بررسي ارزش تشخيصي مقياس "تخمين ديداري" در ارزيابي حجم خونريزي حين عمل جراحي ابدومينال هيستركتومي در مقايسه با تغييرات هموگلوبين و هماتوكريت قبل و بعد از عمل

Evaluation of "the Visual Scale Estimation" Diagnostic Accuracy in Determination of the Blood Loss Volume during Abdominal Hysterectomy Compared with Hemoglobin and Hematocrit Alterations before and after Surgery

زﻣﯿﻨﻪ و ﻫﺪف: ﯾﮑﯽ از ﻣﻬﻤﺘﺮﯾﻦ و ﺷﺎﯾﻌﺘﺮﯾﻦ ﻋﻮارض ﻧﺎﺷﯽ از ﻫﯿﺴﺘﺮﮐﺘﻮﻣﯽ اﺑﺪوﻣﯿﻨﺎل ﺧﻮﻧﺮﯾﺰيﻫﺎي ﺣﯿﻦ ﻋﻤﻞ ﻣﯽﺑﺎﺷﻨﺪ. از روشﻫﺎي ﻣﺨﺘﻠﻔﯽ ﺟﻬﺖ ﺗﺨﻤﯿﻦ ﺧﻮﻧﺮﯾﺰي اﺳﺘﻔﺎده ﻣﯽﺷﻮد ﮐﻪ از ﺟﻤﻠﻪ آﻧﻬﺎ ﻣﯽﺗﻮان ﺑﻪ ﺗﺨﻤﯿﻦ دﯾﺪاري اﺷﺎره ﻧﻤﻮد. اﻟﺒﺘﻪ ﺗﺨﻤﯿﻦ ﺧﻮﻧﺮﯾﺰي ﺑﺮاﺳﺎس ﺗﻐﯿﯿﺮات ﺳﻄﺢ ﻫﻤﻮﮔﻠﻮﺑﯿﻦ و ﻫﻤﺎﺗﻮﮐﺮﯾﺖ دﻗﺖ ﺑﯿﺸﺘﺮي دارد وﻟﯽ ﮔﺬﺷﺘﻪﻧﮕﺮ ﺑﻮده و ﺑﺎﻟﯿﻨﯽ ﻧﻤﯽﺑﺎﺷﺪ. ﺑﻨﺎﺑﺮاﯾﻦ در اﯾﻦ ﻣﻄﺎﻟﻌﻪ ﺑﻪ ﺑﺮرﺳﯽ ارزش ﺗﺸﺨﯿﺼﯽ روش ﺗﺨﻤﯿﻦ دﯾﺪاري ﺟﻬﺖ ارزﯾﺎﺑﯽ ﺧﻮﻧﺮﯾﺰي ﺣﯿﻦ ﻋﻤﻞ در ﻣﻘﺎﯾﺴﻪ ﺑﺎ ﺗﻐﯿﯿﺮات ﻫﻤﻮﮔﻠﻮﺑﯿﻦ و ﻫﻤﺎﺗﻮﮐﺮﯾﺖ ﻗﺒﻞ و ﺑﻌﺪ از ﻋﻤﻞ ﺟﺮاﺣﯽ ﻫﯿﺴﺘﺮﮐﺘﻮﻣﯽ اﺑﺪوﻣﯿﻨﺎل ﭘﺮداﺧﺘﻪ ﺷﺪ. ﻣﻮاد و روش ﻫﺎ: در اﯾﻦ ﻣﻄﺎﻟﻌﻪ 74 ﻣﻮرد ﻫﯿﺴﺘﺮﮐﺘﻮﻣﯽ اﺑﺪوﻣﯿﻨﺎل در ﻣﺮﮐﺰ آﻣﻮزﺷﯽ و درﻣﺎﻧﯽ اﻟﺰﻫﺮا )س( ﺷﻬﺮ رﺷﺖ ﻣﻮرد ارزﯾﺎﺑﯽ ﻗﺮار ﮔﺮﻓﺘﻨﺪ. ﻣﯿﺰان ﺧﻮﻧﺮﯾﺰي ﺣﯿﻦ ﻋﻤﻞ ﺟﺮاﺣﯽ ﺑﻪ دو روش ﺗﻌﯿﯿﻦ ﺷﺪ ﮐﻪ ﯾﮑﯽ ﺑﻪ ﺻﻮرت ﺗﺨﻤﯿﻦ دﯾﺪاري )ﺑﺮاﺳﺎس ﺣﺠﻢ ﺧﻮن ﻣﻮﺟﻮد در دﺳﺘﮕﺎه ﺳﺎﮐﺸﻦ، ﺗﻌﺪاد ﮔﺎزﻫﺎي ﺧﻮن آﻟﻮد ﺟﻤﻊ ﺷﺪه ﻃﯽ ﻋﻤﻞ و ﺧﻮن ازدﺳﺖ رﻓﺘﻪ در ﻣﺤﻞ ﻋﻤﻞ و ﺷﺎنﻫﺎ( و دﯾﮕﺮي ﺑﻪ ﺻﻮرت ﻣﻘﺎﯾﺴﻪ ﻫﻤﻮﮔﻠﻮﺑﯿﻦ و ﻫﻤﺎﺗﻮﮐﺮﯾﺖ ﻗﺒﻞ و 12 ﺳﺎﻋﺖ ﺑﻌﺪ از ﻋﻤﻞ ﺑﻮد. ﻧﺘﺎﯾﺞ ﺑﻪ دﺳﺖ آﻣﺪه در دو روش، ﺟﻬﺖ ﻣﺤﺎﺳﺒﻪ ارزش ﺗﺸﺨﯿﺼﯽ ﻣﻘﯿﺎس ﺗﺨﻤﯿﻦ دﯾﺪاري ﺗﻮﺳﻂ آزﻣﻮنﻫﺎي آﻣﺎري )ﺣﺴﺎﺳﯿﺖ، وﯾﮋﮔﯽ، ارزش ﭘﯿﺸﮕﻮﯾﯽ ﻣﺜﺒﺖ، ارزش ﭘﯿﺸﮕﻮﯾﯽ ﻣﻨﻔﯽ، ﺿﺮﯾﺐ ﺗﻮاﻓﻖ ﮐﺎﭘﺎ و ...( و ﻧﺮم اﻓﺰار SPSS ﻧﺴﺨﻪ 21، ﻣﻮرد ﺗﺠﺰﯾﻪ و ﺗﺤﻠﯿﻞ ﻗﺮار ﮔﺮﻓﺘﻨﺪ. ﯾﺎﻓﺘﻪ ﻫﺎ: در ﺑﺮرﺳﯽ ﺗﻮاﻓﻖ ﻣﯿﺰان ﺧﻮﻧﺮﯾﺰي ﺑﻪ روش ﺗﺨﻤﯿﻦ دﯾﺪاري ﺑﺎ ﻣﯿﺰان ﺧﻮﻧﺮﯾﺰي ﺑﺮ اﺳﺎس اﻓﺖ ﻫﻤﻮﮔﻠﻮﺑﯿﻦ، ﺑﺎ اﺳﺘﻔﺎده از ﺿﺮﯾﺐ kappa ﻧﺘﺎﯾﺞ ﻣﻄﺎﻟﻌﻪ ﺑﯿﺎﻧﮕﺮ ﯾﮏ ﺗﻮاﻓﻖ در ﺣﺪ Kappa = 0.497, P <0/0001) Moderate( و ﺑﺮ اﺳﺎس اﻓﺖ ﻫﻤﺎﺗﻮﮐﺮﯾﺖ ﺑﯿﺎﻧﮕﺮ ﯾﮏ ﺗﻮاﻓﻖ در ﺣﺪ P<0.0001) Substantial و 0/670 =kappa( ﺑﯿﻦ اﯾﻦ دو روش ﺑﻮده اﺳﺖ. دﻗﺖ ﺗﺸﺨﯿﺼﯽ ﺗﺨﻤﯿﻦ دﯾﺪاري ﻣﯿﺰان ﺧﻮﻧﺮﯾﺰي ﺑﺮ اﺳﺎس اﻓﺖ ﻫﻤﻮﮔﻠﻮﺑﯿﻦ ﺑﺎ ﺣﺴﺎﺳﯿﺖ 75%، وﯾﮋﮔﯽ 76/1%، ارزش اﺧﺒﺎري ﻣﺜﺒﺖ 65/6%، ارزش اﺧﺒﺎري ﻣﻨﻔﯽ 83/3% ﺑﻮده اﺳﺖ و ﺑﺮ اﺳﺎس اﻓﺖ ﻫﻤﺎﺗﻮﮐﺮﯾﺖ ﺑﻪ ﺗﺮﺗﯿﺐ ﺑﺮاﺑﺮ ﺑﺎ 81/3 ،%85/7 ،%81/2% و 85/7% ﺑﻮد. ﻧﺘﯿﺠﻪ ﮔﯿـﺮي: ﻣﻘﯿﺎس ﺗﺨﻤﯿﻦ دﯾﺪاري" ﻣﯿﺰان ﺧﻮﻧﺮﯾﺰي ﺣﯿﻦ ﻋﻤﻞ ﺟﺮاﺣﯽ ﻫﯿﺴﺘﺮﮐﺘﻮﻣﯽ اﺑﺪوﻣﯿﻨﺎل روﺷﯽ ﺳﺮﯾﻊ و ﺳﺎده در ارزﯾﺎﺑﯽ ﺣﺠﻢ ﺧﻮﻧﺮﯾﺰي ﺣﯿﻦ ﻋﻤﻞ ﺟﺮاﺣﯽ اﺳﺖ و ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺿﺮﯾﺐ ﺗﻮاﻓﻖ Moderate ﺗﺎ Substantial ﺑﺎ ﺗﻐﯿﯿﺮات ﻫﻤﻮﮔﻠﻮﺑﯿﻦ و ﻫﻤﺎﺗﻮﮐﺮﯾﺖ ﻗﺒﻞ و ﺑﻌﺪ از ﻋﻤﻞ، از دﻗﺖ ﻗﺎﺑﻞ ﻗﺒﻮﻟﯽ ﻧﯿﺰ ﺑﺮﺧﻮردار اﺳﺖ، ﺑﻨﺎﺑﺮاﯾﻦ ﻣﯽﺗﻮاﻧﺪ ﺟﻬﺖ ﺗﺨﻤﯿﻦ ﺧﻮﻧﺮﯾﺰي ﺣﯿﻦ ﺟﺮاﺣﯽ ﻣﻮرد اﺳﺘﻔﺎده ﻗﺮار ﮔﯿﺮد.

Introduction & Objective: Intraoperative hemorrhage is one of the most common complications of abdominal hysterectomy. Various methods are used to estimate the amount of blood loss, visual scale estimation is one of them. Of course blood loss estimation based on changes in hematocrit or hemoglobin levels have greater accuracy but it is a retrospective method not a clinical method. The aim of the present study was to evaluate "the visual scale estimation" diagnostic accuracy in determination of the blood loss volume during abdominal hysterectomy compared with hemoglobin and hematocrit alterations before and after surgery. Materials & Methods: In this study 74 cases of abdominal hysterectomy were evaluated in the training Al Zahra Hospital in Rasht. Intraoperative blood loss was assessed in two ways: visual estimation (based on the volume of blood in the suction device, the number of blood gauze pads accumulated during the procedure and blood loss at the operation sites and Surgical Drapes) and the other way was comparing hemoglobin and hematocrit before and 12 hours after surgery. The results of the two methods were analyzed by statistical tests (sensitivity, specify, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value, Cohen's kappa cofficient &…) using SPSS version 21 for calculating the diagnostic value of visual Scale estimation. Results: In examining the convergence of bleeding by using Cohen's kappa coefficient a moderate agreement was found between Visual estimation and hemoglobin changes (kappa = 0.497, P <0.0001), Scale visual estimation and decrease hematocrit were substantial agreement (P <0.0001, kappa = 0.670). Diagnostic accuracy of visual estimation based on hemoglobin decreasing, was sensitivity = 75%, specificity = 76.1%, positive predictive value = 65.6%, negative predictive value = 83.3% and based on hematocrit decreasing, was 81.2%, 85.7%, 81.3%, 85.7% respectively. Conclusions: The visual scale estimation is a fast and simple way to assess abdominal hysterectomy intraoperative hemorrhage and according to moderate to substantial Cohen's kappa coefficient, this scale has acceptable accuracy with hemoglobin and hematocrit alternations before and after surgery. Therefore, it can be used to assess the intraoperative hemorrhage.