Center for Joint Surgery (W.-N.Z., J.-L.L., F.-Y.W., C.C., and L.Y.) and Department of Orthopaedic Surgery (W.-N.Z. and Q.Z.), Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China.
Department of Orthopaedics, Chongqing General Hospital, Chongqing, People's Republic of China.
J Bone Joint Surg Am. 2018 Feb 21;100(4):295-304. doi: 10.2106/JBJS.16.01585.
The reductions of perioperative blood loss and inflammatory response are important in total knee arthroplasty. Tranexamic acid reduced blood loss and the inflammatory response in several studies. However, the effect of epinephrine administration plus tranexamic acid has not been intensively investigated, to our knowledge. In this study, we evaluated whether the combined administration of low-dose epinephrine plus tranexamic acid reduced perioperative blood loss or inflammatory response further compared with tranexamic acid alone.
This randomized placebo-controlled trial consisted of 179 consecutive patients who underwent primary total knee arthroplasty. Patients were randomized into 3 interventions: Group IV received intravenous low-dose epinephrine plus tranexamic acid, Group TP received topical diluted epinephrine plus tranexamic acid, and Group CT received tranexamic acid alone. The primary outcome was perioperative blood loss on postoperative day 1. Secondary outcomes included perioperative blood loss on postoperative day 3, coagulation and fibrinolysis parameters (measured by thromboelastography), inflammatory cytokine levels, transfusion values (rate and volume), thromboembolic complications, length of hospital stay, wound score, range of motion, and Hospital for Special Surgery (HSS) score.
The mean calculated total blood loss (and standard deviation) in Group IV was 348.1 ± 158.2 mL on postoperative day 1 and 458.0 ± 183.4 mL on postoperative day 3, which were significantly reduced (p < 0.05) compared with Group TP at 420.5 ± 188.4 mL on postoperative day 1 and 531.1 ± 231.4 mL on postoperative day 3 and Group CT at 520.4 ± 228.4 mL on postoperative day 1 and 633.7 ± 237.3 mL on postoperative day 3. Intravenous low-dose epinephrine exhibited a net anti-inflammatory activity in total knee arthroplasty and did not induce an obvious hypercoagulable status. Transfusion values were significantly reduced (p < 0.05) in Group IV, but no significant differences were observed in the incidence of thromboembolic complications, wound score, range of motion, and HSS score among the 3 groups (p > 0.05).
The combined administration of low-dose epinephrine and tranexamic acid demonstrated an increased effect in reducing perioperative blood loss and the inflammatory response compared with tranexamic acid alone, with no apparent increased incidence of thromboembolic and other complications.
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
减少围手术期失血量和炎症反应是全膝关节置换术的重要目标。氨甲环酸在多项研究中均能减少失血量和炎症反应。然而，据我们所知，肾上腺素给药联合氨甲环酸的效果尚未得到深入研究。在这项研究中，我们评估了与单独使用氨甲环酸相比，小剂量肾上腺素联合氨甲环酸是否进一步减少围手术期失血量或炎症反应。
本随机安慰剂对照试验纳入了 179 例接受初次全膝关节置换术的连续患者。患者被随机分为 3 组干预措施：IV 组接受静脉内小剂量肾上腺素联合氨甲环酸，TP 组接受局部稀释肾上腺素联合氨甲环酸，CT 组接受单独氨甲环酸。主要结局是术后第 1 天的围手术期失血量。次要结局包括术后第 3 天的围手术期失血量、凝血和纤溶参数（通过血栓弹性描记术测量）、炎症细胞因子水平、输血值（比例和体积）、血栓栓塞并发症、住院时间、伤口评分、关节活动度和美国特种外科医院（HSS）评分。
IV 组术后第 1 天的计算总失血量（和标准差）为 348.1 ± 158.2 mL，术后第 3 天为 458.0 ± 183.4 mL，与 TP 组术后第 1 天的 420.5 ± 188.4 mL和术后第 3 天的 531.1 ± 231.4 mL以及 CT 组术后第 1 天的 520.4 ± 228.4 mL和术后第 3 天的 633.7 ± 237.3 mL相比均显著降低（p < 0.05）。静脉内小剂量肾上腺素在全膝关节置换术中表现出明显的抗炎活性，且不会引起明显的高凝状态。IV 组的输血值显著降低（p < 0.05），但 3 组间血栓栓塞并发症、伤口评分、关节活动度和 HSS 评分的发生率无显著差异（p > 0.05）。
与单独使用氨甲环酸相比，小剂量肾上腺素联合氨甲环酸在减少围手术期失血量和炎症反应方面效果增强，且血栓栓塞和其他并发症的发生率无明显增加。
治疗学 1 级。详见作者说明获取对证据水平的完整描述。
