Fletcher Allen Health Care, 111 Colchester Avenue, 272-BA1, Burlington, VT 05401, USA.
J Trauma Acute Care Surg. 2012 Apr;72(4):815-20; quiz 1124-5. doi: 10.1097/TA.0b013e31824fbadf.
Percutaneous endoscopic gastrostomy (PEG) and percutaneous dilatational tracheostomy (PDT) are frequently performed bedside in the intensive care unit. Critically ill patients frequently require anticoagulant (AC) and antiplatelet (AP) therapies for myriad indications. There are no societal guidelines proffering strategies to manage AC/AP therapies periprocedurally for bedside PEG or PDT. The aim of this study is to evaluate the management of AC/AP therapies around PEG/PDT, assess periprocedural bleeding complications, and identify risk factors associated with bleeding.
A retrospective, observational study of all adult patients admitted from October 2004 to December 2009 receiving a bedside PEG or PDT was conducted. Patients were identified by procedure codes via an in-hospital database. A medical record review was performed for each included patient.
Four hundred fifteen patients were included, with 187 PEGs and 352 PDTs being performed. Prophylactic anticoagulation was held for approximately one dose before and two doses or less after the procedure. There was wide variation in patterns of holding therapy in patients receiving anticoagulation via continuous infusion. There were 19 recorded minor bleeding events, 1 (0.5%) with PEG and 18 (5.1%) with PDT, with no hemorrhagic events. No association was found between international normalized ratio, prothrombin time, or activated partial thromboplastin time values and bleed risk (p = 0.853, 0.689, and 0.440, respectively). Platelet count was significantly lower in patients with a bleeding event (p = 0.006).
We found that while practice patterns were quite consistent in regard to the management of prophylactic anticoagulation, it varied widely in patients receiving therapeutic anticoagulation. It seems that prophylactic anticoagulation use did not affect bleed risk with PEG/PDT.
经皮内镜下胃造口术（PEG）和经皮扩张气管切开术（PDT）在重症监护病房经常床边进行。重症患者经常因多种原因需要抗凝（AC）和抗血小板（AP）治疗。目前没有社会指南提供策略来管理床边 PEG 或 PDT 围手术期的 AC/AP 治疗。本研究旨在评估 AC/AP 治疗方法在 PEG/PDT 中的应用，评估围手术期出血并发症，并确定与出血相关的风险因素。
回顾性观察性研究纳入 2004 年 10 月至 2009 年 12 月期间接受床边 PEG 或 PDT 的所有成年患者。通过医院内数据库中的程序代码识别患者。对每个纳入的患者进行病历回顾。
共纳入 415 例患者，其中 187 例行 PEG，352 例行 PDT。大约在术前停止使用预防性抗凝 1 个剂量，术后停止使用 2 个剂量或更少。接受连续输注抗凝治疗的患者中，停止治疗的模式存在广泛差异。记录了 19 例轻微出血事件，1 例（0.5%）与 PEG 相关，18 例（5.1%）与 PDT 相关，均无出血事件。国际标准化比值、凝血酶原时间或活化部分凝血活酶时间值与出血风险之间无关联（p = 0.853、0.689 和 0.440）。有出血事件的患者血小板计数明显较低（p = 0.006）。
我们发现，虽然预防性抗凝管理方面的实践模式相当一致，但接受治疗性抗凝的患者的抗凝管理模式差异很大。预防性抗凝似乎并未影响 PEG/PDT 的出血风险。
