Horrow J C, Van Riper D F, Strong M D, Brodsky I, Parmet J L
Division of Cardiothoracic Anesthesia (Department of Anesthesiology), Hahnemann University, Philadelphia, PA 19101-1192.
Circulation. 1991 Nov;84(5):2063-70. doi: 10.1161/01.cir.84.5.2063.
Desmopressin-induced release of tissue plasminogen activator from endothelial cells may explain the absence of its hemostatic effect in patients undergoing cardiac surgery. Prior administration of the antifibrinolytic drug tranexamic acid might unmask such an effect, and combination therapy might thereby improve postoperative hemostasis.
A double-blinded design randomly allocated 163 adult patients undergoing coronary revascularization, valve replacement, both procedures, or repair of atrial septal defect to four treatment groups: placebo, tranexamic acid given as 10 mg/kg over 30 minutes followed by 1 mg.kg-1.hr-1 for 12 hours initiated before skin incision, desmopressin given as 0.3 micrograms/kg over 20 minutes after protamine infusion, and both drugs. One surgeon performed all operations. Blood loss consisted of mediastinal tube drainage over 12 hours. Follow-up visits sought evidence of myocardial infarction and stroke. Desmopressin decreased neither the 12-hour blood loss nor the amount of homologous red cells transfused. Tranexamic acid alone significantly reduced 12-hour blood loss, by 30% (mean, 318 versus 453 ml; p less than 0.0001), without enhancement by desmopressin. Tranexamic acid also decreased the proportion of patients receiving homologous blood within 12 hours of operation (8% versus 21%, p = 0.024) and within 5 days of operation (22% versus 41%, p = 0.011).
Desmopressin exerts no hemostatic effect, with or without prior administration of antifibrinolytic drug. Prophylactic tranexamic acid alone appears economical and safe in decreasing blood loss and transfusion requirement after cardiac surgery.
去氨加压素诱导内皮细胞释放组织型纤溶酶原激活剂，这可能解释了其在心脏手术患者中缺乏止血作用的原因。预先给予抗纤溶药物氨甲环酸可能会揭示这种作用，联合治疗可能会改善术后止血。
采用双盲设计，将163例接受冠状动脉血运重建、瓣膜置换、两种手术或房间隔缺损修复的成年患者随机分为四个治疗组：安慰剂组、在皮肤切开前30分钟给予10mg/kg氨甲环酸，随后12小时给予1mg·kg-1·hr-1的氨甲环酸组、在鱼精蛋白输注后20分钟给予0.3μg/kg去氨加压素组以及两种药物联合组。所有手术均由一名外科医生进行。失血量包括12小时纵隔引流管引流量。随访观察心肌梗死和中风的证据。去氨加压素既未减少12小时失血量，也未减少输注的同源红细胞量。单独使用氨甲环酸显著减少了12小时失血量，减少了30%（平均，318ml对453ml；p<0.0001），去氨加压素未增强其效果。氨甲环酸还降低了手术12小时内（8%对21%，p = 0.024）和手术5天内（22%对41%，p = 0.011）接受同源血的患者比例。
无论是否预先给予抗纤溶药物，去氨加压素均无止血作用。单独预防性使用氨甲环酸在减少心脏手术后失血量和输血需求方面似乎经济且安全。
