Kagoma Yoan K, Crowther Mark A, Douketis James, Bhandari Mohit, Eikelboom John, Lim Wendy
Applied Science and Engineering, University of Toronto, Toronto, Ontario, Canada.
Thromb Res. 2009 Mar;123(5):687-96. doi: 10.1016/j.thromres.2008.09.015. Epub 2008 Nov 12.
Minimizing bleeding and transfusion is desirable given its cost, complexity and potential for adverse events. Concerns have been heightened by recent data demonstrating that bleeding events may predict worse outcomes and by warnings about the safety of erythropoietic stimulating agents. Prior small studies suggest that antifibrinolytic agents may reduce bleeding and transfusion need in patients undergoing total hip replacement (THR) or total knee arthroplasty (TKA). However, no single study has been large enough to definitively determine if these agents are safe and effective. To address this issue we performed a systematic review of randomized trials describing the use of tranexamic acid, epsilon aminocaproic acid, or aprotinin administration in the perioperative setting.
MEDLINE, EMBASE, CINAHL and the Cochrane databases were searched for relevant trials. Two independent reviewers abstracted total blood loss, transfusion requirements, and venous thromboembolism (VTE) rates. Data were combined using the Mantel-Haenszel method and dichotomous data expressed as relative risk (RR) with 95% confidence intervals (CI).
Patients receiving antifibrinolytic agents had reduced transfusion need (RR 0.52; 95% CI, 0.42 to 0.64; P<0.00001), reduced blood loss and no increase in the risk of VTE (RR 0.95% CI, 0.80 to 1.10, I(2)=0%, P=0.531).
We conclude that antifibrinolytic agents may reduce bleeding and transfusion in patients undergoing THR or TKA who receive appropriate antithrombotic prophylaxis. There is a need for a large, adequately powered prospective study to carefully examine the safety and efficacy of these agents.
鉴于出血和输血的成本、复杂性及不良事件发生的可能性，尽量减少出血和输血是可取的。近期数据表明出血事件可能预示着更差的预后，同时有关促红细胞生成素类药物安全性的警告也加剧了人们的担忧。先前的小型研究表明，抗纤溶药物可能减少全髋关节置换术（THR）或全膝关节置换术（TKA）患者的出血和输血需求。然而，尚无一项研究规模足够大到能明确确定这些药物是否安全有效。为解决这一问题，我们对描述围手术期使用氨甲环酸、ε-氨基己酸或抑肽酶的随机试验进行了系统评价。
检索MEDLINE、EMBASE、CINAHL和Cochrane数据库以查找相关试验。两名独立的审阅者提取总失血量、输血需求和静脉血栓栓塞（VTE）发生率。使用Mantel-Haenszel方法合并数据，二分数据表示为相对风险（RR）及95%置信区间（CI）。
接受抗纤溶药物的患者输血需求减少（RR 0.5；95% CI，0.42至0.64；P<0.00001），失血量减少，且VTE风险未增加（RR 0.95% CI，0.80至1.10，I(2)=0%，P=0.531）。
我们得出结论，对于接受适当抗血栓预防的THR或TKA患者，抗纤溶药物可能减少出血和输血。需要进行一项大型、有足够效力的前瞻性研究，以仔细检验这些药物的安全性和有效性。
