Association of thrombelastogram with postoperative hemorrhage after total joint arthroplasty by structural equation modeling

doi:10.3969/j.issn.2095-4344.0026

Abstract

Abstract:

BACKGROUND: Postoperative anticoagulant therapy after hip and knee arthroplasties has been included in the perioperative management guidelines. However, the application of anticoagulant drugs accompanies with the risk of bleeding. Routine coagulation tests provide limited information about the quality of clots because they identify only the first stage of clotting, while thrombelastography provides a comprehensive assessment of coagulation function. But its practicality remains controversial and the research for bleeding after joint replacement is little reported.

OBJECTIVE: To explore the distribution of thrombelastography parameters (time to initial fibrin formation, clotting time, α angle, and maximum amplitude) and to analyze the correlation of the four parameters with postoperative blood loss, thereby providing guidance for improving the safety and effectiveness of anticoagulant therapy.

METHODS: Totally148 patients with detection of thrombelastogram after arthroplasty from August 2015 to March 2017 in Sun Yat-sen Memorial Hospital, Sun Yat-sen University were enrolled, including 76 cases of total hip arthroplasty and 72 cases of total knee arthroplasty. Thrombelastography data were collected on day 1 postoperatively, and the perioperative blood loss was calculated. Structural equation modeling of each group was constructed to investigate the relationship of four parameters and total blood loss.

RESULTS AND CONCLUSION: (1) In the structural equation modeling of hip and knee arthroplasties, the root mean square error of approximation was less than 0.08, goodness-of-fit index, adjusted goodness-of-fit index, normed fit index and comparative fit index was all higher than 0.9, and Parsi-mony goodness-of-fit index was less than 2, so the theoretical model was matched with the data. (2) There was a correlation of postoperative hemorrhage with time to initial fibrin formation, clotting time, α angle, and maximum amplitude. (3) That is to say, thrombelastogram can be used as an efficient tool in predicting bleeding after hip and knee arthroplasties. Future study based on this research will further verify the correlation and provide more information for its clinical practice.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Arthroplasty, Replacement, Thrombelastogram, Hemorrhage, Tissue Engineering

CLC Number:

R318

Zhang Ying-bin, Xu Jie, Weng Jian-hao, Li Deng, Cai Zhi-qing, Huang Yu-lin, Su Bao-hua, Ma Ruo-fan. Association of thrombelastogram with postoperative hemorrhage after total joint arthroplasty by structural equation modeling [J]. Chinese Journal of Tissue Engineering Research, 2018, 22(3): 329-335.

Figures/Tables 8

2.2 基线水平及出血情况本研究髋、膝关节置换者2组病例一般情况见表1。2组间关于年龄、体质量指数和凝血指标等计量资料的区别通过Mann-Whitney U 检验、独立样本t 检验建议进行比较；对性别、卧床制动情况、药物和疾病史等计数资料通过卡方检验比较。如表1所示，组间就年龄、卧床制动情况、心肺病史方面差异无显著性意义。术前TEG所属4个指标差异无显著性意义。统计髋、膝关节置换者2组病例术后均未予输血、补铁、促红细胞生成素等措施纠正贫血措施，术后失血总量、显性失血量及隐形失血量(见表2)，虽失血量有差异，但其百分比构成较为接近。2组患者失血总量、隐性出血量间的差异有显著性意义(P < 0.05)，而显性出血量2组间差异无显著性意义(P=0.50)。 2.3 术后第1天TEG 术后第1天所有入组患者均复测TEG，记录凝血反应时间、凝固时间、凝固角、血栓最大幅度值。术后第1天TEG 4个指数分布情况如图2，3所示，术后第1天患者凝血反应时间、凝固时间较正常值缩短，凝固角、血栓最大幅度稍增大。 2.4 结构方程模型凝血反应时间、凝固时间、凝固角、血栓最大幅度4个观察值与总出血量之间的关系，使用结构方程模型进行分析，由于凝血反应时间、凝固时间、凝固角、血栓最大幅度4个观察变量存在相关性，故用构建潜在变量(indicator)的来消除观察变量的相关性，潜在变量可以避免重复抽取观察变量中相同的信息，仅抽取各观察变量中有差异的信息，保证了信息不会重复。根据理论研究，外因潜在变量Indicator为显性变量，其有凝血反应时间、凝固时间、凝固角、血栓最大幅度等4个测量变量，内因潜在变量(出血)为显性变量，观察变量为总出血量。潜在变量Indicator对内因潜在变量(出血)有直接的影响。E1-e5分别为观察变量凝血反应时间、凝固时间、凝固角、血栓最大幅度与总出血量的误差项，err1为内因潜在变量的误差项。因为内因潜在变量(出血)只有一个观察变量，需将观察变量总出血量的误差项的方差固定为1，且同时认为观察变量总出血量可以完全反映总出血量的特质，故将总出血量到总出血量的路径系数固定为1，见图4。构建结构方程理论模型后，分别纳入髋、膝关节置换术后第1天TEG 4个变量与总出血量进入理论模型并进行拟合并研究凝血反应时间、凝固时间、凝固角、血栓最大幅度4个观察值与总出血量之间的关系。由表3可见，髋关节置换组潜在变量与4个观察变量标准化回归系数水平分别为：凝血反应时间=1.00(P < 0.05)，凝固时间=0.766(P < 0.05)，凝固角=-0.846(P < 0.05)，血栓最大幅度=-0.882(P < 0.05)。indicator和凝血反应时间、凝固时间、凝固角、血栓最大幅度4个值之间存在相关性。模型拟合结果绝对适配指数近似误差均方根为0.044小于0.08，拟合优度指数与调整拟合优度指数值均高于0.9；增值适配指数规范拟合指数值与比较拟合指数值均高于0.9；简约适配度指数χ2/df为1.540小于2。绝对适配指数、增值适配指数、简约适配度指数符合标准，理论模型与数据匹配的(见图5)。indicator与总出血量之间也存在相关性(标准化回归系数=0.445，CR=3.624，P < 0.05)。而由表4可见，膝关节置换组潜在变量indicator和凝血反应时间、凝固时间、凝固角、血栓最大幅度4个值之间也存在相关性。模型拟合结果绝对适配指数近似误差均方根为0.017小于0.08，拟合优度指数与调整拟合优度指数值均高于0.9；增值适配指数规范拟合指数值与比较拟合指数值均高于0.9；简约适配度指数χ2/df为1.540小于2。绝对适配指数、增值适配指数、简约适配度指数符合标准，理论模型与数据匹配(见图6)。indicator与总出血量之间也存在相关性(标准化回归系数=0.432，CR=3.297，P < 0.05)。 "

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