Belay Elshaday S, O'Donnell Jeffrey, Flamant Etienne, Hinton Zoe, Klifto Christopher S, Anakwenze Oke
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
J Shoulder Elbow Surg. 2021 Feb;30(2):312-316. doi: 10.1016/j.jse.2020.05.039. Epub 2020 Jun 24.
Blood loss and transfusions have been highlighted as a significant predictor of postoperative morbidity. Tranexamic acid (TXA) has been shown to decrease blood loss and transfusion in shoulder arthroplasty. However, the utility of topical thrombin in total shoulder arthroplasty (TSA) is unknown. The purpose of this study was to assess the utility of topical thrombin in TSA and compare the effectiveness of topical thrombin to intravenous (IV) TXA.
An institutional database was used to query shoulder arthroplasty patients from January 2017 to July 2019. Patients undergoing TSA were identified with CPT (Current Procedural Terminology) code (23742). After excluding reverse shoulder arthroplasty, arthroplasty for fracture or revision, the study groups were stratified based on intervention with IV TXA, topical thrombin, or neither. Patient demographics, American Society of Anesthesiologists (ASA) class, baseline coagulopathy, preoperative and postoperative hemoglobin levels, operative time, transfusion, length of stay, and 90-day readmission for each treatment group was obtained.
A total of 283 TSA cases were included for final analysis. There was no statistically significant difference in the baseline characteristics with age, body mass index, or ASA class. The postoperative hemoglobin level (mg/dL) was higher in the group that received either IV TXA or thrombin compared with no hemostatic agents (P = .001). Calculated blood loss in TSA was significantly higher in the group without hemostatic agents, 369.8 mL (standard deviation [SD] 59.5), compared with IV TXA or topical thrombin, 344.3 mL (SD 67.1) and 342.9 mL (SD 65.6) (P = .03). Operative time was highest in the group that received no hemostatic agents, 2.3 hours (SD 0.6) (P = .01). The transfusion rate for TSA treated with IV TXA or topical thrombin was equivalent (2.2%) but significantly lower than the no intervention group (12%) (P = .01). The odds ratio for transfusion with IV TXA was 0.16 (95% confidence interval [CI] 0.07-0.40, P = .001) and for topical thrombin, 0.1 (95% CI 0.02-0.42, P = .02).
Topical thrombin is an effective adjunct to reduce blood loss and transfusion risk after TSA and a reasonable intraoperative alternative for TXA for patients with contraindication to IV TXA.
失血和输血一直被视为术后发病率的重要预测指标。已证实氨甲环酸（TXA）可减少肩关节置换术中的失血和输血。然而，局部应用凝血酶在全肩关节置换术（TSA）中的作用尚不清楚。本研究的目的是评估局部应用凝血酶在TSA中的作用，并比较局部应用凝血酶与静脉注射（IV）TXA的效果。
利用机构数据库查询2017年1月至2019年7月期间的肩关节置换术患者。通过现行手术操作术语（CPT）代码（23742）识别接受TSA的患者。在排除反向肩关节置换术、骨折或翻修的关节置换术后，根据是否接受IV TXA、局部应用凝血酶或两者均未应用进行分层，将研究组分为三组。获取了每个治疗组的患者人口统计学数据、美国麻醉医师协会（ASA）分级、基线凝血病、术前和术后血红蛋白水平、手术时间、输血情况、住院时间以及90天再入院情况。
共纳入283例TSA病例进行最终分析。在年龄、体重指数或ASA分级等基线特征方面，各组间无统计学显著差异。与未使用止血剂的组相比，接受IV TXA或凝血酶治疗的组术后血红蛋白水平（mg/dL）更高（P = .001）。未使用止血剂的组TSA术中计算失血量显著高于IV TXA组或局部应用凝血酶组，分别为369.8 mL（标准差[SD] 59.5）、344.3 mL（SD 67.1）和342.9 mL（SD 65.6）（P = .03）。未使用止血剂的组手术时间最长，为2.3小时（SD 0.6）（P = .01）。IV TXA或局部应用凝血酶治疗的TSA输血率相当（2.2%），但显著低于未干预组（12%）（P = .01）。IV TXA输血的比值比为0.16（95%置信区间[CI] 0.07 - 0.40，P = .001），局部应用凝血酶输血的比值比为0.1（95% CI 0.02 - 0.42，P = .02）。
局部应用凝血酶是减少TSA术后失血和输血风险的有效辅助手段，对于有IV TXA禁忌证的患者，是术中TXA的合理替代方案。
