Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
Clin Gastroenterol Hepatol. 2014 Mar;12(3):496-503.e1. doi: 10.1016/j.cgh.2013.08.025. Epub 2013 Aug 24.
BACKGROUND & AIMS: Diagnostic paracentesis is recommended for patients with cirrhosis who are admitted to the hospital for ascites or encephalopathy. However, it is not known whether clinicians in the United States adhere to this recommendation; a relationship between paracentesis and clinical outcome has not been reported. We analyzed a U.S. database to determine the frequency of paracentesis and its association with mortality.
The 2009 Nationwide Inpatient Sample (which contains data from approximately 8 million hospital discharges each year) was used to identify patients with cirrhosis and ascites who were admitted with a primary diagnosis of ascites or encephalopathy. In-hospital mortality, length of stay, and hospital charges were compared for those who did and did not undergo paracentesis. Outcomes were compared for those who received an early paracentesis (within 1 day of admission) and those who received one later.
Of 17,711 eligible admissions, only 61% underwent paracentesis. In-hospital mortality was reduced by 24% among patients who underwent paracentesis (6.5% vs 8.5%; adjusted odds ratio, 0.55; 95% confidence interval, 0.41-0.74). Most paracenteses (66%) occurred ≤1 day after admission. In-hospital mortality was lower among patients who received early paracentesis than those who received it later (5.7% vs 8.1%, P = .049), although this difference was not significant after adjustment for confounders (odds ratio, 1.26; 95% confidence interval, 0.78-2.02). Among patients who underwent paracentesis, the mean hospital stay was 14% longer and hospital charges were 29% greater than for patients who did not receive the procedure.
Paracentesis is underused for patients admitted to the hospital with ascites; the procedure is associated with increased short-term survival. These data support practice guidelines derived from expert opinion. Studies are needed to identify barriers to guideline adherence.
对于因腹水或肝性脑病住院的肝硬化患者，建议进行诊断性腹腔穿刺术。然而，目前尚不清楚美国的临床医生是否遵循这一建议；也尚未有研究报道腹腔穿刺术与临床结局之间的关系。我们分析了一个美国数据库，以确定腹腔穿刺术的实施频率及其与死亡率的关系。
使用 2009 年全国住院患者样本（每年包含约 800 万例住院患者的数据），确定因腹水或肝性脑病的主要诊断而住院的肝硬化和腹水患者。比较行腹腔穿刺术和未行腹腔穿刺术患者的院内死亡率、住院时间和住院费用。比较行早期腹腔穿刺术（入院后 1 天内）和较晚行腹腔穿刺术患者的结局。
在 17711 例合格的入院患者中，仅有 61%接受了腹腔穿刺术。行腹腔穿刺术的患者院内死亡率降低了 24%（6.5% vs. 8.5%；校正比值比，0.55；95%置信区间，0.41-0.74）。大多数腹腔穿刺术（66%）发生在入院后 1 天内。与较晚行腹腔穿刺术的患者相比，早期行腹腔穿刺术的患者院内死亡率更低（5.7% vs. 8.1%，P=0.049），但在校正混杂因素后差异无统计学意义（比值比，1.26；95%置信区间，0.78-2.02）。在接受腹腔穿刺术的患者中，住院时间平均延长 14%，住院费用平均增加 29%，高于未行该手术的患者。
对于因腹水住院的患者，腹腔穿刺术的应用不足；该手术与短期生存率的提高有关。这些数据支持基于专家意见制定的实践指南。需要开展研究以确定遵行指南的障碍。
