臨床整形外科58巻5号

2023年05月発行

増大号特集 できる整形外科医になる！　臨床力UP，整形外科診療のコツとエッセンス 2章　治療

術中出血と術後貧血に対する対処法

著者： 加藤仁志¹ 出村諭¹ 横川文彬¹ 土屋弘行²³

所属機関： ¹金沢大学大学院整形外科 ²横浜栄共済病院 ³金沢大学

ページ範囲：P.621 - P.625

Point!

●高齢者においては外傷や手術に伴う急性出血・貧血に対する予備能が低下しているため，その対策は特に重要である．

●術中の大量出血は手術の完成度を低下させ，手術時間の超過や周術期合併症にも深く関与する．

●止血手技も重要だが，術中の低体温予防やトラネキサム酸の投与も検討する．

●輸血の適応は一般的にHb値7〜8g/dLが推奨されているが，高齢者は早めの実施を考慮する．

参考文献

1) Fukui D, Kawakami M, Nakao SI, et al. Reduced blood loss and operation time in lumbar posterolateral fusion using a bipolar sealer. Eur Spine J 2017;26:726-32.

2) Gordon ZL, Son-Hing JP, Poe-Kochert C, et al. Bipolar sealer device reduces blood loss and transfusion requirements in posterior spinal fusion for adolescent idiopathic scoliosis. J Pediatr Orthop 2013;33(7):700-6.

3) Barsoum WK, Klika AK, Murray TG, et al. Prospective randomized evaluation of the need for blood transfusion during primary total hip arthroplasty with use of a bipolar sealer. J Bone Joint Surg Am 2011;93(6):513-8.

4) Mikhail C, Pennington Z, Arnold PM, et al. Minimizing blood loss in spine surgery. Global Spine J 2020;10(1 Suppl):71S-83S.

5) Wang C, Han Z, Zhang T, et al. The efficacy of a thrombin-based hemostatic agent in primary total knee arthroplasty:a meta-analysis. J Orthop Surg Res 2014;9:90. doi:10.1186/s13018-014-0090-7.

6) Hsu CH, Lin PC, Kuo FC. A regime of two intravenous injections of tranezamic acid reduces blood loss in minimally invasive total hip arthroplasty:a prospective randomized double-blind study. Bone Joint J 2015;97-B(7):905-10.

7) Yamasaki S, Masuhara K, Fuji T. Tranexamic acid reduces postoperative blood loss in cementless total hip arthroplasty. J Bone Joint Surg Am 2005;87(4):766-70.

8) Charoencholvanich K, Siriwattanasakul P. Tranexamic acid reduces blood loss and blood transfusion after TKA:a prospective randomized controlled trial. Clin Orthop Relat Res 2011;469(10):2874-80.

9) Ishii Y, Noguchi H, Sato J, et al. Effect of a single injection of tranexamic acid on blood loss after primary hybrid TKA. Knee 2015;22(3):197-200.

10) Zufferey PJ, Miquet M, Quenet S, et al. Tranexamic acid in hip fracture surgery:a randomized controlled trial. Br J Anaesth 2010;104(1):23-30.

11) Ekinci M, Ok M, Ersin M, et al. A single dose of tranexamic acid infusion is safe and effective to reduce total blood loss during proximal femoral nailing for intertrochanteric fractures:a prospective randomized study. Ulus Travma Acil Cerrahi Derg 2022;28(11):1627-33.

12) Goobie SM, Zurakowski D, Glotzbecker MP, et al. Tranexamic acid is efficacious at decreasing the rate of blood loss in adolescent scoliosis surgery:a randomized placebo-controlled trial. J Bone Joint Surg Am 2018;100(23):2024-32.

13) Poeran J, Rasul R, Suzuki S, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States:retrospective analysis of effectiveness and safety. BMJ 2014;349:g4829. doi:10.1136/bmj.g4829.

14) Honda A, Iizuka Y, Michihata N, et al. Effect of intraoperative tranexamic acid on perioperative major hemorrhage requiring transfusion in patients undergoing elective spine surgery:a propensity score-matched analysis using a national inpatient database. Global Spine J 2022;21925682221123317. doi:10.1177/21925682221123317.

15) Schmied H, Kurz A, Sessler DI, et al. Mild hypothermia increases blood loss and transfusion requirements, during total hip arthroplasty. Lancet 1996;347(8997):289-92.

16) 富士武史，二宮晴夫，脇本信博．周術期の自己血輸血：献血資源節約により日本を救う．総合診療医会誌2019；15(6)：529-33．

17) Lorentz A, Osswald PM, Schilling M, et al. A comparison of autologous transfusion procedures in hip surgery. Anaesthesist 1991;40(4):205-13.

18) 日本整形外科学会，日本骨折治療学会(監)．日本整形外科学会診療ガイドライン委員会，大腿骨頚部/転子部骨折診療ガイドライン策定委員会(編)．大腿骨頚部/転子部骨折診療ガイドライン2021．改訂第3版．東京：南江堂；2021．

19) Brunskill SJ, Millette SL, Shokoohi A, et al. Red blood cell transfusion for people undergoing hip fracture surgery. Cochrane Database Syst Rev 2015;21(4):CD009699. doi:10.1002/14651858.CD009699.pub2.

20) 厚生労働省医薬・生活衛生局．血液製剤の使用指針．2019．https://www.mhlw.go.jp/content/11127000/000493546.pdf(2022年12月13日アクセス)

21) 厚生労働省医薬食品局血液対策課．輸血療法の実施に関する指針(改訂版)．2015．https://www.mhlw.go.jp/new-info/kobetu/iyaku/kenketsugo/5tekisei3a.html(2022年12月13日アクセス)

22) Andrews CM, Lane DW, Bradley JG. Iron pre-load for major joint replacement. Transfus Med 1997;7(4):281-6.

23) Zauber NP, Zauber AG, Gordon FJ, et al. Iron supplementation after femoral head replacement for patients with normal iron store. JAMA 1992;267(4):525-7.