Total Diz Artroplastisinde Cerrahi Yara Kapatılması Öncesinde Kontrollü Arteriyel Hipertansiyon ile Yapılan Hemostazis Kanama Miktarını ve Transfüzyon İhtiyacını Etkiler mi?

Öz

Amaç: Total diz artroplastisinde (TDA) cerrahi yaranın kapatılmasından önce kontrollü olarak arttırılan arteriyel kan basıncı ile yapılan hemostazisin etkinliğinin değerlendirilmesi amaçlanmıştır. Materyal ve Metot: Veriler hipotansif epidural anestezi (HEA) ile TDA ameliyatı olmuş 87 hastanın (65 kadın, 25 erkek) tıbbi kayıtlarından retrospektif olarak toplanmıştır. Hastalar cerrahi yaranın kapatılmasından önce kontrollü arteriyel hipertansiyon uygulanmasına göre iki gruba ayrılmıştır. Grup I (n:44) HEA uygulanan hastaları, grup II (n:43) cerrahi yara kapatılmasından önce kontrollü arteriyel hipertansiyon (operasyon öncesindeki ortalama arteriyel kan basıncından daha yüksek) uygulanan hastaları içermektedir. Temel tanımlayıcılar olarak peroperatif hemoglobin ve hematokrit seviyeleri, sistolik ve diasitolik kan basıncı, transfüze edilen eritrosit süspansiyonu miktarları iki grup arasında kıyaslanmıştır. Bulgular: Gruplardaki ortalama yaş 66,41+6,17 (57-78) dir. Operasyon sonrası 1.(p=0,031), 2.(p=0,032), 4.(p=0,001), 12.(p=0,001), 24.(p=0,001) saatlerdeki kanama miktarı grup II de anlamlı olarak daha düşüktü (Sırasıyla, p=0.031, 0.032, 0.001, 0.001, 0.001). Komplikasyon, cerrahi süre, peroperatif kanama, hastanede yatış ve takip süresi, peroperatif hemoglobin değeri, transfüze edilen eritrosit süspansiyonu miktarı ile peroperatif sistolik-diasitolik kan basıncı değerleri açısından gruplar arasında istatistiksel bir fark yoktu. Sonuç: Bulgularımız TDA’da cerrahi yara kapatılması öncesinde ortalama arteriyel kan basıncının kontrollü olarak yükseltilmesinin daha ayrıntılı bir şekilde kanama kontrolü yapılmasına olanak verdiğini göstermektedir. Bizim bu şekildeki ilk bulgularımızı daha büyük vaka serilerinde yapılan prospektif, randomize, kontrollü çalışmalar destekleyecektir.

Anahtar Kelimeler

• Kanama
• hemostazis
• hipotansif epidural anestezi
• kontrollü hipertansiyon
• total diz artroplastisi

Does Hemostasis with Controlled Arterial Hypertension Before Surgical Wound Closure in Total Knee Arthroplasty Affect the Amount of Bleeding and Transfusion Need?

Abstract

Objective: We aimed to assess the efficacy of hemostasis while controlled augmentation of arterial blood pressure before surgical closure after total knee arthroplasty (TKA). Materials and Methods: This retrospective cohort involved data collected from the medical files of 87 patients (62 women, 25 men) who underwent TKA using hypotensive epidural anesthesia (HEA). Patients were allocated into two groups. Group I (n=44) received HEA, while Group II (n=43) had controlled arterial hypertension before surgical closure. Perioperative hemoglobin and hematocrit levels, systolic and diastolic blood pressure, and the amount of erythrocyte suspension transfusion were compared between the two groups. Results: The average age of our series was 66.41 ± 6.17 (range: 57-78) years. Notably, the amount of bleeding on postoperative 1st, 2nd, 4th, 12th, and 24th (p=0.031, 0.032, 0.001, 0.001, 0.001, respectively) hours was significantly less in Group II. There were no significant differences between the two groups for complications, operative duration, perioperative bleeding, duration of follow-up and hospitalisation, and compared descriptives. Conclusion: Our data indicated that controlled elevation of mean arterial pressure before surgical closure might allow the achievement of meticulous hemostasis after TKA. Further prospective, randomised, controlled trials on more extensive series are warranted to verify our preliminary results.

Keywords

• Bleeding
• controlled hypertension
• hypotensive epidural anesthesia
• hemostasis
• total knee arthroplasty

Kaynakça

1. Kourtzis N, Pafilas D, Kasimatis G. Blood saving protocol in elective total knee arthroplasty. Am J Surg. 2004;187(2):261-7. doi:10.1016/j.amjsurg.2003.11.022
2. Hu Y, Li Q, Wei BG, et al. Blood loss of total knee arthroplasty in osteoarthritis: An analysis of influential factors. J Orthop Surg Res. 2018;13(1):325. doi:10.1186/s13018-018-1038-0
3. Cai L, Chen L, Zhao C, Wang Q, Kang P. Influencing factors of hidden blood loss after primary total hip arthroplasty through the posterior approach: A retrospective study. BMC Musculoskelet Disord. 2023;24(1):582. doi:10.1186/s12891-023-06716-z
4. Minoda Y, Sakawa A, Fukuoka S, Tada K, Takaoka K. Blood management for patients with hemoglobin level lower than 130 g/l in total knee arthroplasty. Arch Orthop Trauma Surg. 2004;124(5):317-9. doi:10.1007/s00402-004-0647-8.
5. Eroglu A, Uzunlar H, Erciyes N. Comparison of hypotensive epidural anesthesia and hypotensive total intravenous anesthesia on intraoperative blood loss during total hip replacement. J Clin Anesth. 2005;17(6):420-5. doi:10.1016/j.jclinane.2004.09.006
6. Freeman AK, Thorne CJ, Gaston CL, et al. Hypotensive epidural anesthesia reduces blood loss in pelvic and sacral bone tumor resections. Clin Orthop Relat Res. 2017;475(3):634-640. doi:10.1007/s11999-016-4858-4
7. Kim TW, Park HJ, Chang MJ, et al. Effect of severity and cause of preoperative anemia on the transfusion rate after total knee arthroplasty. Sci Rep. 2022;12(1):4083. doi:10.1038/s41598-022-08137-9
8. Wang HY, Yuan MC, Pei FX, Zhou ZK, Liao R. Finding the optimal control level of intraoperative blood pressure in no tourniquet primary total knee arthroplasty combine with tranexamic acid: A retrospective cohort study which supports the enhanced recovery strategy. J Orthop Surg Res. 2020;15(1):350. doi:10.1186/s13018-020-01887-0

9. Teni FS, Burström K, Berg J, Leidl R, Rolfson O. Predictive ability of the American Society of Anaesthesiologists physical status classification system on health-related quality of life of patients after total hip replacement: Comparisons across eight EQ-5D-3L value sets. BMC Musculoskelet Disord. 2020;21(1):441. doi:10.1186/s12891-020-03399-8
10. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72(2):220-233. doi:10.1002/art.41142
11. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;(248):13-4.
12. Liao L, Chen Y, Tang Q, Chen YY, Wang WC. Tranexamic acid plus drain-clamping can reduce blood loss in total knee arthroplasty: A systematic review and meta-analysis. Int J Surg. 2018;52:334-341. doi:10.1016/j.ijsu.2018.01.040
13. Farrington SK, Downey C, O'Byrne JM. Tourniquet use during primary total knee arthroplasty-a survey of Irish orthopaedic surgeons in 2022. Ir J Med Sci. 2023;192(4):1731-1735. doi:10.1007/s11845-022-03248-8
14. Schmidt-Braekling T, Goytizolo E, Waldstein W, Sharrock N, Boettner F. The effect of hypotensive anesthesia on hemoglobin levels during total knee arthroplasty. J Clin Med. 2020;10(1):57. doi:10.3390/jcm10010057
15. Zhang T, Ma Y, Liu L, et al. Comparison of clinical effects of general anesthesia and intraspinal anesthesia on total hip arthroplasty. Am J Transl Res. 2021;13(7):8241-8246.
16. Dragosloveanu S, Dragosloveanu C, Petre M, Gherghe ME, Cotor DC. The impact of tourniquet usage on TKA outcome: A single-center prospective trial. Medicina (Kaunas). 2023;59(5):870. doi:10.3390/medicina59050870
17. Williams-Russo P, Sharrock NE, Haas SB, et al. Randomized trial of epidural versus general anesthesia: Outcomes after primary total knee replacement. Clin Orthop Relat Res. 1996;(331):199-208. doi:10.1097/00003086-199610000-00028
18. Kim E, Cho MR, Byun SH, et al. Sympathetic predominance before tourniquet deflation is associated with a reduction in arterial blood pressure after tourniquet deflation during total knee arthroplasty. Physiol Res. 2021;70(3):401-412. doi:10.33549/physiolres.934639
19. Sharrock NE, Go G, Sculco TP, Ranawat CS, Maynard MJ, Harpel PC. Changes in circulatory indices of thrombosis and fibrinolysis during total knee arthroplasty performed under tourniquet. J Arthroplasty. 1995;10(4):523-8. doi:10.1016/s0883-5403(05)80155-x
20. Zhang Y, Li D, Liu P, Wang X, Li M. Effects of different methods of using pneumatic tourniquet in patients undergoing total knee arthroplasty: A randomized control trial. Ir J Med Sci. 2017;186(4):953-959. doi:10.1007/s11845-017-1585-0
21. Tripković B, Jakovina Blažeković S, Bratić V, Tripković M. Contemporary recommendations on patient blood management in joint Arthroplasty. Acta Clin Croat. 2022;61(Suppl2):78-83. doi:10.20471/acc.2022.61.s2.09
22. Leão MGS, Souza HAP, Ferreira YMC. Evaluation of blood loss after early or late release of ischemia in patients undergoing total knee replacement. Rev Bras Ortop. 2013;48(2):152-158. doi:10.1016/j.rboe.2012.03.003