脊柱外科手术创面大、手术时间长、围手术期出血量大,大量失血使患者发生心肺相关疾病、肾衰竭和脑梗死的风险更高,这时患者往往会输血,然而输血就会导致输血反应、感染和凝血状况的改变,同时输血通常还受到血液供应、潜在免疫反应风险和传染病传播的限制。目前,氨甲环酸(Tranexamic Acid, TXA)作为抗纤维蛋白溶解药物已经被广泛应用到脊柱外科手术中,可降低患者围手术期失血量和输血率,然而TXA给药的途径、最佳剂量、以及安全性尚存较大争议。本篇综述总结了近年来TXA在脊柱外科围手术期的研究与应用进展。
Spine surgery has large wounds, long operation time, and large perioperative bleeding. A large amount of blood loss puts patients at higher risk of heart and lung-related diseases, renal failure and cerebral infarction. At this time, patients often receive blood transfusions, but blood transfusions can lead to transfusion reactions, changes in infection and coagulation status, and blood transfusion is usually restricted by blood supply, potential risk of immune response, and the spread of infectious diseases. Currently, Tranexamic Acid (TXA) has been widely used as an anti-fibrinolytic drug in spine surgery, which can reduce perioperative blood loss and transfusion rate. However, the route, optimal dose and safety of TXA administration remain controversial. This review summarizes the recent progress in the research and application of TXA in perioperative spine surgery.
氨甲环酸,脊柱外科,围手术期,给药途径,用药剂量, Tranexamic Acid Spine Surgery Perioperative Delivery Way Dosage摘要
Spine surgery has large wounds, long operation time, and large perioperative bleeding. A large amount of blood loss puts patients at higher risk of heart and lung-related diseases, renal failure and cerebral infarction. At this time, patients often receive blood transfusions, but blood transfusions can lead to transfusion reactions, changes in infection and coagulation status, and blood transfusion is usually restricted by blood supply, potential risk of immune response, and the spread of infectious diseases. Currently, Tranexamic Acid (TXA) has been widely used as an anti-fibrinolytic drug in spine surgery, which can reduce perioperative blood loss and transfusion rate. However, the route, optimal dose and safety of TXA administration remain controversial. This review summarizes the recent progress in the research and application of TXA in perioperative spine surgery.
崔旭忠,刘 瑞,年利伟,李屹洲. 氨甲环酸在脊柱外科围手术期的应用进展Progress of Tranexamic Acid in Perioperative Spine Surgery[J]. 临床医学进展, 2021, 11(11): 5471-5476. https://doi.org/10.12677/ACM.2021.1111810
参考文献ReferencesMu, X., Wei, J., Wang, C., et al. (2019) Intravenous Administration of Tranexamic Acid Significantly Reduces Visible and Hidden Blood Loss Compared with Its Topical Administration for Double-Segment Posterior Lumbar Interbody Fusion: A Single-Center, Placebo-Controlled, Randomized Trial. World Neurosurgery, 122, e821-e827.
<br>https://doi.org/10.1016/j.wneu.2018.10.154Du, Y. and Feng, C. (2018) The Efficacy of Tranexamic Acid on Blood Loss from Lumbar Spinal Fusion Surgery: A Meta-Analysis of Randomized Controlled Trials. World Neurosurgery, 119, e228-e234.
<br>https://doi.org/10.1016/j.wneu.2018.07.120葛军勇, 季兴华, 冼群泽, 等. 氨甲环酸在脊柱外科围手术期中的应用[J]. 中华老年多器官疾病杂志, 2020, 19(6): 474-476.Gong, M., Liu, G., Chen, L., et al. (2019) The Efficacy and Safety of Intravenous Tranexamic Acid in Reducing Surgical Blood Loss in Posterior Lumbar Interbody Fusion for the Adult: A Systematic Review and a Meta-Analysis. World Neurosurgery, 122, 559-568. <br>https://doi.org/10.1016/j.wneu.2018.09.115Wang, F., Nan, L., Feng, X., et al. (2020) The Efficacy and Safety of Multiple-Dose Intravenous Tranexamic Acid in Reducing Perioperative Blood Loss in Patients with Thoracolumbar Burst Fracture. Clinical Neurology and Neurosurgery, 193, Article ID: 105766. <br>https://doi.org/10.1016/j.clineuro.2020.105766赵洪顺, 阿尖措, 高顺红, 等. 全髋关节置换局部应用氨甲环酸术中术后失血及白细胞介素6和C-反应蛋白的变化[J]. 中国组织工程研究, 2019, 23(4): 493-498.罗兴鹏, 解京明, 王迎松, 等. 氨甲环酸在脊柱外科患者围手术期中的应用研究进展[J]. 山东医药, 2020, 60(11): 87-90.Sentilhes, L., Merlot, B., Madar, H., et al. (2016) Postpartum Haemorrhage: Prevention and Treatment. Expert Review of Hematology, 9, 1043-1061. <br>https://doi.org/10.1080/17474086.2016.1245135Brenner, A., Ker, K., Shakur-Still, H., et al. (2019) Tranexamic Acid for Post-Partum Haemorrhage: What, Who and When. Best Practice & Research: Clinical Obstetrics & Gynaecology, 61, 66-74.
<br>https://doi.org/10.1016/j.bpobgyn.2019.04.005Sun, H., Deng, L., Deng, J., et al. (2019) The Efficacy and Safety of Prophylactic Intravenous Tranexamic Acid on Perioperative Blood Loss in Patients Treated with Posterior Lumbar Interbody Fusion. World Neurosurgery, 125, e198-e204. <br>https://doi.org/10.1016/j.wneu.2019.01.040He, B., Li, Y., Xu, S., et al. (2020) Tranexamic Acid for Blood Loss after Transforaminal Posterior Lumbar Interbody Fusion Surgery: A Double-Blind, Placebo-Controlled, Randomized Study. BioMed Research International, 2020, Article ID: 8516504. <br>https://doi.org/10.1155/2020/8516504Kang, T., Park, S.Y., Nam, J.J., et al. (2019) Patient Blood Management during Lumbar Spinal Fusion Surgery. World Neurosurgery, 130, e566-e572. <br>https://doi.org/10.1016/j.wneu.2019.06.153Larson, E., Evans, T., Long, J., et al. (2019) Does Prophylactic Administration of TXA Reduce Mean Operative Time and Postoperative Blood Loss in Posterior Approach Lumbar Spinal Fusion Surgery Performed for Degenerative Spinal Disease. Clinical Spine Surgery, 32, E353-E358. <br>https://doi.org/10.1097/BSD.0000000000000770Luo, W., Sun, R.X., Jiang, H., et al. (2018) The Efficacy and Safety of Topical Administration of Tranexamic Acid in Spine Surgery: A Meta-Analysis. Journal of Orthopaedic Surgery and Research, 13, 96.
<br>https://doi.org/10.1186/s13018-018-0815-0Liang, J.Q., Rong, T.H., Liu, H.Z., et al. (2020) Topical Injection of Tranexamic Acid via a Drain plus Drain-Clamping to Reduce Blood Loss in Degenerative Lumbar Scoliosis Surgery. Orthopaedic Surgery, 12, 67-73.
<br>https://doi.org/10.1111/os.12583Xu, D., Chen, X., Li, Z., et al. (2020) Tranexamic Acid Reduce Hidden Blood Loss in Posterior Lumbar Interbody Fusion (PLIF) Surgery. Medicine (Baltimore), 99, e19552. <br>https://doi.org/10.1097/MD.0000000000019552Hui, S., Peng, Y., Tao, L., et al. (2021) Tranexamic Acid Given into Wound Reduces Postoperative Drainage, Blood Loss, and Hospital Stay in Spinal Surgeries: A Meta-Analysis. Journal of Orthopaedic Surgery and Research, 16, 401.
<br>https://doi.org/10.1186/s13018-021-02548-6Mallepally, A.R., Mahajan, R., Rustagi, T., et al. (2020) Use of Topical Tranexamic Acid to Reduce Blood Loss in Single-Level Transforaminal Lumbar Interbody Fusion. Asian Spine Journal, 14, 593-600.
<br>https://doi.org/10.31616/asj.2019.0134Lecker, I., Wang, D.S., Whissell, P.D., et al. (2016) Tranexamic Acid-Associated Seizures: Causes and Treatment. Annals of Neurology, 79, 18-26. <br>https://doi.org/10.1002/ana.24558Liang, J., Liu, H., Huang, X., et al. (2016) Using Tranexamic Acid Soaked Absorbable Gelatin Sponge Following Complex Posterior Lumbar Spine Surgery: A Randomized Control Trial. Clinical Neurology and Neurosurgery, 147, 110-114. <br>https://doi.org/10.1016/j.clineuro.2016.06.001Sudprasert, W., Tanaviriyachai, T., Choovongkomol, K., et al. (2019) A Randomized Controlled Trial of Topical Application of Tranexamic Acid in Patients with Thoracolumbar Spine Trauma Undergoing Long-Segment Instrumented Posterior Spinal Fusion. Asian Spine Journal, 13, 146-154. <br>https://doi.org/10.31616/asj.2018.0125Zhang, L., Li, Y., Liu, D., et al. (2020) Combined Use of Tranexamic Acid and Rivaroxaban in Posterior Lumbar Interbody Fusion Safely Reduces Blood Loss and Transfusion Rates without Increasing the Risk of Thrombosis—A Prospective, Stratified, Randomized, Controlled Trial. International Orthopaedics, 44, 2079-2087.
<br>https://doi.org/10.1007/s00264-020-04699-3Li, J., Wang, L., Bai, T., et al. (2020) Combined Use of Intravenous and Topical Tranexamic Acid Efficiently Reduces Blood Loss in Patients Aged over 60 Operated with a 2-Level Lumbar Fusion. Journal of Orthopaedic Surgery and Research, 15, 339. <br>https://doi.org/10.1186/s13018-020-01758-8Ou, Y., Wei, J., Li, R., et al. (2018) Clinical Research of Combined Intravenous Administration and Topical Application of Tranexamic Acid to a Surgical Wound during Posterior Lumbar Fusion. Surgical Innovation, 25, 128-135.
<br>https://doi.org/10.1177/1553350617751449Wang, X., Yang, R., Sun, H., et al. (2019) Different Effects of Intravenous, Topical, and Combined Application of Tranexamic Acid on Patients with Thoracolumbar Fracture. World Neurosurgery, 127, e1185-e1189.
<br>https://doi.org/10.1016/j.wneu.2019.04.095Lin, J.D., Lenke, L.G., Shillingford, J.N., et al. (2018) Safety of a High-Dose Tranexamic Acid Protocol in Complex Adult Spinal Deformity: Analysis of 100 Consecutive Cases. Spine Deformity, 6, 189-194.
<br>https://doi.org/10.1016/j.jspd.2017.08.007Farrokhi, M.R., Kazemi, A.P., Eftekharian, H.R., et al. (2011) Efficacy of Prophylactic Low Dose of Tranexamic Acid in Spinal Fixation Surgery: A Randomized Clinical Trial. Journal of Neurosurgical Anesthesiology, 23, 290-296.
<br>https://doi.org/10.1097/ANA.0b013e31822914a1Yuan, Q.M., Zhao, Z.H. and Xu, B.S. (2017) Efficacy and Safety of Tranexamic Acid in Reducing Blood Loss in Scoliosis Surgery: A Systematic Review and Meta-Analysis. European Spine Journal, 26, 131-139.
<br>https://doi.org/10.1007/s00586-016-4899-0Kim, K.T., Kim, C.K., Kim, Y.C., et al. (2017) The Effectiveness of Low-Dose and High-Dose Tranexamic Acid in Posterior Lumbar Interbody Fusion: A Double-Blinded, Placebo-Controlled Randomized Study. European Spine Journal, 26, 2851-2857. <br>https://doi.org/10.1007/s00586-017-5230-4Wanderman, N., Robinson, W., Carlson, B., et al. (2019) Tranexamic Acid in Thoracic and Lumbar Fusions and Perioperative Blood Loss. Clinical Spine Surgery, 32, E462-E468. <br>https://doi.org/10.1097/BSD.0000000000000851熊振成, 谭明生. 氨甲环酸在脊柱手术围手术期中的应用进展[J]. 中国微侵袭神经外科杂志, 2020, 25(7): 334-336.Nishihara, S. and Hamada, M. (2015) Does Tranexamic Acid Alter the Risk of Thromboembolism after Total Hip Arthroplasty in the Absence of Routine Chemical Thromboprophylaxis. The Bone & Joint Journal, 97-B, 458-462.
<br>https://doi.org/10.1302/0301-620X.97B4.34656Soroceanu, A., Oren, J.H., Smith, J.S., et al. (2016) Effect of Antifibrinolytic Therapy on Complications, Thromboembolic Events, Blood Product Utilization, and Fusion in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976), 41, E879-E886. <br>https://doi.org/10.1097/BRS.0000000000001454Ko, B.S., Cho, K.J., Kim, Y.T., et al. (2020) Does Tranexamic Acid Increase the Incidence of Thromboembolism after Spinal Fusion Surgery. Clinical Spine Surgery, 33, E71-E75. <br>https://doi.org/10.1097/BSD.0000000000000860Zhang, L. and Zou, X.Y. (2016) Tranexamic Acid-Associated Seizures: A Meta-Analysis. Seizure, 36, 70-73.
<br>https://doi.org/10.1016/j.seizure.2016.02.011