增加,差异有统计学意义（P〈0.05）;而在围手术期总失血量、隐性失血量、输血比例、输血量A组较B组明显减少,差异有统计学意义（P〈0.05）。结论在TKA手术当中截骨完成后开始使用止血带的方法,是一种能够明显减少围手术期总失血量、降低输血比例及输血量的新手术方式,同时减少了手术后并发症的发生率。     

Comparision of blood loss between computer assisted and conventional total knee arthroplasty

Background:

Bleeding during total knee arthroplasty (TKA) can cause significant morbidity and mortality. One proposed benefit of computer assisted TKA is decreased bleeding as the femoral canal is not invaded. This study assessed blood loss between computer assisted surgery (CAS) and conventional TKA.

Materials and Methods:

73 consecutive patients (37 males, 36 females) underwent primary TKA between 2006 and 2009. Thirty eight patients underwent navigated TKA and 35 underwent conventional TKA for symptomatic osteoarthritis of the knee. These patients were matched for age, gender, and body mass index (BMI). Average age was 70.3 years (range 47-91 years). Mean BMI was 30 (range 17-49). Average preoperative hemoglobin was 13.26 g/dL (range 8.7-18.4 g/dL) in the navigated group and 13.47 g/dL (range 9.6-15.8 g/dL) in the conventional group (P = 0.9). Average tourniquet time was 110 min (range 90-150 min) in the navigated group and 96.7 min (range 60-145 min) in the conventional group (P = 0.77).

Results:

Average postoperative hemoglobin in the navigated group was 10.34 g/dL (range 7.5-14.8 g/dL) and in the conventional group was 10.03 g/dL (range 7.5-12.2 g/dL) (P = 0.17). Six patients in both groups required blood transfusions. The mean drain collection was 599 mL (range 150-1370 mL) in the navigated group and 562 mL (range 750-1000 mL) in the conventional group (P = 0.1724). These results suggest that there is no significant reduction in blood loss in CAS TKA.

Conclusion:

These results suggest that there is no significant difference in blood loss in CAS TKA and conventional TKA. This study also highlights the heterogeneity of methods used in studies related to CAS TKA. We believe that there is a need for a large multicenter prospective randomized controlled trial to be performed before a consensus can be reached on the influence of CAS techniques on blood loss during primary TKA.     

全膝关节置换术中氨甲环酸局部不同给药方式控制术后出血的效果评价

目的 前瞻性研究初次全膝关节置换术（total knee arthroplasty,TKA）中,氨甲环酸（Tranexamic Acid,TXA）注射液局部不同给药方式对术后出血的控制情况。 方法 前瞻性观察2012年4月至2014年11月间行单侧初次TKA的患者共计80例,年龄55-78岁,随机等分为两组：试验组和对照组,各40例,术中两组采取两种不同的局部给药方式：试验组行TXA关节周围注射,对照组行传统关节腔灌洗处理。观察两组TKA术后术腔引流量的差异性,对比两组术后24h血红蛋白（hemoglobin,Hb）和红细胞比容（hematocrit,HCT）指标有无差异。 结果 两组术前Hb及HCT无明显差异（P>0.05）,两组术后术腔引流量有明显统计学差异（P<0.05）,术后24h复查结果对比有明显差异（P<0.05）。 结论 TKA术中TXA关节周围注射的止血效果优于关节腔灌洗的局部给药方式。     

Assessment of perioperative total blood loss during total ankle arthroplasty

BackgroundAlthough many authors have discussed total blood loss after arthroplasty of the knee, hip, and shoulder, reports on perioperative blood loss after total ankle arthroplasty (TAA) are rare. The purpose of this study was to assess total blood loss after TAA and to identify correlated factors.MethodsA total of 103 cases (99 patients) of TAA for end-stage ankle osteoarthritis were enrolled in this study. Perioperative total blood loss was divided into intraoperative and postoperative blood loss. The patient-related variables evaluated for total blood loss were age, sex, body mass index, American Society of Anesthesiologists Classification score, comorbidities, history of previous ankle surgery, preoperative use of anticoagulants, platelet count and prothrombin time/international normalized ratio. Operation-related variables including type of anesthesia, operation time, TAA implant, and procedures performed in addition to TAA (if any) were evaluated to analyze correlations with total blood loss. In addition, the rate of transfusions after surgery was identified, and risk factors for transfusion were statistically analyzed.ResultsThe total blood loss was mean 795.5 ± 351.1 mL, which included 462.2 ± 248.5 mL of intraoperative blood loss and 333.2 ± 228.6 mL of postoperative blood loss. Sex, TAA implant, and additional bony procedures performed along with TAA were significantly correlated with total blood loss (p = 0.039, 0.024, 0.024, respectively) but the other variables were not significant (p > 0.05). Transfusions were administered for 4 cases (3.8%) but no risk factors for transfusion could be identified.ConclusionThe total blood loss after TAA was 795.5 mL and the rate of transfusions was 3.8%. This study demonstrated that male sex, use of TAA implants with a larger cutting surface, and bony procedures performed in addition to TAA were associated with an increase in total blood loss after TAA. The findings of this study will help surgeons to better predict blood loss and make optimal surgical plans accordingly.Level of evidenceLevel IV, retrospective case series.     

Perioperative blood loss in cementless or hybrid total knee arthroplasty without patellar resurfacing: a prospective, randomized study

The use of cement is considered as an important way to control perioperative blood loss in knee arthroplasty. We prospectively randomized 57 patients (60 knees) who underwent total knee arthroplasty with (30 knees) or without (30 knees) tibial cement to evaluate perioperative blood loss. The measured total blood loss did not differ significantly between the 2 groups (with tibial cement, 731 +/- 288 mL; without cement, 731 +/- 331 mL; P = .9117). The red blood cell count, hemoglobin level, and hematocrit returned to the preoperative levels within 3 months in both groups. Therefore, tibial cement does not appear to affect perioperative blood loss. This finding has implications when planning blood replacement in cementless and hybrid-type arthroplasties.