The Effect Of Tranexamic Acid On Hidden Bleeding In Elderly Intertrochanteric Fracture Patients Treated With Intramedullary Nails

Objecitive:Along with the aging society gradually,the incidence of intertrochanteric fractures in elderly was increasing year by year.Proximal femoral intramedullary nail(PFNA)is the preferred method for treatment of intertrochanteric fractures.However,there is a lot of hidden blood loss after sugery.Anemia caused by hidden blood loss if not promptly corrected,would prolong the wound healing time and hospitalization time,increase the incidence of postoperative pulmonary edema,cerebral edema and a series of problems.Allogeneic blood transfusion must be performed to correct hidden blood loss,but in this process there are complications such as hematogenous transmission of infectious diseases,transfusion-related acute lung injury,graft versus host disease.Tranexamic acid is a traditional antifibrinolytic agent,which effectively blocks fibrinolytic activity by blocking the lysine binding sites of plasminogen and prevents the degradation of fibrin.Literatures reported that tranexamic acid could reduce blood loss successfully in thoracic,liver and gynecological surgical procedures.In the field of orthopedics,tranexamic acid is mainly used to reduce blood loss and blood transfusion rate in the hip and knee replacements and spinal surgeries.But there is no report about the effect of tranexamic acid on hidden blood loss after surgery of intertrochanteric fractures in the elderly.This study aims to investigate the effect of tranexamic acid on hidden bleeding in elderly intertrochanteric fracture patients treated with intramedullary nails.Methods:We conducted the study between January 2016 and January2017,a total of 100 elderly patients with intertrochanteric fractures were enrolled in this study.According to the table of random numbers,patients were randomly divided into two groups namely tranexamic acid(TXA)group and blank control group,each group of 50 cases.The TXA group comprisedwith 19 males and 31 females,mean age 77.7years,average heights 1.63 m and mean body weight 64.37 kg.The types of fracture were classified according to the OTA classification,included A1 fractures 24 cases,A2 fractures 19 cases and A3 fractures 7 cases.According to the American Society of Anesthesiologists(ASA)scores divided into three classes: ASAⅠ9 cases,ASAⅡ29 cases,ASAⅢ12 cases.All patients in this group were treated with intramedullary nails,and that tranexamic acid 10 mg.kg-1 10 minutes preoperative and 5 hours postoperative by intravenous drip.The control group comprised with 14 males and 36 females,mean age 79.3years,average heights1.60 m and mean body weight 59.03 kg.The types of fracture included A1 fractures 29 cases,A2 fractures 15 cases and A3 fractures 6 cases.According to the ASA scores,ASAⅠ9 cases,ASAⅡ23 cases,ASAⅢ18 cases.The treatment is the same as the TXA group,but not used tranexamic acid.Blood routine examination occurred in 8 AM on surgery day for all patients.Record the intraoperative blood loss,postoperative drainage and postoperative blood transfusion.Review the blood routine in 8 AM Day2 after surgery.Calculated the total blood loss and hidden blood loss of two groups of patients separately according to the Gross equation.All patients examined deep vein ultrasound of lower limbs in preoperative and 1 week postoperative to record the thrombosis occurs.Statistical analysis with SPSS 21.0 statistical processing,mean with (?) ±S.T test was used to the comparison of count data,while measurement data by chi-square test.The significance level used for all tests was p <0.05.Results:In TXA group the overt bleeding was(113.34±75.82)ml,include the blood loss during operation(73.25±30.22)ml and drainage after operation(40.09±16.54)ml.The average total blood loss was(515.30±278.79)ml and the hidden blood loss was(401.96±260.72)ml.There are 24 cases received blood transfusion,the average amount of blood transfusion was(160±71.73)ml,blood transfusion rate was 48.0%.In control group the overt bleeding was(164.29±88.052)ml,including the blood loss during operation(107.43±33.29)ml and drainage after operation(56.86±20.20)ml.The average total blood loss was(696.88±275.00)ml and the hidden blood loss was(532.60±253.41)ml.There are 34 cases received blood transfusion,the average amount of bloodtransfusion was(270±109.41)ml,blood transfusion rate was 68.0%.In TXA group the overt bleeding,total blood loss and hidden blood loss,blood transfusion and transfusion rates are lower than the control group.There are statistically significant in the two groups(P <0.05).In TXA group,patients with short nail fixation had a 123.04 ml reduction in hidden blood loss than those with long nails and have a significant difference(P=0.024).In control group,the hidden blood loss reduced 142.53 ml and have a significant difference(P=0.016).There were no statistically significant differences in the incidence of deep vein thrombosis of lower limbs between the two groups(P=0.938).Conclusion:Tranexamic acid could significantly reduce hidden blood loss in elderly intertrochanteric fracture patients treated with intramedullary nails,but did not increase the risk of thrombosis in lower limbs deep veins.