慢加急性肝功能衰竭患者接受腹腔穿刺术后严重出血并发症的观察

Hemorrhagic complications following abdominal paracentesis in patients with acute-on-chronic liver failure

目的：分析慢加急性肝功能衰竭（ACLF）患者腹腔穿刺后严重出血并发症的发生率及其危险因素。方法前瞻性选取2010年1月至2013年12月在福建医科大学附属第一医院住院治疗的确诊为 ACLF 且进行1次以上腹腔穿刺的患者，观察术后腹腔或腹壁出血并发症的发生率。记录每次操作前3 d 内的指标。连续变量采用 t 检验，离散变量采用卡方检验，采用二元 Logistic 回归方法分析术后出血的危险因素。结果2010年1月至2013年12月入组185例 ACLF 患者，共进行525次腹腔穿刺术，其中289（55．0％）次为诊断性腹腔穿刺，236（45．0％）次为腹腔穿刺放腹水治疗。最终观察到16（3．0％）例出血事件，其中4例为腹壁血肿，12例为腹腔内出血。根据是否出现出血并发症，将所有患者分为出血组和未出血组，两组在年龄、性别、Child-Pugh 评分、穿刺腹水量、是否存在肝硬化基础、血小板计数、凝血酶时间等方面差异无统计学意义（均 P ＞0．05）。出血组 PT、国际标准化比值（INR）、活化部分凝血活酶时间（APTT）及终末期肝病模型（MELD）评分显著高于未出血组，纤维蛋白原水平则低于未出血组（均 P ＜0．05）。多因素回归分析提示，低纤维蛋白原血症是腹腔穿刺后出血的独立危险因素（OR＝0．105，95％CI ：0．018～0．608，P ＝0．012）。随着纤维蛋白原水平的下降，出血的风险随之增高，当纤维蛋白原≤0．8 g／L 时，出血风险高达11．76％（12／102）。结论低纤维蛋白原血症是 ACLF 患者腹腔穿刺后严重出血并发症的独立危险因素。

Objective The aim of this prospective observational study was to analyze the prevalence and the predictive factors of hemorrhagic events after abdominal paracentesis in patients with acute-on-chronic liver failure （ACLF）.Methods ACLF patients who received at least one episode of abdominal paracentesis were prospectively enrolled between January 2010 to December 2013. Prevalences of intraperitoneal and abdomen hemorrhage complications were examined. t test was performed for continuous variables and chi-square test was performed for categorical variables.Binary Logistic regression was used to analyze the risk factors of hemorrhage.Results A total of 525 abdominal paracenteses were carried out on 185 ACLF patients within a 4-year period,with 289 （55 .0%）for diagnostic purpose and 236 （45 .0%）for therapeutic purpose.A total of 16 （3.0%）hemorrhagic complications were identified, with 4 cases of abdominal wall hematomas and 12 cases of intraperitoneal hemorrhage.Patients were divided into hemorrhage group and non-hemorrhage group according to this complication.Age,gender, Child-Pugh score,volume of ascitic fluid removed,underlying cirrhosis,platelet count and thrombin time were not significantly different between two groups （all P ＆gt; 0.05 ）.Patients with bleeding events had lower fibrinogen levels and higher prothrombin time,international normalized ratio,activated partial thromboplastin time and model for end-stage liver disease score （all P 〈0.05）.After adjustment of other nbsp;factors,multivariate regression analysis indicated that low fibrinogen level was the only independent predictor of hemorrhagic complication （OR=0.105,95%CI ：0.018-0.608,P =0.012）.Conclusion Low fibrinogen level is the independent predictor of severe hemorrhagic complications following paracenteses in patients with ACLF.