Lieberman J R, Wollaeger J, Dorey F, Thomas B J, Kilgus D J, Grecula M J, Finerman G A, Amstutz H C
Department of Orthopaedic Surgery, University of California at Los Angeles School of Medicine, 90095, USA.
J Bone Joint Surg Am. 1997 Mar;79(3):319-25. doi: 10.2106/00004623-199703000-00001.
The selection of a prophylaxis regimen and its implementation have been influenced considerably by the decreased duration of hospital stays and the pressures of cost containment. The purpose of the present study was to determine the rate of symptomatic pulmonary embolism both before and after discharge, the number of days required to achieve an adequate level of anticoagulation, and the complications associated with the use of low-dose warfarin after total hip arthroplasty. Between 1987 and 1993, 1099 primary and revision total hip arthroplasties were performed in 940 patients who received low-dose warfarin for prophylaxis against thromboembolic disease. The average duration of prophylaxis was fifteen days (range, one to twenty-nine days). The target level of anticoagulation (as indicated by a prothrombin time of fourteen to seventeen seconds) was achieved an average of three days (range, one to sixteen days) after the operation. The level of anticoagulation was lower than the target range at the time of discharge after 257 total hip arthroplasties (23.4 per cent), and the target level was never achieved during the period of hospitalization after fifty-four such procedures (4.9 per cent). Twelve total hip arthroplasties were associated with a symptomatic pulmonary embolism; the over-all prevalence of this complication therefore was 1.1 per cent (95 per cent confidence interval, 0.4 to 1.9 per cent). Four pulmonary emboli were diagnosed before discharge and eight, after discharge. A fatal pulmonary embolism occurred after one procedure (0.1 per cent). Patients who had a history of symptomatic venous thromboembolic disease had a significantly increased risk of symptomatic pulmonary embolism after total hip arthroplasty (p = 0.001, Fisher exact test). A major bleeding episode occurred after thirty-two total hip arthroplasties (2.9 per cent). Patients who had a prothrombin time of more than seventeen seconds had a significantly increased risk of hematoma formation (p = 0.003, chi-square analysis). Prophylaxis with low-dose warfarin is safe and effective for the prevention of pulmonary embolism after total hip arthroplasty.
预防方案的选择及其实施在很大程度上受到住院时间缩短和成本控制压力的影响。本研究的目的是确定出院前后有症状的肺栓塞发生率、达到足够抗凝水平所需的天数，以及全髋关节置换术后使用低剂量华法林相关的并发症。1987年至1993年间，对940例接受低剂量华法林预防血栓栓塞性疾病的患者进行了1099例初次和翻修全髋关节置换术。预防的平均持续时间为15天（范围为1至29天）。抗凝的目标水平（以凝血酶原时间14至17秒表示）在术后平均3天（范围为1至16天）达到。257例全髋关节置换术后出院时抗凝水平低于目标范围（23.4%），54例此类手术（4.9%）在住院期间从未达到目标水平。12例全髋关节置换术与有症状的肺栓塞相关；因此，该并发症的总体发生率为1.1%（95%置信区间为0.4至1.9%）。4例肺栓塞在出院前诊断，8例在出院后诊断。1例手术（0.1%）后发生致命性肺栓塞。有症状的静脉血栓栓塞病史的患者在全髋关节置换术后有症状的肺栓塞风险显著增加（p = 0.001，Fisher精确检验）。32例全髋关节置换术后发生大出血事件（2.9%）。凝血酶原时间超过17秒的患者血肿形成风险显著增加（p = 0.003，卡方分析）。低剂量华法林预防对全髋关节置换术后预防肺栓塞是安全有效的。
