門診中以腸胃道內視鏡輔助大容積穿刺術安全有效


  Aug. 23, 2004 - 根據一項發表於8月號肝臟學(Hepatology)期刊的研究結果顯示,在門診以腸胃道內視鏡輔助進行大容積穿刺術是安全且有效的,即使對患有嚴重血小板低下或凝血脢原時間延長的病患,也是如此。
  
  明尼蘇達羅契斯特市梅約醫學中心進展性肝臟疾病研究團隊Catherine M. Grabau執照執業護士與其同事指出,大容積穿刺術,是偏好於有症狀、緊繃、因肝硬化造成腹水的治療方式;傳統上以住院、由醫師來執行,顯示更理想腹水治療方法,將可以減少醫師資源的消耗並且避免併發症發生。
  
  執業護士被訓練為腸胃道內視鏡助手,而且勝任3至7次獨立的穿刺術(平均4.4±1.6次);助手們為628位病患執行1,100次大容積穿刺術,這些病患大部份是肝硬化患者(513位),或惡性腹水(91位)。
  
  手術時間平均花費時間少於2個小時(平均97±24分鐘),以大約每6分鐘移除1升的速度移除了平均8.7±2.8升腹水,最大移除體積為31升。
  
  穿刺術前,平均國際標準凝血時間為1.7±0.46(範圍從0.9-8.7;四分位數範圍為1.4-2.2),而平均血小板數目為每微升5.04 x 103個(範圍從每微升19 x 103個至每微升341 x 103個;四分位數範圍為,每微升42 x 103個至每微升56 x 103個)。
  
  雖然大部分病患的凝血脢原時間延長,而且患有嚴重的血小板低下,並沒有發生需要住院的併發症,例如出血;3位病患發生姿態性低血壓,4位病患發生不超過48小時的腹水滲漏。
  
  研究人員指出,如果我們的結果在另一項大型試驗中獲得確認,可能不再需要常規性地監測凝血脢原時間及血小板數目,提供有經驗的操作者來執行穿刺術;此外,這與美國肝臟疾病研究協會的治療準則相符合,不全然需要由有經驗的人員常規性地矯正凝血脢原時間延長或血小板低下。
  
  根據這項試驗,門診方式由助手來執行穿刺術是項可以省下醫生時間且不會增加病患風險的方式。
  
  研究人員進一步指出,這項方式主要的好處是降低醫師資源需求,醫生僅僅需要訓練助手,強調足夠訓練(最好是經由10次手術指導)以避免例如出血、腸穿孔與死亡等併發症的重要性。
  
  根據健康照護組織鑑定聯合委員會(JCAHO)的準則,允許腸胃道內視鏡助手執行大容積穿刺術的行為已經由研究者於2001年7月時終止。
  
  研究人員總結指出,大容積穿刺術可以安全地以門診方式,由受過訓練的腸胃道內視鏡助手來執行;JCAHO的準則可能需要重新修正。

Outpatient Large-Volume Parace

By Yael Waknine
Medscape Medical News

Aug. 23, 2004 — Large-volume paracentesis performed by gastrointestinal endoscopy assistants in an outpatient setting is safe and efficient, even in patients with marked thrombocytopenia or prolonged prothrombin time, according to the results of a study published in the August issue of Hepatology.

"Large-volume paracentesis, the preferred treatment for patients with symptomatic tense ascites due to cirrhosis, has traditionally been performed by physicians as an inpatient procedure," write Catherine M. Grabau, LPN, and colleagues, from the Advanced Liver Diseases Study Group at the Mayo Clinic in Rochester, Minnesota, suggesting that a more ideal treatment of ascites would use fewer physician resources while avoiding complications.

Practical nurses were trained as gastrointestinal endoscopy assistants and achieved competence after three to seven independent paracentesis procedures (mean, 4.4 ± 1.6). Assistants performed 1,100 large-volume paracenteses in 628 patients, the majority having cirrhosis of the liver (n = 513) or malignant ascites (n = 91).

Mean duration of the procedure was less than two hours (mean, 97 minutes ± 24 minutes), with a mean 8.7 L ± 2.8 L of ascitic fluid removed at a rate of approximately 1 L every six minutes. The largest volume removed was 31 L.

Prior to paracentesis, the mean international normalized ratio for prothrombin time was 1.7 ± 0.46 (range, 0.9 - 8.7; interquartile range, 1.4 - 2.2), and the mean platelet count was 5.04 x 103/µL (range, 19 x 103/µL - 341 x 103/µL; interquartile range, 42 x 103/µL - 56 x 103/µL).

Although the majority of patients had prolonged prothrombin times and marked thrombocytopenia, there were no complications requiring hospitalization, such as hemorrhage. Postural hypotension occurred in three patients, and four patients had leakage of ascitic fluid lasting fewer than 48 hours.

"If our results are confirmed in another large study, routine measurement of prothrombin time and platelet count may no longer be required, provided that experienced operators carry out the paracentesis," the authors write, agreeing with practice guidelines by the American Association for the Study of Liver Diseases that discount the need for routine correction of prolonged prothrombin time or thrombocytopenia by experienced personnel.

Saving physician time without increased patient risk is a major benefit of outpatient paracentesis performed by assistants, according to the study.

"The major benefit of our approach is that it decreases the requirement for physician resources, as physician participation may be limited to training of personnel," the authors point out, emphasizing the importance of adequate training (optimally through 10 guided procedures) in avoiding complications such as bleeding, bowel perforation, and death.

Based on guidelines from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the practice of allowing gastrointestinal endoscopy assistants to carry out large-volume paracentesis was discontinued by the investigators in June 2001.

"[L]arge-volume paracentesis can be performed safely as an outpatient procedure by trained gastrointestinal endoscopy assistants," the authors conclude. "[JCAHO guidelines]...may need to be readdressed."

The authors report no pertinent financial disclosures.

Hepatology. 2004;40:484-488

Reviewed by Gary D. Vogin, MD

    
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