周家強(qiáng),馬登越,孫振輝,王磊,劉軍△
全膝關(guān)節(jié)置換術(shù)后放置引流與加壓包扎對(duì)失血量的影響
周家強(qiáng)1,馬登越1,孫振輝2,王磊3,劉軍3△
目的明確全膝關(guān)節(jié)置換(TKA)術(shù)后放置引流與加壓包扎對(duì)術(shù)后失血的影響。方法回顧分析天津醫(yī)科大學(xué)總醫(yī)院濱海醫(yī)院及天津市人民醫(yī)院骨關(guān)節(jié)科2013年1月—2014年1月行初次TKA治療的內(nèi)翻型膝關(guān)節(jié)骨性關(guān)節(jié)炎患者120例(120膝),男20例,女100例,平均年齡(65.18±6.88)歲。根據(jù)是否安置引流將所有患者分為引流組(60例)和加壓包扎組(60例)。分析TKA術(shù)后血常規(guī)變化、失血量和輸血情況。結(jié)果引流組和加壓包扎組TKA術(shù)后總體失血量分別為(1 026.85±274.44)、(789.52±251.58)mL,加壓包扎組低于引流組(t=4.938,P<0.01)。術(shù)后異體輸血:引流組14例,加壓包扎組5例,加壓包扎組輸血率低于引流組(χ2=5.065,P<0.05)。2組患者術(shù)后髕上周徑差和關(guān)節(jié)活動(dòng)度比較差異均無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論TKA術(shù)中采用傷口加壓包扎手術(shù)操作簡(jiǎn)單,能夠減少患者圍手術(shù)期出血、降低異體輸血率。
關(guān)節(jié)成形術(shù),置換,膝;失血,手術(shù);負(fù)壓傷口療法;引流術(shù);全膝關(guān)節(jié)置換;加壓包扎
全膝關(guān)節(jié)置換(total knee arthroplasty,TKA)是治療膝關(guān)節(jié)晚期病變的有效方法,可極大改善患者膝關(guān)節(jié)疼痛、畸形、功能受限等情況[1]。TKA術(shù)后出血相關(guān)的貧血可導(dǎo)致膝關(guān)節(jié)局部腫脹、疼痛、身體抵抗力下降,并影響膝關(guān)節(jié)功能練習(xí),通常需要異體血輸注予以改善,并由此出現(xiàn)輸血相關(guān)并發(fā)癥[2]。目前,TKA術(shù)后處理方式多樣,如術(shù)后冰敷、局部加壓包扎、放置引流等方式[3-4],但是何種處理手段既能明顯減少術(shù)后出血、減少局部腫脹,又不影響膝關(guān)節(jié)功能康復(fù)仍無(wú)定論。為明確TKA術(shù)后放置引流及單純加壓包扎對(duì)失血量的影響,筆者對(duì)行初次TKA手術(shù)的120例患者進(jìn)行了回顧性分析,報(bào)告如下。
1.1 一般資料本研究獲得院醫(yī)學(xué)倫理委員會(huì)批準(zhǔn),所有患者術(shù)前均簽署TKA手術(shù)知情同意書(shū)。選擇天津醫(yī)科大學(xué)總醫(yī)院濱海醫(yī)院及天津人民醫(yī)院骨關(guān)節(jié)科2013年1月—2014年1月行初次TKA手術(shù)的120例患者納入本研究,男20例,女100例,年齡47~80歲,平均(65.18±6.88)歲。對(duì)所有具備手術(shù)指征的患者進(jìn)行術(shù)前檢查,除外心、肺功能不全及凝血功能障礙者,將術(shù)前血紅蛋白(Hb)≥100 g/L、凝血功能正常的患者均納入本研究。120例患者均為內(nèi)翻型膝關(guān)節(jié)骨性關(guān)節(jié)炎病例且均為單膝關(guān)節(jié)置換,采用封閉信封法將單膝置換術(shù)患者隨機(jī)分為2組:引流組(60例)和加壓包扎組(60例)。2組研究對(duì)象性別、年齡、術(shù)前膝關(guān)節(jié)活動(dòng)度(range of motion,ROM)等一般資料比較差異無(wú)統(tǒng)計(jì)學(xué)意義,見(jiàn)表1。
Tab.1Comparison of the pre-operative demographic data between the two groups表1 引流組和加壓包扎組患者術(shù)前一般資料比較(n=60)
1.2 治療情況2組患者均采用全麻或腰麻,平臥位,患肢應(yīng)用充氣止血帶,壓力300 mmHg(1 mmHg=0.133 kPa)。本研究所有TKA手術(shù)均由一名高年資醫(yī)師實(shí)施。術(shù)前30 min靜脈滴注抗生素預(yù)防感染,手術(shù)均采用膝前正中切口髕旁?xún)?nèi)側(cè)入路,部分切除髕下脂肪墊,外翻髕骨;脛骨髓外、股骨髓內(nèi)定位并截骨;采用測(cè)量截骨技術(shù)進(jìn)行股骨四合一截骨和屈伸間隙平衡;股骨髓腔開(kāi)口采用自體骨塊封閉;髕骨均未置換。所有患者均選用后穩(wěn)定型假體。
引流組在關(guān)節(jié)腔內(nèi)放置橡膠引流管外接常壓引流袋后縫合切口,傷口棉墊保護(hù),彈力繃帶加壓包扎。加壓包扎組在仔細(xì)止血后直接縫合傷口,傷口棉墊保護(hù),彈力繃帶加壓包扎。術(shù)后2組患者麻醉蘇醒后即刻開(kāi)始下肢肌肉收縮練習(xí),同時(shí)行直腿抬高和屈膝練習(xí);間斷冰敷48 h。參照中國(guó)骨科大手術(shù)靜脈血栓栓塞癥預(yù)防指南[5],術(shù)后12 h予低分子肝素鈣6 000單位臍周注射持續(xù)2周。引流組在術(shù)后48 h內(nèi)在引流量少于100 mL時(shí)拔除引流管。
1.3 觀察方法術(shù)后第5天進(jìn)行血常規(guī)檢查,Hb低于70 g/ L時(shí)進(jìn)行懸浮紅細(xì)胞輸注改善貧血。根據(jù)Nadler方程計(jì)算患者血容量[6];根據(jù)血細(xì)胞比容的變化通過(guò)Gross方程計(jì)算總失血量;術(shù)后輸血患者占各組患者的百分比為術(shù)后輸血比例;患者腫脹程度以治療前、后患肢髕上10 cm處周徑差異值(cm)表示。術(shù)后關(guān)節(jié)功能由同一主治醫(yī)師檢查判斷。
1.4 統(tǒng)計(jì)學(xué)方法采用SPSS 19.0軟件包進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料數(shù)據(jù)以均數(shù)±標(biāo)準(zhǔn)差表示,2組間比較采用獨(dú)立樣本t檢驗(yàn);計(jì)數(shù)資料組間比較采用χ2檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2組患者TKA手術(shù)操作均順利完成,圍手術(shù)期未出現(xiàn)手術(shù)相關(guān)并發(fā)癥。所有患者膝關(guān)節(jié)手術(shù)切口均Ⅰ期愈合,無(wú)脂肪液化、淺表感染、皮緣壞死等并發(fā)癥。引流組手術(shù)時(shí)間(止血帶充氣至放松)和加壓包扎組比較差異無(wú)統(tǒng)計(jì)學(xué)意義。引流組術(shù)后總體失血量大于加壓包扎組,引流組術(shù)后異體輸血率高于加壓包扎組(14/60 vs 5/60,χ2=5.065,均P<0.05)。2組患者術(shù)后髕上周徑差和ROM比較差異均無(wú)統(tǒng)計(jì)學(xué)意義,見(jiàn)表2。
Tab.2Comparison of the surgical condition and allograft blood transfusion rate between the two groups表2 2組患者手術(shù)情況、術(shù)后輸血情況比較(n=60,)
Tab.2Comparison of the surgical condition and allograft blood transfusion rate between the two groups表2 2組患者手術(shù)情況、術(shù)后輸血情況比較(n=60,)
**P<0.01
組別引流組加壓包扎組t或χ2 ROM(°)119.30±18.19 118.30±15.63 0.862手術(shù)時(shí)間(min)100.50±17.31 95.92±12.90 1.644總失血量(mL)1 026.85±274.44 789.52±251.58 4.938**髕上周徑差(cm)2.58±0.22 2.60±0.14 0.594
TKA術(shù)后常常伴有大量出血,給術(shù)后患者的體力恢復(fù)及免疫力方面帶來(lái)一定影響。同時(shí),目前血源緊張的現(xiàn)實(shí)也困擾著臨床醫(yī)生。此外TKA手術(shù)人群多為伴有不同程度心腦血管疾病的高齡患者,其耐受術(shù)后貧血的代償能力較差。TKA手術(shù)時(shí)常規(guī)使用止血帶止血,以減少術(shù)中出血及保持術(shù)野清晰,然而在使用止血帶時(shí),會(huì)使下肢組織缺氧,當(dāng)突然松開(kāi)止血帶時(shí),會(huì)導(dǎo)致血管驟然擴(kuò)張,引發(fā)機(jī)體纖溶系統(tǒng)被暫時(shí)激活,這雖能促使局部血運(yùn)通暢并減少血栓形成的風(fēng)險(xiǎn),但也增加了出血量[7]。術(shù)后常規(guī)使用抗凝藥物(低分子肝素鈣、低分子肝素鈉等)雖然有效預(yù)防下肢深靜脈血栓及肺栓塞的發(fā)生,同時(shí)也增加了失血量[8]。Jung等[9]報(bào)道的TKA術(shù)后出血量可達(dá)1 500 mL。因此,TKA圍手術(shù)期往往需要異體輸血來(lái)改善貧血、預(yù)防心腦血管并發(fā)癥。
為了減少TKA術(shù)后失血,臨床可采用術(shù)前自體血儲(chǔ)存、控制性降壓、術(shù)中和術(shù)后血液回收、微創(chuàng)手術(shù)、應(yīng)用抗纖溶藥物等方法[10]。TKA術(shù)后自體血回吸收器能夠降低異體血輸血率,避免異體血輸入引起的相關(guān)不良反應(yīng)[11-12]。Singh等[13]指出TKA術(shù)后常規(guī)引流平均血紅蛋白降低,輸血率、平均輸血量均
明顯高于自體血回輸組。然而Al-Zahid等[14]對(duì)TKA術(shù)后閉合引流、自體血回吸收和無(wú)引流進(jìn)行對(duì)比研究后發(fā)現(xiàn),3組間術(shù)后血紅蛋白降低和輸血率比較無(wú)明顯差異,推薦TKA術(shù)后無(wú)需安置自體血回吸收或閉合引流。
術(shù)后常規(guī)放置引流管可引出關(guān)節(jié)腔內(nèi)積血,減輕周?chē)浗M織張力,避免皮下血腫形成,減少術(shù)后瘢痕粘連及切口滲出[15],但卻使創(chuàng)腔內(nèi)血腫填塞作用消失,關(guān)節(jié)內(nèi)壓力下降,增加了術(shù)后的失血量。同時(shí)也可能成為細(xì)菌入侵關(guān)節(jié)腔的門(mén)戶(hù)[16]。本文加壓包扎組圍手術(shù)期總失血量較引流組明顯減少,分析原因TKA術(shù)后切口出血主要是微動(dòng)脈、微靜脈及毛細(xì)血管的滲血,其特點(diǎn)是滲血面廣泛,電凝及結(jié)扎等方法難以止血,采用壓迫止血的效果最為理想。術(shù)后未放置引流管創(chuàng)面的滲血增加了關(guān)節(jié)腔內(nèi)的壓力,閉塞了微小血管滲血的同時(shí)促進(jìn)自體凝血,減少了術(shù)后失血量??傊?,TKA術(shù)后加壓包扎方法操作簡(jiǎn)單,能夠減少患者圍手術(shù)期出血、節(jié)約用血并減少輸血傳播疾病的危險(xiǎn)性。
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(2015-04-24收稿 2015-06-10修回)
(本文編輯 李國(guó)琪)
Effect of drainge and compressive bandage dressing on blood loss after total knee arthroplasty
ZHOU Jiaqiang1,MA Dengyue1,SUN Zhenhui2,WANG Lei3,LIU Jun3△
1 Department of Orthopedics,Binhai Hospital of Tianjin Medial University,Tianjin 300480,China;2 Department of Orthopedics,Tianjin Peoples'Hospital;3 Department of Joint Orthopaedics,Tianjin Hospital△
ObjectiveTo compare the efficiency of compressive bandage dressing and drainage on the blood loss after total knee arthroplasty(TKA).MethodsPatients(n=120)who visited Tianjin General Hospital Bin Hai Branch and Tianjin People's Hospital due to varus knee osteoarthritis and underwent TKA were retrospectively analyzed.There are 20 males and 100 females with,mean age was 65.18±6.88 years.Depending on whether placement of drainage,patients were divided into drainage group(60 cases)and pressure bandage dressing group(60 cases).Blood loss,blood transfusion and full blood count(FBC)were all analyzed after TKA in both groups.ResultsBlood loss after TKA in drainage and pressure dressing group were(1 026.85±274.44),(789.52±251.58)mL respectively.Blood loss was less severe in pressure dressing group than that in drainage group(t=4.938,P<0.01).Allogeneic transfusions were needed in 14 cases of drainage group and five cases of pres?sure bandage dressing group.The circumstances that requires blood transfusion was significantly lower in pressure bandage group than that in drainage group(χ2=5.065,P<0.05).The postoperative limb swelling and postoperative joint mobility did not show statistical significance(P>0.05).ConclusionApplication of compressive bandage dressing in TKA surgery is easy to be operate and can reduce perioperative blood loss and allogeneic transfusion incidence.
arthroplasty,replacement,knee;blood loss,surgical;negative-pressure wound therapy;drainage;total knee arthroplasty;pressure dressing
R687.4
A
10.11958/j.issn.0253-9896.2015.10.029
1天津醫(yī)科大學(xué)總醫(yī)院濱海醫(yī)院骨科(郵編300480);2天津市人民醫(yī)院關(guān)節(jié)外科;3天津市天津醫(yī)院關(guān)節(jié)外科
周家強(qiáng)(1962),男,副主任醫(yī)師,主要從事骨與關(guān)節(jié)疾病研究
△通訊作者E-mail:drliujun@hotmail.com