Effectiveness and safety of tranexamic acid combined with intraoperative controlled hypotension on reducing perioperative blood loss in primary total hip arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Qingyi ^1,2 , YIN Shijiu ¹ , HUANG Kai ^1,2 , WANG Miye ³ , XIE Huiqi ^1,2 , LIAO Ren ⁴ ,  ZENG Yi ^1,2 ,  YANG Jing ¹

1. Department of Orthopedics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;
2. Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;
3. Information Center of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;
4. Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

ZENG Yi, Email: zengyigd@126.com; YANG Jing, Email: cd-yangjing@163.com

Keywords：

Tranexamic acid; intraoperative controlled hypotension; perioperative blood loss; transfusion; total hip arthroplasty

DOI：

10.7507/1002-1892.202103230

Video：

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Objective To evaluate the effectiveness and safety of tranexamic acid (TXA) combined with intraoperative controlled hypotension (ICH) for reducing perioperative blood loss in primary total hip arthroplasty (THA).Methods The clinical data of 832 patients with initial THA due to osteonecrosis of femoral head between January 2017 and July 2020 were retrospectively analyzed. All patients received TXA treatment, and 439 patients (hypotension group) received ICH treatment with an intraoperative mean arterial pressure (MAP) below 80 mm Hg (1 mm Hg=0.133 kPa) while 393 patients (normotension group) received standard general anesthesia with no special invention on blood pressure. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists (ASA) classification, basic arterial pressure, hip range of motion, internal diseases, preoperative hemoglobin (HB) and hematocrit (HCT), coagulation function, surgical approach, and TXA dosage between the two groups (P>0.05). The perioperative blood loss and blood transfusion, anesthesia and operation time, hospitalization stay, postoperative range of motion, and complications were recorded and compared between the two groups. The patients were further divided into MAP<70 mm Hg group (group A), MAP 70-80 mm Hg group (group B), and normotension group (group C). The perioperative blood loss and postoperative complications were further analyzed to screen the best range of blood pressure.Results The intraoperative MAP, total blood loss, dominant blood loss, recessive blood loss, blood transfusion rate and blood transfusion volume, anesthesia time, operation time, and hospitalizarion stay in the hypotension group were significantly lower than those in the normotension group (P<0.05). The postoperative hip flexion range of motion in the hypotension group was significantly better than that of the normotension group (Z=2.743, P=0.006), but there was no significant difference in the abduction range of motion between the two groups (Z=0.338, P=0.735). In terms of postoperative complications, the incidence of postoperative hypotension in the hypotension group was significantly higher than that in the normotension group (χ²=6.096, P=0.014), and there was no significant difference in the incidence of other complications (P>0.05). There was no stroke, pulmonary embolism, or deep vein thrombosis in the two groups, and no patients died during hospitalization. Subgroup analysis showed that there was no significant difference in total blood loss, dominant blood loss, and recessive blood loss in groups A and B during the perioperative period (P>0.05), which were significantly lower than those in group C (P<0.05). There was no significant difference in blood transfusion rate, blood transfusion volume, and incidence of acute myocardial injury between 3 groups (P>0.05); the incidence of acute kidney injury in group A was significantly higher than that in group B, and the incidence of postoperative hypotension in group A was significantly higher than that in groups B and C (P<0.05), but no significant difference was found between groups B and C (P>0.05).Conclusion The combination of TXA and ICH has a synergistic effect. Controlling the intraoperative MAP at 70-80 mm Hg can effectively reduce the perioperative blood loss during the initial THA, and it is not accompanied by postoperative complications.

Citation： ZHANG Qingyi, YIN Shijiu, HUANG Kai, WANG Miye, XIE Huiqi, LIAO Ren, ZENG Yi, YANG Jing. Effectiveness and safety of tranexamic acid combined with intraoperative controlled hypotension on reducing perioperative blood loss in primary total hip arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(9): 1133-1140. doi: 10.7507/1002-1892.202103230 Copy

1.	Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet, 2007, 370(9597): 1508-1519.
2.	Stulberg BN, Zadzilka JD. Blood management issues using blood management strategies. J Arthroplasty, 2007, 22(4 Suppl 1): 95-98.
3.	Kim JL, Park JH, Han SB, et al. Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: A meta-analysis. J Arthroplasty, 2017, 32(1): 320-325.
4.	Lemaire R. Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg (Br), 2008, 90(9): 1128-1136.
5.	Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta Orthop Scand, 1996, 67(1): 91-107.
6.	Wang D, Wang HY, Luo ZY, et al. Finding the optimal regimen for oral tranexamic acid administration in primary total hip arthroplasty: A randomized controlled trial. J Bone Joint Surg (Am), 2019, 101(5): 438-445.
7.	周宗科, 翁习生, 孙天胜, 等. 中国骨科手术加速康复——围术期血液管理专家共识. 中华骨与关节外科杂志, 2017, 10(1): 1-7.
8.	Xie J, Cai Y, Ma J, et al. Oral mosapride can provide additional anti-emetic efficacy following total joint arthroplasty under general anesthesia: a randomized, double-blinded clinical trial. BMC Anesthesiol, 2020, 20(1): 297. doi: 10.1186/s12871-020-01214-4.
9.	Wang HY, Yuan MC, Pei FX, et al. 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.
10.	Huang Z, Xie X, Li L, et al. Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary total knee arthroplasty: A prospective, randomized controlled trial. J Bone Joint Surg (Am), 2017, 99(24): 2053-2061.
11.	Hahn RG. Estimating allowable blood loss with correction for variations in blood volume. Acta Anaesthesiol Scand, 1989, 33(6): 508-512.
12.	Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology, 2014, 120(3): 564-578.
13.	Salmasi V, Maheshwari K, Yang D, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: A retrospective Cohort analysis. Anesthesiology, 2017, 126(1): 47-65.
14.	Liem VGB, Hoeks SE, Mol KHJM, et al. Postoperative hypotension after noncardiac surgery and the association with myocardial injury. Anesthesiology, 2020, 133(3): 510-522.
15.	Bierbaum BE, Callaghan JJ, Galante JO, et al. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg (Am), 1999, 81(1): 2-10.
16.	岳辰, 周宗科, 裴福兴, 等. 中国髋、膝关节置换术围术期抗纤溶药序贯抗凝血药应用方案的专家共识. 中华骨与关节外科杂志, 2015, 8(4): 281-285.
17.	Wu YG, Zeng Y, Yang TM, et al. The efficacy and safety of combination of intravenous and topical tranexamic acid in revision hip arthroplasty: A randomized, controlled trial. J Arthroplasty, 2016, 31(11): 2548-2553.
18.	Sharrock NE, Go G, Mineo R, et al. The hemodynamic and fibrinolytic response to low dose epinephrine and phenylephrine infusions during total hip replacement under epidural anesthesia. Thromb Haemost, 1992, 68(4): 436-441.
19.	Fredin H, Gustafson C, Rosberg B. Hypotensive anesthesia, thromboprophylaxis and postoperative thromboembolism in total hip arthroplasty. Acta Anaesthesiol Scand, 1984, 28(5): 503-507.
20.	Paul JE, Ling E, Lalonde C, et al. Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: a meta-analysis of randomized controlled trials. Can J Anaesth, 2007, 54(10): 799-810.
21.	Jiang J, Zhou R, Li B, et al. Is deliberate hypotension a safe technique for orthopedic surgery?: a systematic review and meta-analysis of parallel randomized controlled trials. J Orthop Surg Res, 2019, 14(1): 409. doi: 10.1186/s13018-019-1473-6.
22.	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.
23.	Banerjee S, Issa K, Kapadia BH, et al. Intraoperative nonpharmacotherapeutic blood management strategies in total knee arthroplasty. J Knee Surg, 2013, 26(6): 387-393.
24.	Liu X, Zhang X, Chen Y, et al. Hidden blood loss after total hip arthroplasty. J Arthroplasty, 2011, 26(7): 1100-1105.
25.	King L, Randle R, Dare W, et al. Comparison of oral vs. combined topical/intravenous/oral tranexamic acid in the prevention of blood loss in total knee arthroplasty: A randomised clinical trial. Orthop Traumatol Surg Res, 2019, 105(6): 1073-1077.
26.	Yue C, Kang P, Yang P, et al. Topical application of tranexamic acid in primary total hip arthroplasty: a randomized double-blind controlled trial. J Arthroplasty, 2014, 29(12): 2452-2456.
27.	Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, et al. Intra-articular tranexamic acid mitigates blood loss and morphine use after total knee arthroplasty. A randomized controlled trial. J Arthroplasty, 2019, 34(5): 877-881.
28.	Huang Z, Ma J, Shen B, et al. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty, 2014, 29(12): 2342-2346.
29.	Sharrock NE, Mineo R, Urquhart B. Haemodynamic effects and outcome analysis of hypotensive extradural anaesthesia in controlled hypertensive patients undergoing total hip arthroplasty. Br J Anaesth, 1991, 67(1): 17-25.
30.	Sharrock NE, Mineo R, Urquhart B, et al. The effect of two levels of hypotension on intraoperative blood loss during total hip arthroplasty performed under lumbar epidural anesthesia. Anesth Analg, 1993, 76(3): 580-584.
31.	Sharrock NE, Mineo R, Urquhart B. Hemodynamic response to low-dose epinephrine infusion during hypotensive epidural anesthesia for total hip replacement. Reg Anesth, 1990, 15(6): 295-299.
32.	Andel D, Andel H, Hörauf K, et al. The influence of deliberate hypotension on splanchnic perfusion balance with use of either isoflurane or esmolol and nitroglycerin. Anesth Analg, 2001, 93(5): 1116-1120.
33.	Jeong J, Portnof JE, Kalayeh M, et al. Hypotensive anesthesia: Comparing the effects of different drug combinations on mean arterial pressure, estimated blood loss, and surgery time in orthognathic surgery. J Craniomaxillofac Surg, 2016, 44(7): 854-858.
34.	Sabaté S, Mases A, Guilera N, et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth, 2011, 107(6): 879-890.
35.	Bombardieri AM, Sharrock NE, Ma Y, et al. An Observational study of cerebral blood flow velocity during hypotensive epidural anesthesia. Anesth Analg, 2016, 122(1): 226-233.
36.	Neal JM, Barrington MJ, Brull R, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine: Executive summary 2015. Reg Anesth Pain Med, 2015, 40(5): 401-430.
37.	Thompson GE, Miller RD, Stevens WC, et al. Hypotensive anesthesia for total hip arthroplasty: a study of blood loss and organ function (brain, heart, liver, and kidney). Anesthesiology, 1978, 48(2): 91-96.
38.	Williams-Russo P, Sharrock NE, Mattis S, et al. Randomized trial of hypotensive epidural anesthesia in older adults. Anesthesiology, 1999, 91(4): 926-935.
39.	Lieberman JR, Huo MM, Hanway J, et al. The prevalence of deep venous thrombosis after total hip arthroplasty with hypotensive epidural anesthesia. J Bone Joint Surg (Am), 1994, 76(3): 341-348.
40.	Ho MC, Beathe JC, Sharrock NE. Hypotensive epidural anesthesia in patients with aortic stenosis undergoing total hip replacement. Reg Anesth Pain Med, 2008, 33(2): 129-133.
41.	Sharrock NE, Beksac B, Flynn E, et al. Hypotensive epidural anaesthesia in patients with preoperative renal dysfunction undergoing total hip replacement. Br J Anaesth, 2006, 96(2): 207-212.
42.	Sharrock NE, Bading B, Mineo R, et al. Deliberate hypotensive epidural anesthesia for patients with normal and low cardiac output. Anesth Analg, 1994, 79(5): 899-904.
43.	Maheshwari K, Turan A, Mao G, et al. The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis. Anaesthesia, 2018, 73(10): 1223-1228.
44.	Sun LY, Wijeysundera DN, Tait GA, et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology, 2015, 123(3): 515-523.
45.	Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology, 2013, 119(3): 507-515.
46.	Wesselink EM, Kappen TH, Torn HM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth, 2018, 121(4): 706-721.
47.	Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology, 2015, 123(2): 307-319.
48.	Mascha EJ, Yang D, Weiss S, et al. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology, 2015, 123(1): 79-91.
49.	Maheshwari K, Ahuja S, Khanna AK, et al. Association between perioperative hypotension and delirium in postoperative critically ill patients: A retrospective Cohort analysis. Anesth Analg, 2020, 130(3): 636-643.

1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet, 2007, 370(9597): 1508-1519.
2. Stulberg BN, Zadzilka JD. Blood management issues using blood management strategies. J Arthroplasty, 2007, 22(4 Suppl 1): 95-98.
3. Kim JL, Park JH, Han SB, et al. Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: A meta-analysis. J Arthroplasty, 2017, 32(1): 320-325.
4. Lemaire R. Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg (Br), 2008, 90(9): 1128-1136.
5. Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta Orthop Scand, 1996, 67(1): 91-107.
6. Wang D, Wang HY, Luo ZY, et al. Finding the optimal regimen for oral tranexamic acid administration in primary total hip arthroplasty: A randomized controlled trial. J Bone Joint Surg (Am), 2019, 101(5): 438-445.
7. 周宗科, 翁习生, 孙天胜, 等. 中国骨科手术加速康复——围术期血液管理专家共识. 中华骨与关节外科杂志, 2017, 10(1): 1-7.
8. Xie J, Cai Y, Ma J, et al. Oral mosapride can provide additional anti-emetic efficacy following total joint arthroplasty under general anesthesia: a randomized, double-blinded clinical trial. BMC Anesthesiol, 2020, 20(1): 297. doi: 10.1186/s12871-020-01214-4.
9. Wang HY, Yuan MC, Pei FX, et al. 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.
10. Huang Z, Xie X, Li L, et al. Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary total knee arthroplasty: A prospective, randomized controlled trial. J Bone Joint Surg (Am), 2017, 99(24): 2053-2061.
11. Hahn RG. Estimating allowable blood loss with correction for variations in blood volume. Acta Anaesthesiol Scand, 1989, 33(6): 508-512.
12. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology, 2014, 120(3): 564-578.
13. Salmasi V, Maheshwari K, Yang D, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: A retrospective Cohort analysis. Anesthesiology, 2017, 126(1): 47-65.
14. Liem VGB, Hoeks SE, Mol KHJM, et al. Postoperative hypotension after noncardiac surgery and the association with myocardial injury. Anesthesiology, 2020, 133(3): 510-522.
15. Bierbaum BE, Callaghan JJ, Galante JO, et al. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg (Am), 1999, 81(1): 2-10.
16. 岳辰, 周宗科, 裴福兴, 等. 中国髋、膝关节置换术围术期抗纤溶药序贯抗凝血药应用方案的专家共识. 中华骨与关节外科杂志, 2015, 8(4): 281-285.
17. Wu YG, Zeng Y, Yang TM, et al. The efficacy and safety of combination of intravenous and topical tranexamic acid in revision hip arthroplasty: A randomized, controlled trial. J Arthroplasty, 2016, 31(11): 2548-2553.
18. Sharrock NE, Go G, Mineo R, et al. The hemodynamic and fibrinolytic response to low dose epinephrine and phenylephrine infusions during total hip replacement under epidural anesthesia. Thromb Haemost, 1992, 68(4): 436-441.
19. Fredin H, Gustafson C, Rosberg B. Hypotensive anesthesia, thromboprophylaxis and postoperative thromboembolism in total hip arthroplasty. Acta Anaesthesiol Scand, 1984, 28(5): 503-507.
20. Paul JE, Ling E, Lalonde C, et al. Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: a meta-analysis of randomized controlled trials. Can J Anaesth, 2007, 54(10): 799-810.
21. Jiang J, Zhou R, Li B, et al. Is deliberate hypotension a safe technique for orthopedic surgery?: a systematic review and meta-analysis of parallel randomized controlled trials. J Orthop Surg Res, 2019, 14(1): 409. doi: 10.1186/s13018-019-1473-6.
22. 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.
23. Banerjee S, Issa K, Kapadia BH, et al. Intraoperative nonpharmacotherapeutic blood management strategies in total knee arthroplasty. J Knee Surg, 2013, 26(6): 387-393.
24. Liu X, Zhang X, Chen Y, et al. Hidden blood loss after total hip arthroplasty. J Arthroplasty, 2011, 26(7): 1100-1105.
25. King L, Randle R, Dare W, et al. Comparison of oral vs. combined topical/intravenous/oral tranexamic acid in the prevention of blood loss in total knee arthroplasty: A randomised clinical trial. Orthop Traumatol Surg Res, 2019, 105(6): 1073-1077.
26. Yue C, Kang P, Yang P, et al. Topical application of tranexamic acid in primary total hip arthroplasty: a randomized double-blind controlled trial. J Arthroplasty, 2014, 29(12): 2452-2456.
27. Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, et al. Intra-articular tranexamic acid mitigates blood loss and morphine use after total knee arthroplasty. A randomized controlled trial. J Arthroplasty, 2019, 34(5): 877-881.
28. Huang Z, Ma J, Shen B, et al. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty, 2014, 29(12): 2342-2346.
29. Sharrock NE, Mineo R, Urquhart B. Haemodynamic effects and outcome analysis of hypotensive extradural anaesthesia in controlled hypertensive patients undergoing total hip arthroplasty. Br J Anaesth, 1991, 67(1): 17-25.
30. Sharrock NE, Mineo R, Urquhart B, et al. The effect of two levels of hypotension on intraoperative blood loss during total hip arthroplasty performed under lumbar epidural anesthesia. Anesth Analg, 1993, 76(3): 580-584.
31. Sharrock NE, Mineo R, Urquhart B. Hemodynamic response to low-dose epinephrine infusion during hypotensive epidural anesthesia for total hip replacement. Reg Anesth, 1990, 15(6): 295-299.
32. Andel D, Andel H, Hörauf K, et al. The influence of deliberate hypotension on splanchnic perfusion balance with use of either isoflurane or esmolol and nitroglycerin. Anesth Analg, 2001, 93(5): 1116-1120.
33. Jeong J, Portnof JE, Kalayeh M, et al. Hypotensive anesthesia: Comparing the effects of different drug combinations on mean arterial pressure, estimated blood loss, and surgery time in orthognathic surgery. J Craniomaxillofac Surg, 2016, 44(7): 854-858.
34. Sabaté S, Mases A, Guilera N, et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth, 2011, 107(6): 879-890.
35. Bombardieri AM, Sharrock NE, Ma Y, et al. An Observational study of cerebral blood flow velocity during hypotensive epidural anesthesia. Anesth Analg, 2016, 122(1): 226-233.
36. Neal JM, Barrington MJ, Brull R, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine: Executive summary 2015. Reg Anesth Pain Med, 2015, 40(5): 401-430.
37. Thompson GE, Miller RD, Stevens WC, et al. Hypotensive anesthesia for total hip arthroplasty: a study of blood loss and organ function (brain, heart, liver, and kidney). Anesthesiology, 1978, 48(2): 91-96.
38. Williams-Russo P, Sharrock NE, Mattis S, et al. Randomized trial of hypotensive epidural anesthesia in older adults. Anesthesiology, 1999, 91(4): 926-935.
39. Lieberman JR, Huo MM, Hanway J, et al. The prevalence of deep venous thrombosis after total hip arthroplasty with hypotensive epidural anesthesia. J Bone Joint Surg (Am), 1994, 76(3): 341-348.
40. Ho MC, Beathe JC, Sharrock NE. Hypotensive epidural anesthesia in patients with aortic stenosis undergoing total hip replacement. Reg Anesth Pain Med, 2008, 33(2): 129-133.
41. Sharrock NE, Beksac B, Flynn E, et al. Hypotensive epidural anaesthesia in patients with preoperative renal dysfunction undergoing total hip replacement. Br J Anaesth, 2006, 96(2): 207-212.
42. Sharrock NE, Bading B, Mineo R, et al. Deliberate hypotensive epidural anesthesia for patients with normal and low cardiac output. Anesth Analg, 1994, 79(5): 899-904.
43. Maheshwari K, Turan A, Mao G, et al. The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis. Anaesthesia, 2018, 73(10): 1223-1228.
44. Sun LY, Wijeysundera DN, Tait GA, et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology, 2015, 123(3): 515-523.
45. Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology, 2013, 119(3): 507-515.
46. Wesselink EM, Kappen TH, Torn HM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth, 2018, 121(4): 706-721.
47. Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology, 2015, 123(2): 307-319.
48. Mascha EJ, Yang D, Weiss S, et al. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology, 2015, 123(1): 79-91.
49. Maheshwari K, Ahuja S, Khanna AK, et al. Association between perioperative hypotension and delirium in postoperative critically ill patients: A retrospective Cohort analysis. Anesth Analg, 2020, 130(3): 636-643.

Chinese Journal of Reparative and Reconstructive Surgery

Effectiveness and safety of tranexamic acid combined with intraoperative controlled hypotension on reducing perioperative blood loss in primary total hip arthroplasty

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