Dammert Pedro, Pratter Melvin, Boujaoude Ziad
Division of Pulmonary and Critical Care Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ.
J Bronchology Interv Pulmonol. 2013 Jan;20(1):16-20. doi: 10.1097/LBR.0b013e31828194f9.
The safety of small-bore chest tubes insertion with ultrasound (US) guidance has been well demonstrated in patients not receiving antiplatelet therapy. Given the current widespread use of these agents, pulmonologists frequently encounter patients on this therapy and requiring drainage of the pleural space. The use of these agents clearly increases the risk of bleeding, but it is not always possible to stop this therapy before the procedure, especially in patients requiring urgent drainage and those with coronary stents. The purpose of this study is to report our experience on the safety of US-guided small-bore chest tube placement in patients receiving clopidogrel.
This was a retrospective review of the charts of adult patients who underwent small-bore chest tube insertion by the pulmonary service while on clopidogrel. Data collected included patient's and effusion characteristics, indication for clopidogrel and for the procedure, and any significant bleeding complication defined as hemothorax, chest wall hematoma, a reduction in hemoglobin of >2 g/dL, or any bleeding requiring blood transfusion, surgery, or chest tube insertion. US of the chest was performed before insertion but did not include Doppler study of intercostal arteries. Lateral insertion at or anterior to the posterior axillary line was the preferred choice when possible.
Forty-three procedures were performed in 30 patients. Seventy percent were male with a mean age of 71 years. The indications for clopidogrel were coronary stents (50%), acute coronary syndrome (27%), prevention of graft occlusion after coronary artery bypass graft (CABG) (13%), femoral stent or endarterectomy (7%), and carotid endarterectomy (3%). The etiology of the effusions was post-CABG (43%), heart failure (17%), end-stage renal disease (13%), pneumothorax (10%), and others (17%). The procedures were therapeutic in 41 cases and diagnostic in 2. The indications for the procedure were respiratory distress (65%), respiratory failure (23%), and pneumothorax (7%). Fifteen procedures (35%) were performed in 10 patients in the ICU and 6 of them were mechanically ventilated. Nine patients were obese based on body mass index. Neither significant bleeding nor other minor complications were seen.
OH 44195: The insertion of small-bore chest tube in patients receiving clopidogrel can be safe if performed by experienced operators and by using US guidance along with lateral insertion site, which has the lowest risk of lacerating the intercostal arteries.
超声（US）引导下置入细径胸管在未接受抗血小板治疗的患者中的安全性已得到充分证实。鉴于目前这些药物的广泛使用，肺科医生经常会遇到正在接受此类治疗且需要进行胸腔引流的患者。使用这些药物显然会增加出血风险，但在操作前并非总能停用该治疗，尤其是在需要紧急引流的患者以及有冠状动脉支架的患者中。本研究的目的是报告我们在接受氯吡格雷治疗的患者中进行超声引导下细径胸管置入安全性方面的经验。
这是一项对成年患者病历的回顾性研究，这些患者在接受氯吡格雷治疗期间由肺科进行细径胸管置入。收集的数据包括患者和胸腔积液特征、氯吡格雷及该操作的适应证，以及任何定义为血胸、胸壁血肿、血红蛋白下降>2 g/dL或任何需要输血、手术或再次置入胸管的出血等严重出血并发症。在置入前进行了胸部超声检查，但未包括肋间动脉的多普勒研究。尽可能选择在腋后线或其前方进行侧方置入。
30例患者共进行了43次操作。70%为男性，平均年龄71岁。使用氯吡格雷的适应证为冠状动脉支架（50%）、急性冠状动脉综合征（27%）、冠状动脉旁路移植术（CABG）后预防移植物闭塞（13%）、股动脉支架或动脉内膜切除术（7%）以及颈动脉内膜切除术（3%）。胸腔积液的病因是CABG术后（43%）、心力衰竭（17%）、终末期肾病（13%）、气胸（10%）以及其他（17%）。41例操作具有治疗目的，2例为诊断性操作。操作的适应证为呼吸窘迫（65%）、呼吸衰竭（23%）和气胸（7%）。10例患者在重症监护病房（ICU）进行了15次操作（35%），其中6例为机械通气患者。9例患者根据体重指数属于肥胖。未观察到严重出血或其他轻微并发症。
俄亥俄州44195：如果由经验丰富的操作人员进行，并采用超声引导以及侧方置入部位（该部位撕裂肋间动脉的风险最低），那么在接受氯吡格雷治疗的患者中置入细径胸管可能是安全的。
