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Background: We previously published a retrospective study of kidney biopsies performed in a tertiary care hospital in London, Ontario from 2012 to 2017. This study resulted in a change of practice in our institution to shorter postbiopsy monitoring for outpatients as well as the development of a risk calculator to predict serious bleeding complications. Objective: The primary objective of this study was to determine whether this shorter monitoring time is adequate in the outpatient setting. A secondary objective was to validate the bleeding risk calculator in both inpatients and outpatients. Design: This was a retrospective chart review. Setting: This study was performed at a tertiary academic hospital in London, Ontario, Canada. Participants: This was a retrospective study of 400 adult patients who underwent kidney biopsy between April 30, 2018 and February 25, 2022 at a tertiary academic hospital in London, Canada. Methods: We retrospectively assessed frequency and timing of major bleeding complications in patients who underwent kidney biopsy. In secondary analyses, we examined the prediction performance of the risk calculator in discrimination and calibration. Results: Major bleeding occurred in 7 patients (1.8%). Five of these patients required blood transfusions (1.3%) and 2 required embolization (0.5%). In the outpatient setting, any major bleeding events were identified immediately (1 patient) or on the routine 2-hour ultrasounds (1 patient). The risk calculator showed good discrimination (C-statistic, 0.91, 95% confidence interval [CI] = [0.84 to 0.95]) and calibration (slope, 1.10, 95% CI = [0.47 to 1.74]; intercept, 95% CI = -0.02 [-0.79 to 0.75]), but with much uncertainty in the estimates. Limitations: The occurrence of only a few major bleeding events limits the reliability of our assessment of our risk calculator. Conclusions: There appears to be little yield in extending observation beyond 2 hours after an outpatient kidney biopsy with the use of immediate and 2-hour postbiopsy ultrasounds. The bleeding risk calculator (http://perioperativerisk.com/kbrc) warrants further validation.

Contexte: Nous avons publié précédemment une étude rétrospective des biopsies rénales effectuées entre 2012 et 2017 dans un hôpital de soins tertiaires de London, en Ontario. Les résultats de cette précédente étude ont entraîné un changement de pratique dans notre établissement, soit une réduction de la durée de la surveillance post-biopsie pour les patients ambulatoires, et la mise au point d'un calculateur de risque permettant de prédire les complications hémorragiques graves. Objectifs: L'objectif principal de l'étude en cours était de vérifier si ce temps de surveillance plus court est adéquat pour les patients ambulatoires. Un deuxième objectif était de valider le calculateur de risque d'hémorragie chez les patients hospitalisés et les patients ambulatoires. Conception: Étude rétrospective des dossiers médicaux. Cadre: Étude réalisée dans un hôpital de soins tertiaires de London, en Ontario (Canada). Sujets: Cette étude rétrospective portait sur 400 patients adultes ayant subi une biopsie rénale entre le 30 avril 2018 et le 25 février 2022 dans un centre hospitalier universitaire de soins tertiaires de London, au Canada. Méthodes: Nous avons procédé à un examen rétrospectif de la fréquence des complications hémorragiques graves, et du moment où celles-ci surviennent, chez les patients ayant subi une biopsie rénale. Dans les analyses secondaires, nous avons examiné la puissance prédictive du calculateur de risque en matière de discrimination et d'étalonnage. Résultats: Sept patients (1,75 %) ont subi une hémorragie majeure; de ces patients, cinq ont eu besoin de transfusions sanguines (1,3 %) et deux, d'une embolisation (0,5 %). En contexte ambulatoire, tous les événements hémorragiques graves ont été détectés immédiatement (un patient) ou lors de l'échographie de routine à deux heures (un patient). Le calculateur de risque a montré une bonne discrimination (statistique C : 0,91 [IC 95 % : 0,84 à 0,95]) et un bon étalonnage (pente : 1,10 [0,47 à 1,74]; point d'intersection : -0,02 [-0,79 à 0,75]), mais une grande incertitude dans les estimations. Limitations: La fiabilité de l'évaluation de notre calculateur de risque est limitée par le très faible échantillon d'événements hémorragiques graves étant survenus. Conclusion: Il semble y avoir peu d'intérêt à prolonger la surveillance au-delà de deux heures après une biopsie rénale chez les patients ambulatoires lorsqu'une échographie est pratiquée immédiatement après la procédure et deux heures plus tard. Le calculateur de risque d'hémorragie (http://perioperativerisk.com/kbrc) nécessite une validation plus approfondie.

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Summary: Multiple studies confirm that point of care ultrasound (PoCUS) has a high sensitivity and specificity for cholelithiasis and cholecystitis. However, there is poor perceived reliability of biliary PoCUS by surgeons. This survey was performed to assess surgeons' opinions on using PoCUS in gallstone disease and barriers that exist for its institution. The majority (60.3%) of respondents reported a total lack of confidence in PoCUS for the diagnosis of biliary disease. Most felt the sensitivity of PoCUS was poor and had concerns about the user-dependent nature of the test and the lack of imaging details provided. If offered ideal clinical/laboratory findings with PoCUS results, only 4.7% of surgeons would definitely operate for unremitting biliary colic and 5.4% for cholecystitis. The ability to replicate findings independently increased confidence in clinical decision-making. Our findings suggest there is substantial distrust in biliary PoCUS but that specific ultrasound training for the surgical workforce may prove tremendously beneficial for its utilization.

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BACKGROUND: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as a diagnostic tool. The purpose of this study is to analyze the usefulness of POCUS in predicting the need for surgical intervention in biliary disease. METHODS: A retrospective study of patients visiting the emergency department who received a biliary POCUS from December 1, 2016 to July 15, 2017 was performed. The physician interpretations of the biliary POCUS scans were collected, as well as data from the electronic health records including lab values, the subsequent use of diagnostic imaging, surgical consultation or intervention, and 28 days follow-up for representation or complication. RESULTS: Two hundred and eighty-three patients were identified as having received biliary POCUS. Of the patients referred to general surgery who received biliary POCUS 43% received a cholecystectomy. For the outcome of cholecystectomy, the finding of gallstones on POCUS was 55% sensitive (95% CI 40% to 70%) and 92% specific (95% CI 87% to 95%). A sonographic Murphy's sign was 16% sensitive (95% CI 7% to 30%) but 95% specific (95% CI 92% to 97%) and, gallbladder wall thickness was 18% sensitive (95% CI 9% to 33%) and 98% specific (95% CI 95% to 99%). Patients who received POCUS but did not proceed to confirmatory radiology department imaging had a shorter length of stay (433 min ± 50 min vs. 309 min ± 30 min, P<0.001). DISCUSSION: Point-of-care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gallstones and increased gallbladder wall thickness are highly predictive of the need for surgical intervention, and use of POCUS is associated with shorter ER visits. LEVEL OF EVIDENCE: Retrospective cohort study, level III.