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Varizen postoperative Phase Transfusion Strategies for Acute Upper Gastrointestinal Bleeding — NEJM


❶Varizen postoperative Phase||Varizen postoperative Phase | Varizen postoperative Phase|Besenreiser betreffen Männer genauso oft wie Frauen und können generell an allen Stellen des Beines entstehen. Besonders oft treten sie aber auf den Oberschenkeln.|Transfusion Strategies for Acute Upper Gastrointestinal Bleeding|Page Views]

N Engl J Med ; Comments open read article January 8, The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. Full Text of Background We enrolled patients with severe acute upper gastrointestinal bleeding and link assigned of them to a restrictive strategy transfusion when the hemoglobin level fell below 7 g per deciliter and to Varizen postoperative Phase liberal strategy transfusion when the hemoglobin fell below 9 g per deciliter.

Randomization was stratified according to the presence or absence of liver cirrhosis. Full Text of Methods The probability of survival was slightly Varizen postoperative Phase with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer hazard ratio, 0.

Full Text of Results As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. Full Text of Discussion Acute upper gastrointestinal bleeding is a common emergency condition associated with high morbidity and mortality. Transfusion learn more here be lifesaving in patients with massive exsanguinating bleeding.

However, in most cases hemorrhage is not so severe, and in such circumstances the safest and most effective transfusion strategy Varizen postoperative Phase controversial. Restricted transfusion strategies may be appropriate in some settings. Controlled trials have shown that for critically ill patients, a restrictive transfusion strategy is at least as effective as a liberal strategy, while substantially reducing the use of blood supplies. Observational studies and Lenny Rossolovsky Varizen controlled trials have suggested that transfusion may be harmful in patients with hypovolemic anemia, 6,7 even in learn more here with gastrointestinal bleeding.

We performed a randomized, controlled trial in which we assessed whether a restrictive threshold for red-cell transfusion in patients with acute gastrointestinal bleeding was safer and more effective than a liberal transfusion strategy that was based on the threshold recommended in guidelines at the time the study was designed. From June ätherische Krampfadern Öle Decemberwe consecutively enrolled patients with gastrointestinal bleeding who were admitted to Hospital de la Santa Creu i Sant Pau in Barcelona.

Written informed consent was obtained from all the patients or their next of kin, and the trial was approved by the institutional ethics committee at the hospital. The protocolincluding the statistical analysis plan, is available with the full text of this article at NEJM. No commercial support was involved in the study. All the authors vouch for the integrity and the accuracy of the analysis and for the fidelity of the study to the protocol. No one who is not an author contributed to the manuscript.

Patients older than 18 years of age who had Varizen postoperative Phase or bloody nasogastric aspiratemelena, or both, as confirmed by the hospital staff, were considered for inclusion. Patients were excluded if they declined to undergo a blood transfusion. Additional exclusion criteria were click here exsanguinating bleeding; an acute coronary syndrome, symptomatic peripheral vasculopathy, stroke, transient ischemic attack, or transfusion within the previous 90 days; a recent history of trauma or surgery; lower gastrointestinal bleeding; a previous decision on the part of the attending physician that the patient should avoid specific medical therapy; and a clinical Rockall score of 0 with a hemoglobin level higher than 12 g per deciliter.

The Rockall score is a system for assessing the risk of further bleeding or death among patients with gastrointestinal bleeding; scores range from 0 to 11, Varizen postoperative Phase a score of 2 or lower indicating low risk and scores of 3 to 11 indicating increasingly greater risk. Immediately after admission, patients were randomly assigned to a restrictive transfusion strategy or a liberal transfusion strategy. Randomization was performed with the use of computer-generated random numbers, Varizen postoperative Phase the group assignments placed in sealed, consecutively numbered, opaque envelopes.

Randomization was stratified according to the presence or absence of liver cirrhosis and was Varizen postoperative Phase in blocks of four. Cirrhosis was diagnosed according to clinical, biochemical, and ultrasonographic findings. In the restrictive-strategy group, the hemoglobin threshold Varizen postoperative Phase transfusion was 7 g per deciliter, with a target range for the post-transfusion hemoglobin level of 7 to 9 g per deciliter. In the liberal-strategy group, the hemoglobin threshold for transfusion was 9 g per deciliter, with a target range for the post-transfusion hemoglobin level of 9 to 11 g per deciliter.

In both groups, 1 unit of red cells was transfused initially; the hemoglobin level was assessed after the transfusion, and an additional unit was transfused if the hemoglobin level was below the threshold value.

The protocol allowed for a transfusion to be administered any time symptoms or signs related to anemia developed, massive bleeding occurred during follow-up, or surgical intervention was required. Only prestorage leukocyte-reduced units of packed red cells were used for Varizen postoperative Phase. Hemoglobin levels were Varizen postoperative Phase after admission and again every 8 hours during the first 2 days and every day thereafter.

Hemoglobin levels were also assessed when further bleeding was suspected. All the patients underwent emergency gastroscopy within the first 6 hours. When endoscopic examination disclosed a nonvariceal lesion with active arterial bleeding, a nonbleeding visible vessel, or an adherent clot, patients underwent endoscopic therapy with injection of adrenaline plus multipolar electrocoagulation or application of endoscopic clips.

Patients with peptic ulcer received a continuous intravenous infusion of omeprazole 80 mg per hour Varizen postoperative Phase after an initial bolus of 80 mg for the first 72 hours, followed by oral administration of omeprazole. Bleeding esophageal varices were also treated with band ligation or with sclerotherapy, and gastric varices with injection of cyanoacrylate. In patients Varizen postoperative Phase variceal bleeding, portal pressure Varizen postoperative Phase measured within the first 48 hours and again 2 to 3 days later to assess the effect of the transfusion strategy on portal hypertension.

Portal pressure was estimated with the use of the hepatic venous pressure gradient HVPGas described elsewhere. The primary outcome measure was the rate of death from any cause within the first 45 days.

Secondary outcomes included the rate of further bleeding and the rate of in-hospital complications. Further bleeding was considered solgar mit Krampfadern indicate therapeutic failure; if the bleeding involved nonvariceal lesions, the Varizen postoperative Phase underwent repeat endoscopic therapy or emergency surgery, whereas in the case of further variceal bleeding, transjugular intrahepatic portosystemic shunting TIPS was considered.

Complications were defined as any untoward events that necessitated active therapy or prolonged hospitalization. Side effects were considered to be severe if the health or safety of the patient was endangered. The statistical analysis was performed according to the intention-to-treat principle. Varizen postoperative Phase tests were used for comparisons of proportions and means. Continuous variables are expressed as means and standard deviations. Actuarial probabilities were calculated with the use of the Kaplan—Meier method and were compared with the use of the log-rank test.

A Cox proportional-hazards regression model was used to compare the two transfusion-strategy groups with respect to the primary and secondary end points, with adjustment for baseline risk factors see the Supplementary Appendixavailable at NEJM. Prespecified subgroup analyses were performed to assess the efficacy of transfusion strategies according to the source of bleeding lesions related to portal hypertension or peptic ulcer.

All P values are Varizen postoperative Phase. Calculations were performed with the use of the SPSS statistical package, version During the study period, patients were admitted to the hospital for gastrointestinal bleeding and were screened.

Of these, 41 declined to participate and were excluded; among the reasons for exclusion were exsanguinating bleeding requiring transfusion in 39 patients and a low risk of rebleeding patients Figure 1 Figure 1 Screening, Randomization, and Follow-up. During the study period, patients with gastrointestinal bleeding were screened, and patients were excluded.

The reasons for exclusion included massive exsanguinating bleeding requiring transfusion before randomization 39 patients and Varizen postoperative Phase low risk of rebleeding patients. A low risk of rebleeding was defined as a clinical Rockall score of 0 and hemoglobin levels higher than 12 g per deciliter. The Rockall score is a system for assessing the risk of further bleeding or death among patients with gastrointestinal bleeding; scores range from 0 to 11, with higher scores indicating greater risk.

Patients were also excluded if they declined blood transfusion 14 patients ; other exclusion criteria were an acute coronary syndrome 58symptomatic peripheral vasculopathy 12stroke or transient ischemic attack 7or transfusion 10 within the previous 90 days; lower gastrointestinal bleeding 51 http://m.0eko.de/vortraege-krampfadern.php pregnancy 3 ; a recent history of trauma or surgery 41 ; a decision by the attending physician that the patient should avoid medical therapy 9 ; or inclusion in this study within the previous 90 days or inclusion more than twice Varizen postoperative Phase A total of patients underwent randomization, of whom 32 were withdrawn: A total of patients underwent randomization and 32 withdrew or were withdrawn by the investigators after randomization see Figure 1 for detailsleaving patients in the restrictive-strategy group and in the liberal-strategy group for the intention-to-treat analysis.

The baseline characteristics were similar in the two groups Table 1 Table 1 Baseline Characteristics of the Patients. The hemoglobin concentration at admission was similar in the two groups Table 2 Table 2 Hemoglobin Levels, Transfusions, and Cointerventions.

The percentage of patients in whom the lowest hemoglobin level was less than 7 g per deciliter was higher in the restrictive-strategy group than in the liberal-strategy group. The hemoglobin concentration at 45 days was similar in the two groups. The percentage of patients who Varizen postoperative Phase a transfusion of fresh-frozen plasma, the percentage of patients who received a transfusion of platelets, and the total amount of fluid administered were similar in the two groups.

Mortality at 45 days was significantly lower in the restrictive-strategy group than in the liberal-strategy group: Panel A shows the Kaplan—Meier estimates of the 6-week survival rate in the two groups. The probability of survival was significantly higher in the restrictive-strategy group than in the liberal-strategy group. The gray arrows indicate the day on which data from a patient were censored.

The inset shows the same data on an enlarged y axis. The risk of death was virtually unchanged after adjustment for baseline risk factors for death hazard ratio with restrictive strategy, 0. Among all patients with Varizen postoperative Phase, the risk of death was slightly lower in the restrictive-strategy group than in the liberal-strategy group Figure 2.

In the subgroup of patients Varizen postoperative Phase cirrhosis and Child—Pugh class A or B disease, the risk of death was significantly lower among patients in the restrictive-strategy group than among those in the liberal-strategy group, whereas in the subgroup of patients with cirrhosis and Child—Pugh class C disease, the risk was similar in the two groups. Among patients with bleeding from a peptic ulcer, the risk of death was slightly lower with the restrictive strategy than with the liberal strategy.

Death was due to unsuccessfully controlled bleeding in 3 patients 0. Death was caused by complications of treatment in 3 patients 2 in the liberal-strategy group and 1 in the restrictive-strategy group.

In the remaining 44 patients 19 in the restrictive-strategy group and 25 in the liberal-strategy grouphemorrhage was controlled and death was due to associated diseases. The rate of further bleeding was significantly lower in the restrictive-strategy group than Varizen postoperative Phase the liberal-strategy group: The risk of further bleeding was significantly lower with the restrictive strategy after adjustment for baseline risk factors for further bleeding hazard ratio, 0.

In addition, the length of hospital stay was shorter in the restrictive-strategy group than in the liberal-strategy group. In the subgroup of patients with cirrhosis, the risk of es wenn nennen, keine Phlebologe Varizen, die zu ist bleeding was lower with the restrictive transfusion strategy than with the liberal transfusion strategy among patients with Child—Pugh class A or B disease and was similar in the two groups among patients Varizen postoperative Phase Child—Pugh class C disease Table 3.

Rescue therapy with balloon tamponade or with transjugular intrahepatic portosystemic shunt was required less frequently in the restrictive-strategy group than in the liberal-strategy group.

A baseline hepatic hemodynamic study Operation nach tun der Krampfadern performed in 86 patients in the restrictive-strategy group and Varizen postoperative Phase 89 in the liberal-strategy group, and it was repeated 2 to 3 days later in 74 Varizen postoperative Phase 77 patients, respectively, to assess changes.

Patients Varizen postoperative Phase the liberal-strategy group had a significant increase in the mean Varizen Harnsymptome venous pressure gradient between the first hemodynamic study and the second from There was no significant change in mean hepatic venous pressure gradient in the restrictive-strategy group during that Varizen postoperative Phase. Among patients with bleeding from a peptic ulcer, there was a trend toward a lower risk of further Varizen postoperative Phase in the restrictive-strategy group Table 3.

Transfusion reactions and cardiac events, mainly pulmonary edema, occurred more frequently in the liberal-strategy group Table 3. The rates of other adverse events, such as acute kidney injury or bacterial infections, did not differ significantly between the groups Varizen postoperative Phase S5 in the Supplementary Appendix.

We found that Varizen postoperative Phase patients with severe acute upper gastrointestinal bleeding, the outcomes were significantly improved with a restrictive transfusion strategy, in which the hemoglobin threshold was 7 g per deciliter, as compared with a liberal transfusion strategy, in which the hemoglobin threshold was 9 g per deciliter. The most relevant finding was the improvement in survival rates observed with the restrictive transfusion Varizen postoperative Phase. This advantage was probably related to a better control of factors contributing to death, such as Varizen postoperative Phase bleeding, the need for rescue therapy, and serious adverse events.


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