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伴或不伴凝血障碍的患者腰穿后发生脊髓血肿的风险相差不大
2020-10-15 16:21

丹麦新奥尔堡大学医院Henrik Nielsen团队研究了伴或不伴凝血障碍的患者在腰穿后发生脊髓血肿的风险。2020年10月13日,该研究发表在《美国医学会杂志》上。

凝血障碍可能会阻止医生进行腰穿。为了确定伴或不伴凝血障碍的患者腰穿后发生脊髓血肿的风险,研究组在丹麦进行了一项全国性、以人群为基础的队列研究,使用2008年1月1日至2018年12月31日接受腰椎穿刺并进行脑脊液分析的患者数据。主要结局为30天内脊髓血肿的风险。

64730例经历腰椎穿刺的患者中51%为女性,平均年龄为43岁。其中7875例患者(9%)发生血小板减少症,1393例(2%)INR较高,2604例(3%)APTT延长。超过99%的参与者都完成了随访。总体而言,没有凝血障碍的49526名患者中有99名(0.20%)在30天内发生脊髓血肿,而10371名有凝血障碍的患者中有24名(0.23%)。

脊髓血肿的独立危险因素是男性(校正后的风险比为1.72),41-60岁的人群(1.96),以及61-80岁的人群(2.20)。脊髓血肿的风险并没有随凝血障碍的总体严重程度而显著增加,也没有根据手术的累积次数而显著增加。与正常INR相比,创伤性腰椎穿刺在INR水平为1.5-2.0(36.8%)、2.1-2.5(43.7%)和2.6-3.0(41.9%)的患者中更为常见。APTT为40-60秒(26.3%)的患者外伤性脊髓穿刺的发生率为26.3%,显著高于正常APTT的患者(21.3%)。

总之,伴或不伴凝血障碍的患者在腰穿后发生脊髓血肿的风险相差不大。

附:英文原文

Title: Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy

Author: Jacob Bodilsen, Theis Mariager, Hannah Holm Vestergaard, Mikkel Hjberg Christiansen, Mikkel Kunwald, Hans Rudolf Lüttichau, Bo Traberg Kristensen, Carsten Reidies Bjarkam, Henrik Nielsen

Issue&Volume: 2020/10/13

Abstract:

Importance  Coagulopathy may deter physicians from performing a lumbar puncture.

Objective  To determine the risk of spinal hematoma after lumbar puncture in patients with and without coagulopathy.

Design, Setting, and Participants  Danish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150×109/L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds.

Exposures  Coagulopathy at the time of lumbar puncture.

Main Outcomes and Measures  Thirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300×106 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models.

Results  A total of 83711 individual lumbar punctures were identified among 64730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49526 patients (0.20%; 95% CI, 0.16%-0.24%) without coagulopathy vs 24 of 10371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%).

Conclusions and Relevance  In this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture.

DOI: 10.1001/jama.2020.14895

Source: https://jamanetwork.com/journals/jama/article-abstract/2771609

JAMA-Journal of The American Medical Association:《美国医学会杂志》,创刊于1883年。隶属于美国医学协会,最新IF:51.273
官方网址:https://jamanetwork.com/
投稿链接:http://manuscripts.jama.com/cgi-bin/main.plex


本期文章:《美国医学会杂志》:Vol 324 No 14

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