• 北京大學第三醫(yī)院骨科（北京，100191）;

目的?人工全膝關節(jié)置換術（total knee arthroplasty，TKA）后使用抗凝藥物可預防下肢深靜脈血栓形成，但可能造成圍手術期失血量增加。通過與TKA術后使用阿司匹林患者進行比較，分析低分子肝素對初次TKA術后隱性失血及輸血率的影響。?方法?回顧性分析2007年10月－2009年8月初次行TKA的286例患者臨床資料，其中166例（試驗組）術后8～12 h開始每天給予低分子肝素4 000～ 6 000 U，120例（對照組）每天給予阿司匹林150 mg，共14 d。試驗組：男27例，女139例；年齡22～82歲，平均66.1歲。體重指數（body mass index，BMI）為26.79 ± 3.87。左膝99例，右膝67例。病程1.8～8.6年，平均4.1年。對照組：男21例，女99例；年齡40～84歲，平均64.9歲。BMI為27.87 ± 3.62。左膝78例，右膝42例。病程1.5～8.2年，平均4.9年。兩組患者性別、年齡、病程等一般資料比較，差異均無統(tǒng)計學意義（P  gt; 0.05），具有可比性。?結果?兩組患者術后切口均Ⅰ期愈合。術后65例出現(xiàn)下肢深靜脈血栓形成，其中試驗組37例，對照組28例，經對癥處理后治愈。術后患者均獲隨訪，隨訪時間12～34個月，平均21.6個月。末次隨訪時，兩組膝關節(jié)功能美國特種外科醫(yī)院（HSS）評分與術前比較，差異均有統(tǒng)計學意義（P  lt; 0.05），兩組間比較差異無統(tǒng)計學意義（P  gt; 0.05）。試驗組和對照組隱性失血量分別為（40.55 ± 37.75）、（32.52 ± 40.13）g/L，差異有統(tǒng)計學意義（t=3.387，P=0.001）；顯性失血量分別為（24.08 ± 14.63）、（27.91 ± 18.47）g/L，差異無統(tǒng)計學意義（t= —1.899，P=0.059）。術后試驗組輸血率為40.4%（67/166），對照組為30.0%（36/120），差異無統(tǒng)計學意義（χ2=2.771，P=0.081）。試驗組和對照組術后輸血量分別為（1.44 ±4.03）、（0.97 ± 3.50）U，差異有統(tǒng)計學意義（t=2.071，P=0.039）。?結論? 初次TKA術后應用低分子肝素將影響患者 隱性失血，增加了術后失血量及輸血率，需在抗凝治療的同時密切關注血紅蛋白變化，及時補充血容 量。

引用本文： 高福強,李子劍,張克,劉延青,田華,劉巖,劉忠軍. 低分子肝素對初次人工全膝關節(jié)置換術后隱性失血與輸血率的影響. 中國修復重建外科雜志, 2011, 25(4): 393-396. doi: 復制

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1. Bell TH, Berta D, Ralley F, et al. Factors affecting perioperative blood loss and transfusion rates in primary total joint arthroplasty: a prospective analysis of 1642 patients. Can J Surg, 2009, 52(4): 295-301.
2. Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest, 2003, 124(6 Suppl): 379S-385S.
3. Colwell CW Jr. Low molecular weight heparin prophylaxis in total knee arthroplasty: the answer. Clin Orthop Relat Res, 2001, (392): 245-248.
4. Lotke PA. The role of aspirin for thromboembolic disease in total joint arthroplasty. Am J Knee Surg, 1999, 12(1): 61-63.
5. Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res, 2006, (452): 175-180.
6. Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty. Pneumatic plantar compression and aspirin compared with aspirin alone. J Bone Joint Surg (Am), 1996, 78(6): 826-834.
7. Bozic KJ, Vail TP, Pekow PS, et al. Does Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty, 2010, 25(7): 1053-1060.
8. Schnurr C, Csécsei G, Eysel P, et al. The effect of computer navigation on blood loss and transfusion rate in TKA. Orthopedics, 2010, 33(7): 474.
9. Muñoz M, García-Vallejo JJ, Ruiz MD, et al. Transfusion of post-operative shed blood: laboratory characteristics and clinical utility. Eur Spine J, 2004, 13 Suppl 1: S107-113.
10. Southern EP, Huo MH, Mehta JR, et al. Unwashed wound drainage blood. What are we giving our patients? Clin Orthop Relat Res, 1995, (320): 235-246.
11. 王效東, 黃小強, 鞏四海, 等. 低分子肝素對關節(jié)置換術后出血量的影響. 陜西醫(yī)學雜志, 2007, 36(3): 351-352.
12. 邱貴興, 楊慶銘, 余楠生, 等. 低分子肝素預防髖、膝關節(jié)手術后下肢深靜脈血栓形成的多中心研究. 中華骨科雜志, 2006, 26(12): 819-822.
13. 李曉林, 盧偉杰, 余楠生, 等. 低分子肝素預防髖膝關節(jié)術后下肢深靜脈血栓形成. 中國修復重建外科雜志, 2001, 15(1): 39-41.
14. Horloeker TT. Low molecular weight heparin and neuraxial anesthesia. Thromb Res, 2001, 101(1): V141-154.
15. 馬衛(wèi)華, 張樹棟, 慕宏杰, 等. 低分子肝素使用時機對關節(jié)置換手術失血量和DVT發(fā)生率的影響. 中華骨科雜志, 2008, 28(10): 833-837.
16. Francis CW, Pellegrini VD Jr, Totterman S, et al. Prevention of deep-vein thrombosis after total hip arthroplasty. Comparison of warfarin and dalteparin. J Bone Joint Surg (Am), 1997, 79(9): 1365-1372.
17. Stern SH, Wixson RL, O’Connor D. Evaluation of the safety and efficacy of enoxaparin and warfarin for prevention of deep vein thrombosis after total knee arthroplasty. J Arthroplasty, 2000, 15(2): 153-158.
18. Pagnano M, Cushner FD, Hansen A, et al. Blood management in two-stage revision knee arthroplasty for deep prosthetic infection. Clin Orthop Relat Res, 1999, (367): 238-242.
19. Juelsgaard P, Larsen UT, Sorensen JV, et al. Hypotensive epidural anesthesia in total knee replacement without tourniquet: reduced blood loss and transfusion. Reg Anesth Pain Med, 2001, 26(2): 105-110.
  1. 1. Bell TH, Berta D, Ralley F, et al. Factors affecting perioperative blood loss and transfusion rates in primary total joint arthroplasty: a prospective analysis of 1642 patients. Can J Surg, 2009, 52(4): 295-301.
  2. 2. Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest, 2003, 124(6 Suppl): 379S-385S.
  3. 3. Colwell CW Jr. Low molecular weight heparin prophylaxis in total knee arthroplasty: the answer. Clin Orthop Relat Res, 2001, (392): 245-248.
  4. 4. Lotke PA. The role of aspirin for thromboembolic disease in total joint arthroplasty. Am J Knee Surg, 1999, 12(1): 61-63.
  5. 5. Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res, 2006, (452): 175-180.
  6. 6. Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty. Pneumatic plantar compression and aspirin compared with aspirin alone. J Bone Joint Surg (Am), 1996, 78(6): 826-834.
  7. 7. Bozic KJ, Vail TP, Pekow PS, et al. Does Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty, 2010, 25(7): 1053-1060.
  8. 8. Schnurr C, Csécsei G, Eysel P, et al. The effect of computer navigation on blood loss and transfusion rate in TKA. Orthopedics, 2010, 33(7): 474.
  9. 9. Muñoz M, García-Vallejo JJ, Ruiz MD, et al. Transfusion of post-operative shed blood: laboratory characteristics and clinical utility. Eur Spine J, 2004, 13 Suppl 1: S107-113.
  10. 10. Southern EP, Huo MH, Mehta JR, et al. Unwashed wound drainage blood. What are we giving our patients? Clin Orthop Relat Res, 1995, (320): 235-246.
  11. 11. 王效東, 黃小強, 鞏四海, 等. 低分子肝素對關節(jié)置換術后出血量的影響. 陜西醫(yī)學雜志, 2007, 36(3): 351-352.
  12. 12. 邱貴興, 楊慶銘, 余楠生, 等. 低分子肝素預防髖、膝關節(jié)手術后下肢深靜脈血栓形成的多中心研究. 中華骨科雜志, 2006, 26(12): 819-822.
  13. 13. 李曉林, 盧偉杰, 余楠生, 等. 低分子肝素預防髖膝關節(jié)術后下肢深靜脈血栓形成. 中國修復重建外科雜志, 2001, 15(1): 39-41.
  14. 14. Horloeker TT. Low molecular weight heparin and neuraxial anesthesia. Thromb Res, 2001, 101(1): V141-154.
  15. 15. 馬衛(wèi)華, 張樹棟, 慕宏杰, 等. 低分子肝素使用時機對關節(jié)置換手術失血量和DVT發(fā)生率的影響. 中華骨科雜志, 2008, 28(10): 833-837.
  16. 16. Francis CW, Pellegrini VD Jr, Totterman S, et al. Prevention of deep-vein thrombosis after total hip arthroplasty. Comparison of warfarin and dalteparin. J Bone Joint Surg (Am), 1997, 79(9): 1365-1372.
  17. 17. Stern SH, Wixson RL, O’Connor D. Evaluation of the safety and efficacy of enoxaparin and warfarin for prevention of deep vein thrombosis after total knee arthroplasty. J Arthroplasty, 2000, 15(2): 153-158.
  18. 18. Pagnano M, Cushner FD, Hansen A, et al. Blood management in two-stage revision knee arthroplasty for deep prosthetic infection. Clin Orthop Relat Res, 1999, (367): 238-242.
  19. 19. Juelsgaard P, Larsen UT, Sorensen JV, et al. Hypotensive epidural anesthesia in total knee replacement without tourniquet: reduced blood loss and transfusion. Reg Anesth Pain Med, 2001, 26(2): 105-110.