卒中后PEG置管的实践模式与认知：一项针对神经科医师的调查

文献信息

中文摘要

背景： 卒中后PEG（经皮内镜下胃造瘘）管置入是一项在临床和伦理上复杂的决策。当前证据并未显示PEG喂养在改善卒中后生存或功能方面具有明确获益，然而临床实践中仍存在显著差异。
目的： 评估指导临床实践中卒中后PEG喂养临床医生决策的关键主题。
方法： 一项包含26个条目的网络调查，由美国神经病学学会Synapse Communities平台托管并分发，由来自不同亚专业和实践环境的64名医师完成。采用描述性统计对结果进行解读。
结果： 共收到64份调查回复，其中75%认为该问题与其临床实践高度或较为相关。大多数（87.5%）认为PEG喂养总体上使患者获益，72%倾向于在卒中后2周置管，78%对其做出适当PEG置管决策的能力表示高度自信。与纯粹的临床指征相比，伦理和患者生活质量问题在决策方法中被赋予较少重要性。在探索性分析中，血管神经科医师相比其他专业报告了高度自信（31/33（94%）vs 18/30（62%）；绝对差（AD）为32个百分点（pp）（95% CI，12.8-51.2）），而随访频率较低的临床医生更倾向于较早置入PEG（26/31（84%）vs 19/31（61%）；AD 22.8 pp（95%CI，1.33-44.2））。结论：临床医生报告在卒中后PEG置管决策方面具有高度自信，尽管指南依从性不一致，并倾向于高估PEG喂养的获益。需要结构化的照护目标讨论以及个体化的风险-获益评估，纳入操作风险和临床恢复预后。

英文摘要

BACKGROUND: PEG (percutaneous endoscopic gastrostomy) tube placement after stroke is a clinically and ethically complex decision. Current evidence does not show a clear benefit of PEG-feeding in improving survival or function after stroke, yet substantial variations exist in clinical practice.
OBJECTIVE: To assess key themes guiding clinician decision-making for PEG-feeding after stroke in clinical practice.
METHODS: A 26-item web-based survey, hosted and distributed on the American Academy of Neurology Synapse Communities platform, was completed by 64 physicians across diverse sub-specialties and practice settings. Descriptive statistics were used to interpret results.
RESULTS: 64 survey responses were received, of whom 75% found this issue highly or fairly relevant to their practice. The majority (87.5%) felt that PEG-feeds benefited patients overall, 72% preferred placement 2 weeks after stroke and 78% expressed high-confidence in their ability to make appropriate PEG placement decisions. Ethical and patient quality of life issues were given less importance as compared to purely clinical indications for approaching decision-making. On exploratory analysis, vascular neurologists reported high confidence compared to other specialties (31/33(94%) vs 18/30(62%); absolute difference(AD) of 32 percentage points(pp) (95% CI, 12.8-51.2)) and clinicians with less frequent follow-up were more likely to prefer earlier PEG placement (26/31(84%) vs 19/31(61%); AD 22.8 pp (95%CI, 1.33-44.2)) CONCLUSION: Clinicians report high confidence in making decisions about PEG-placement after stroke despite inconsistent guideline adherence, with a tendency to overestimate benefits of PEG-feeding. Structured goals-of-care conversations and individualized risk-benefit assessment incorporating procedural risks and prognosis for clinical recovery are needed.