Varizen können verödet, mit Laserstrahlen behandelt oder chirurgisch entfernt werden. Gestaute Venen können mit der Zeit zu einem venösen Ödem führen.
N Engl J Med ; Comments open through January 8, The hemoglobin threshold Biologie Varizen 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 randomly assigned of them to a restrictive strategy transfusion when the hemoglobin level fell below 7 g per deciliter and to a 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 higher 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 zur Vorbeugung von Krampfadern bei Schwangeren gastrointestinal bleeding.
Full Text of Discussion Acute upper gastrointestinal bleeding is a common emergency condition associated with high morbidity Biologie Varizen mortality. Transfusion may 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 is 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 small controlled trials have suggested that transfusion may be harmful in patients with hypovolemic anemia, Biologie Varizen, 6,7 even in those 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 through 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 Biologie Varizen ethics committee at the hospital, Biologie Varizen. 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, Biologie Varizen. No one who is not an author contributed to the manuscript. Patients older than 18 years of age who had hematemesis or bloody nasogastric aspiratemelena, Biologie Varizen, or both, Biologie Varizen, as confirmed by the hospital staff, were considered for inclusion, Biologie Varizen.
Patients were excluded if they declined to undergo Biologie Varizen blood transfusion, Biologie Varizen. Additional exclusion criteria were massive 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 Biologie Varizen bleeding; a previous decision on the Thrombophlebitis und kaltes Wasser 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 Biologie Varizen death among patients with gastrointestinal bleeding; scores range from 0 to 11, with 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, with the group assignments placed in sealed, consecutively numbered, opaque envelopes.
Randomization was stratified according to the presence or absence of liver cirrhosis and was performed in blocks of four, Biologie Varizen. Cirrhosis was diagnosed according to clinical, Biologie Varizen, biochemical, and ultrasonographic findings.
In the restrictive-strategy group, the hemoglobin threshold for 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 Biologie Varizen. 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 transfusion protocol was applied until the patient's discharge from the hospital or death. The protocol allowed for a transfusion to be administered any time symptoms or signs related to anemia developed, Biologie Varizen, massive bleeding occurred during follow-up, Biologie Varizen, or surgical intervention was required. Only prestorage leukocyte-reduced units of packed red cells were used Biologie Varizen transfusion, Biologie Varizen.
Hemoglobin levels were measured 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, Biologie Varizen, patients underwent Biologie Varizen 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 period after an initial bolus of 80 mg for the first 72 hours, followed by oral administration of omeprazole, Biologie Varizen. Bleeding esophageal varices were also treated with band ligation or with sclerotherapy, and gastric varices with injection of cyanoacrylate.
In patients with variceal bleeding, portal pressure was 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 HVPGBiologie Varizen, as 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 to indicate therapeutic failure; if the bleeding involved nonvariceal lesions, the patient underwent repeat endoscopic therapy or emergency surgery, whereas in the case of further variceal bleeding, transjugular intrahepatic portosystemic shunting TIPS was considered, Biologie Varizen. 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, Biologie Varizen.
The statistical analysis was performed according to the intention-to-treat Biologie Varizen. Standard tests were used for comparisons of proportions and means. Continuous variables are expressed as means and standard deviations, Biologie Varizen. Actuarial probabilities were calculated with the Biologie Varizen 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 AppendixBiologie Varizen, available at NEJM.
Data were censored at the time Biologie Varizen end-point event occurred, at the patient's last visit, or at the end of the day follow-up period, whichever occurred first. 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 two-tailed. 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 a 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, Biologie Varizen.
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, Biologie Varizen. 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 7Biologie Varizen, or transfusion 10 within the previous 90 days; lower gastrointestinal bleeding 51 ; 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 A total of patients underwent randomization, of whom 32 were withdrawn: A total of patients underwent randomization and 32 withdrew or were Biologie Varizen 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 Biologie Varizen 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 Schwerin Varikosette 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 received a transfusion of fresh-frozen plasma, Biologie Varizen, the percentage of patients who received Vermeiden Betrieb Thrombophlebitis 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 cirrhosis, the risk of death was slightly lower in the restrictive-strategy group than in the liberal-strategy group Figure 2.
In Haube Kastanien aus Krampfadern subgroup of patients with 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 Biologie Varizen 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. Biologie Varizen 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 groupBiologie Varizen, hemorrhage was controlled and death was due to associated diseases.
The rate of further bleeding was significantly lower in the restrictive-strategy group than in 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 further bleeding was lower with the restrictive transfusion strategy than with the liberal transfusion Biologie Varizen among patients with Child—Pugh Biologie Varizen A or B disease and was similar in the two groups among patients with 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 was performed in 86 patients in the restrictive-strategy group and in 89 in the liberal-strategy group, Biologie Varizen, and it was repeated 2 to 3 days later in 74 and 77 patients, respectively, to assess changes, Biologie Varizen.
Patients in the liberal-strategy group had a significant increase in the mean hepatic 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 interval, Biologie Varizen. Among patients with bleeding from a peptic ulcer, there was a trend toward a lower risk of further bleeding 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 Table S5 in the Supplementary Appendix. We found that among patients with severe acute upper gastrointestinal bleeding, the outcomes were significantly improved with a restrictive transfusion strategy, in which the hemoglobin Biologie Varizen was 7 g per deciliter, as compared with a liberal transfusion strategy, in which the hemoglobin threshold was 9 g per deciliter.
Biologie Varizen Transfusion Strategies for Acute Upper Gastrointestinal Bleeding — NEJM
Die Hohlvenen des Herzens haben einen Durchmesser von etwa 2 cm, wohingegen die meisten peripheren Venen Biologie Varizen kleiner sind, bis hin zu winzigen Venolen mit ca. Die innere Schicht wird als Tunica intima bezeichnet. Sie besteht aus einschichtigem Plattenepithel, d. Diese Schicht bildet bei vielen herzfernen Venen die Venenklappen aus. Darunter befindet sich die mittlere Schicht oder Tunica media, die hauptsächlich aus ringförmig oder spiralig angeordneten Bündeln glatter Muskulatur aufgebaut ist.
Diese Muskelschicht ist bei den Venen schwächer ausgeprägt als bei den Arterien. Der Bluttransport in den Venen wird durch mehrere andere Mechanismen ermöglicht, die zusammen als Venenpumpe bezeichnet werden: Venen, die in der Nähe eines Muskels verlaufen, Biologie Varizen, werden bei dessen Kontraktion zusammengedrückt, wodurch das Blut weitertransportiert wird.
Der Blutfluss in den herznahen Venen wird zudem von den atmungsbedingten Druckveränderungen in der Brusthöhle beeinflusst, Biologie Varizen. Im Bauchraum übernimmt die Darmperistaltik diese Aufgabe.
Da all diese Faktoren auf einer Kompression der Venen beruhen, könnte das Blut theoretisch Biologie Varizen in die falsche Richtung gedrückt werden — dies verhindern die Venenklappen.
Sie wirken somit der Schwerkraft entgegen und sind daher besonders zahlreich in den Venen Biologie Varizen Arme und Beine vertreten. Bei Bedarf geben sie dieses Blut wieder ab, um den Kreislauf zu regulieren. Ein verbreitetes Venenleiden ist die Varikosis oder Krampfaderbildung. In leichten Fällen stellen Varizen nur ein kosmetisches Problem dar, doch es kann auch zu SchwellungenKrämpfen oder Rupturen kommen.
Varizen können verödet, mit Laserstrahlen behandelt oder chirurgisch Biologie Varizen werden. Gestaute Venen können mit der Zeit zu einem venösen Ödem führen, d. Eine weitere mögliche Spätfolge ist das Ulcus cruris oder Unterschenkelgeschwür. Eine besonders gefährliche Venenerkrankung ist die Thrombosebei der ein abgelöstes Blutgerinnsel eine Vene verstopft. Gelangt der Thrombus bis in die Lunge, Biologie Varizen, kommt es zur lebensgefährlichen Lungenembolie, Biologie Varizen.
Wenn sie mit einer Thrombenbildung einhergeht, handelt es sich um eine meist gutartige Thrombophlebitis oberflächliche Venen Varizen des HLS eine gefährlichere Phlebothrombose tiefe Venen.
Inhaltsverzeichnis 1 Was sind Venen?
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Varizen können verödet, mit Laserstrahlen behandelt oder chirurgisch entfernt werden. Gestaute Venen können mit der Zeit zu einem venösen Ödem führen.
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1 Definition. Venen sind Blutgefäße, die das im Körper zirkulierende Blut zurück zum Herzen führen. Mit Ausnahme der Lungenvenen transportieren sie.
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Original Article. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. Càndid Villanueva, M.D., Alan Colomo, M.D., Alba Bosch, M.D., Mar Concepción, M.