静脉鱼油注射患者术后出血风险：是真的吗？

　　ω-3脂肪酸被认为会影响机体的凝血功能，为了探讨静脉给予鱼油后的出血风险，波士顿儿童医院、贝斯以色列女执事医疗中心对219例静脉注射鱼油脂肪乳的儿童进行回顾性分析，发现尽管鱼油会影响凝血功能，但出血风险并无显著增加。鱼油注射后出血概率不超过2%～8%，因此可作为肠外营养的安全选择，但在准备有创操作或使用鱼油治疗后发生出血时应停止使用。

JPEN J Parenter Enteral Nutr. 2016;40(4):138-139.

Risk of Postprocedural Bleeding in Patients on Intravenous Fish Oil: Is it Real?

Lorenzo Anez-Bustillos; Prathima Nandivada; Alison O'Loughlin; Paul Mitchell; Meredith A. Baker; Duy T. Dao; Gillian Fell; Bennet S. Cho; Alexis K. Potemkin; Kathleen M. Gura; Mark Puder.

Boston Children's Hospital, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA.

Purpose: Omega-3 fatty acids are known to affect hemostatic pathways. Despite this knowledge, an abundance of clinical evidence fails to translate these effects into an increased risk of bleeding. Surgeons, however, continue to be concerned about bleeding, and many recommend discontinuing the use of omega-3 fatty acids before invasive procedures. In the pediatric population, intravenous fish oil lipid emulsion (FOLE) is used for management of intestinal failure-associated liver disease (IFALD) in parenteral nutrition-dependent patients. The publication of a recent isolated case report has raised concern for an increased risk of postprocedural bleeding while on FOLE. The objective of this study is to describe the incidence of clinically significant postprocedural bleeding (CSPPB) based on our experience using fish oil monotherapy among a large cohort of patients with IFALD.

Methods: We performed a retrospective chart review of prospectively enrolled patients at Boston Children's Hospital treated with the FOLE Omegaven for IFALD between September 2004 and July 2015 and subjected to any type of invasive procedure, defined as any intervention that involves violation of a vascularized and epithelialized surface. Clinically significant bleeding was defined as the presence of at least 1 of the following up to 1 month postprocedure: (1) reexploration or return to operating room for bleeding, (2) need for antibleeding therapy, (3) readmission for bleeding, or (4) death due to bleeding. Preprocedure data—including complete blood count, coagulation profile, liver function tests, and fatty acid profile—were collected, as was duration of therapy at the time of procedure.

Results: Charts from 219 patients treated with FOLE were reviewed, for whom 180 (82%) underwent at least 1 invasive procedure for a total of 728. The patient sample was 58% male and had a median age of 10.1 months (interquartile range, 5.2-24.0) at the time of procedure. Forty-three percent of these were related to vascular access; 28% were abdominal; and 14% pertained to invasive endoscopic procedures. Only 4 of 728 (0.55%, 95% CI: 0.15%-1.40%) procedures resulted in CSPPB. Three were of gastrointestinal origin and required return to the operating room. The first one followed a small bowel resection and returned for esophagogastroduodenoscopy, which failed to reveal the source of bleeding; it was later found to be from a vessel at the ileostomy site, which was controlled at bedside. The second one occurred after an ostomy takedown and required laparotomy for push enteroscopy, which did not identify a true source of bleeding but allowed for 2 questionable areas at the anastomosis to be oversewn. The third one occurred in a coagulopathic patient with portal hypertension, which presented with persistent bleeding from the stomal site and failed initial cauterization and suture ligation. A fourth case followed placement of a central venous line, which required neck reexploration upon patient awakening with an expanding hematoma. An oozing defect in the sidewall of a small vessel feeding into the internal jugular vein was repaired. Of note, FOLE therapy was never interrupted in any of the events. No distinct pattern among those that developed CSPPB nor deaths were seen.

Conclusions: While hemostatic changes with fish oil therapy exist, we hereby show that these may not translate into an increased risk of significant bleeding. Our data suggest that fish oil monotherapy is safe, with a postprocedural bleeding risk that does not exceed the 2%-8% that is generally reported. FOLE may thus continue to be offered as a lifesaving therapy for parenteral nutrition-dependent children with IFALD and should not be held in preparation for invasive procedures, let alone interrupted in the event of CSPPB.

Financial support: None.