Objective: To evaluate the effectiveness and safety of tranexamic acid (TXA) combined with intraoperative controlled hypotension (ICH) for reducing perioperative blood loss in primary total hip arthroplasty (THA).
Methods: The clinical data of 832 patients with initial THA due to osteonecrosis of femoral head between January 2017 and July 2020 were retrospectively analyzed. All patients received TXA treatment, and 439 patients (hypotension group) received ICH treatment with an intraoperative mean arterial pressure (MAP) below 80 mm Hg (1 mm Hg=0.133 kPa) while 393 patients (normotension group) received standard general anesthesia with no special invention on blood pressure. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists (ASA) classification, basic arterial pressure, hip range of motion, internal diseases, preoperative hemoglobin (HB) and hematocrit (HCT), coagulation function, surgical approach, and TXA dosage between the two groups ( P>0.05). The perioperative blood loss and blood transfusion, anesthesia and operation time, hospitalization stay, postoperative range of motion, and complications were recorded and compared between the two groups. The patients were further divided into MAP<70 mm Hg group (group A), MAP 70-80 mm Hg group (group B), and normotension group (group C). The perioperative blood loss and postoperative complications were further analyzed to screen the best range of blood pressure.
Results: The intraoperative MAP, total blood loss, dominant blood loss, recessive blood loss, blood transfusion rate and blood transfusion volume, anesthesia time, operation time, and hospitalizarion stay in the hypotension group were significantly lower than those in the normotension group ( P<0.05). The postoperative hip flexion range of motion in the hypotension group was significantly better than that of the normotension group ( Z=2.743, P=0.006), but there was no significant difference in the abduction range of motion between the two groups ( Z=0.338, P=0.735). In terms of postoperative complications, the incidence of postoperative hypotension in the hypotension group was significantly higher than that in the normotension group ( χ 2=6.096, P=0.014), and there was no significant difference in the incidence of other complications ( P>0.05). There was no stroke, pulmonary embolism, or deep vein thrombosis in the two groups, and no patients died during hospitalization. Subgroup analysis showed that there was no significant difference in total blood loss, dominant blood loss, and recessive blood loss in groups A and B during the perioperative period ( P>0.05), which were significantly lower than those in group C ( P<0.05). There was no significant difference in blood transfusion rate, blood transfusion volume, and incidence of acute myocardial injury between 3 groups ( P>0.05); the incidence of acute kidney injury in group A was significantly higher than that in group B, and the incidence of postoperative hypotension in group A was significantly higher than that in groups B and C ( P<0.05), but no significant difference was found between groups B and C ( P>0.05).
Conclusion: The combination of TXA and ICH has a synergistic effect. Controlling the intraoperative MAP at 70-80 mm Hg can effectively reduce the perioperative blood loss during the initial THA, and it is not accompanied by postoperative complications.
目的: 评价氨甲环酸（tranexamic acid，TXA）联合术中控制性降压（intraoperative controlled hypotension，ICH）减少初次全髋关节置换术（total hip arthroplasty，THA）围术期失血的安全性与有效性。.
方法: 回顾分析 2017 年 1 月—2020 年 7 月 832 例因股骨头坏死行初次 THA 患者的临床资料，所有患者均接受 TXA 治疗，其中 439 例（降压组）术中联合 ICH 将术中平均动脉压（mean arterial blood，MAP）控制在 80 mm Hg（1 mm Hg=0.133 kPa）以下，393 例（常压组）术中血压不进行特殊干预。两组患者年龄、性别、身体质量指数、美国麻醉师协会（ASA）分级、基础动脉压、髋关节活动度、合并内科疾病、术前血红蛋白（hemoglobin，Hb）及红细胞压积（hematocrit，HCT）水平、凝血功能、手术入路、TXA 用量等一般资料比较差异均无统计学意义（ P>0.05）。记录并比较两组患者围术期失血及输血情况、麻醉及手术时间、住院时间、术后关节活动度及并发症情况。并进一步将纳入患者分为 MAP<70 mm Hg 组（A 组）、MAP 70～80 mm Hg 组（B 组）和常压组（C 组）3 组，对围术期失血及术后并发症发生情况进一步行亚组分析，以筛选最佳血压范围。.
结果: 降压组术中 MAP、总失血量、显性失血量、隐性失血量、输血率及输血量、麻醉时间、手术时间和住院时间均低于常压组（ P<0.05）。降压组术后髋关节屈曲活动度优于常压组（ Z=2.743， P=0.006），但两组外展活动度比较差异无统计学意义（ Z=0.338， P=0.735）。术后并发症方面，降压组患者术后低血压发生率高于常压组（ χ 2=6.096， P=0.014），其余并发症发生率比较差异无统计学意义（ P>0.05）。两组均无脑卒中、肺动脉栓塞及下肢深静脉血栓形成发生，住院期间无死亡患者。亚组分析提示 A、B 组围术期总失血量、显性失血量及隐性失血量比较差异均无统计学意义（ P>0.05），均显著低于 C 组（ P<0.05）；3 组间输血率、输血量及急性心肌损伤发生率差异均无统计学意义（ P>0.05）；A 组急性肾损伤发生率显著高于 B 组，术后低血压发生率显著高于 B、C 组（ P<0.05），B、C 组间比较均无统计学意义（ P>0.05）。.
结论: TXA 联合 ICH 具有协同效应，将术中 MAP 控制在 70～80 mm Hg 能有效降低初次 THA 围术期失血，且不增加术后并发症发生风险。.
Keywords: Tranexamic acid; intraoperative controlled hypotension; perioperative blood loss; total hip arthroplasty; transfusion.