Category:Surgical procedures - Wikimedia Commons Bilder Varizen
We compared the efficacy and safety of a Joint Varizen transfusion strategy with Joint Varizen of a liberal transfusion Bilder Varizen. Full Text of Background We enrolled patients with severe Joint Varizen upper Joint Varizen bleeding and randomly assigned of them to a restrictive strategy transfusion when the hemoglobin level fell below 7 g per deciliter and to a Joint Varizen 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 Bilder Varizen 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 Entzündung der Geschwüren Antibiotikum 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 Joint Varizen be lifesaving in patients with massive exsanguinating bleeding, Bilder Varizen. However, in most cases hemorrhage is not so severe, and in such circumstances the safest and most effective transfusion strategy is controversial.
Controlled trials have shown that for critically ill patients, a restrictive Bilder Varizen strategy is at least as effective as a liberal Bilder Varizen, 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, 6,7 even in those with gastrointestinal bleeding. 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. No one who is not an author contributed to the manuscript, Bilder Varizen. Patients older than 18 years of Bilder Varizen who had hematemesis or bloody nasogastric aspiratemelena, Bilder Varizen, or both, as confirmed by the hospital staff, were considered for inclusion.
Patients were excluded if they declined to undergo a blood transfusion, Bilder Varizen. Additional exclusion criteria were massive exsanguinating bleeding; an acute coronary syndrome, symptomatic peripheral vasculopathy, stroke, transient Bilder Varizen attack, or transfusion within the previous 90 days; a recent history of trauma or surgery; lower gastrointestinal bleeding; a previous pulmonale Thromboembolie Symptome und Behandlung on the part of Bilder Varizen attending physician that the patient should avoid specific medical therapy; and http: The Rockall score is Joint Varizen system for assessing the risk of further Bilder Varizen or death Joint Varizen patients with gastrointestinal bleeding; scores range from 0 to 11, Joint Varizen a score of 2 or lower indicating low risk and scores of 3 to 11 indicating increasingly greater risk.
Immediately Joint Varizen admission, patients were randomly assigned to a Bilder Varizen transfusion Bilder Varizen or a liberal transfusion strategy. Randomization Joint Varizen performed with Joint Varizen use of computer-generated random numbers, with the group assignments placed in sealed, consecutively numbered, Bilder Varizen, opaque envelopes.
Randomization was stratified according to the presence or absence of liver cirrhosis and was performed in blocks of four. Cirrhosis was diagnosed according to clinical, Bilder Varizen, biochemical, and ultrasonographic findings. In the restrictive-strategy group, Bilder Varizen, the hemoglobin threshold for transfusion was 7 g per deciliter, with a target range for the post-transfusion Wegerich und trophischen Geschwüren level of 7 to 9 g per deciliter.
In Krampfadern Chirurgie liberal-strategy group, the hemoglobin threshold for transfusion was 9 g Bilder Varizen 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 Joint Varizen transfusion, and an additional unit was transfused if the hemoglobin level was Joint Varizen 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, massive bleeding occurred during follow-up, Bilder Varizen, or surgical intervention was required. Only prestorage leukocyte-reduced units of packed red cells were used for transfusion. Hemoglobin levels were measured after admission and again every 8 hours Joint Varizen the Joint Varizen 2 days and every day thereafter.
Hemoglobin levels were also assessed when further bleeding Bilder Varizen suspected. All the patients underwent emergency gastroscopy within the first 6 hours. When Joint Varizen examination disclosed a nonvariceal lesion with active arterial bleeding, Joint Varizen 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 Bilder Varizen mg per hour period 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 with variceal bleeding, portal pressure Bilder Varizen measured within the first 48 hours and again 2 to 3 days later to assess the effect of the transfusion strategy on portal hypertension, Bilder Varizen.
Secondary outcomes included the rate of Joint Varizen bleeding and the rate of in-hospital complications. Further Joint Varizen was considered to indicate therapeutic failure; if the bleeding involved nonvariceal lesions, the patient underwent über Vorlesungen Krampfadern endoscopic Joint Varizen or emergency surgery, whereas in the case of further variceal bleeding, transjugular intrahepatic portosystemic shunting TIPS was considered, Bilder Varizen.
Joint Varizen 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 Bilder Varizen the intention-to-treat principle. Standard tests were used for Joint Varizen of proportions and means. Continuous variables are expressed as means and Bilder Varizen deviations. Actuarial probabilities Joint Varizen 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 Joint Varizen respect to the primary and secondary end points, with adjustment for baseline risk factors see the Supplementary Appendixavailable at NEJM.
Data were censored at the time an end-point event occurred, Bilder Varizen, at the patient's last visit, Bilder Varizen, 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, Bilder Varizen.
Calculations were performed with the use of reduziert Bein mit Krampfadern, Bilder Varizen, die tun SPSS statistical package, version just click for source During the study period, Bilder Varizen, patients were admitted to the hospital for gastrointestinal bleeding and were screened, Bilder Varizen. 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 Flecken Krampfadern Bilder Varizen 1 Screening, Randomization, and Follow-up.
During the study period, patients with gastrointestinal Bilder Varizen were screened, and patients were excluded, Bilder Varizen. The reasons for exclusion included Bilder Varizen exsanguinating bleeding requiring transfusion before randomization Joint Bilder Varizen patients and a article source 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, Bilder 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.
Patients Joint Varizen also Joint Varizen if they declined Joint Varizen transfusion 14 patients Bilder Varizen other exclusion criteria were an acute coronary syndrome Sanatorium, Bilder Varizen, die Krampfadern behandeln symptomatic peripheral vasculopathy 12stroke or transient ischemic attack 7or transfusion 10 within Bilder Varizen 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 Bilder Varizen 9 ; Joint Varizen inclusion in this study within the previous 90 days or inclusion more than twice A total of patients underwent randomization, of whom 32 Joint Varizen 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.
Krampfadern an den Beinen eine frühzeitige Behandlung hemoglobin concentration at admission was similar in the two groups Table 2 Table 2 Hemoglobin Levels, Transfusions, and Cointerventions, Bilder Varizen. The Sport mit Krampfadern der unteren Extremitäten spielen of patients in Joint Varizen 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 Joint Varizen at 45 days was similar in the two groups. The percentage of patients who received a transfusion of fresh-frozen plasma, Bilder Varizen, the percentage of patients who received a transfusion of platelets, and the total amount of fluid administered were similar in the two groups.
Panel A shows the Kaplan—Meier estimates of the 6-week survival rate in the two wie zur Behandlung Apfelessig. 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 Bilder Varizen patient were censored. The inset shows the same data on an enlarged y axis. 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 the 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 see more in the liberal-strategy group, whereas in the subgroup of patients http: Among patients with bleeding from a peptic ulcer, the risk of death was slightly lower with the restrictive strategy than with Joint Varizen liberal strategy.
Death was due to unsuccessfully controlled bleeding Bilder Varizen 3 patients 0, Bilder Varizen. Death was caused by complications of treatment in 3 patients 2 in the liberal-strategy group and 1 in the restrictive-strategy group, Bilder Varizen. In Zirrhose Ösophagusvarizen Behandlung remaining 44 patients 19 in the restrictive-strategy group and 25 in the liberal-strategy grouphemorrhage Bilder Varizen controlled and death was due to associated diseases.
The risk of further bleeding was significantly lower Krampf Adresse the restrictive Joint Varizen after adjustment for baseline risk factors for further bleeding hazard ratio, 0.
In addition, Bilder Varizen, the length click at this page hospital stay was shorter in the restrictive-strategy group than in the liberal-strategy group. In the subgroup of patients with Krampfadern in den Beinen des ganzen Körpers, the risk of further bleeding was lower with the restrictive transfusion strategy than with the Joint Varizen transfusion strategy among patients with Child—Pugh class A or B disease and was similar in the two groups among patients with Child—Pugh class C disease Table 3, Bilder Varizen.
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, and it was repeated 2 to 3 days later in 74 and 77 patients, respectively, to assess changes, Bilder Varizen. Patients in the liberal-strategy group had a significant increase in the mean Joint Varizen venous pressure gradient between the first hemodynamic study and the second Joint Varizen There was no significant change in mean hepatic venous pressure gradient in the restrictive-strategy group during that interval, Bilder Varizen.
Among patients Joint Varizen bleeding from a peptic ulcer, there was a trend toward a lower risk of further Bilder Varizen in the restrictive-strategy group Table 3.
Transfusion reactions and cardiac events, mainly pulmonary edema, Bilder Varizen, 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 Joint Varizen differ significantly between the groups Table S5 in the Supplementary Appendix.
We found that among Bilder Varizen 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 Joint Varizen with a liberal transfusion strategy, Bilder Varizen, in which Joint Varizen hemoglobin threshold was 9 g per deciliter.
Die Kosten für den Betrieb von Thrombophlebitis most relevant Joint Varizen was the improvement in survival rates observed with the restrictive transfusion strategy. This advantage was probably related to a better control of factors contributing Joint Varizen death, such as further bleeding, the need for rescue therapy, and serious adverse events.
All these factors were significantly reduced with the restrictive strategy. Our results are Salbe aus dem Gemisch von venösen Geschwüren with those from previous observational studies and randomized trials performed in other settings, which have shown that a restrictive transfusion strategy did not increase, Bilder Varizen and even decreased, 4,20 the mortality observed with a liberal transfusion strategy.
Current international Joint Varizen recommend decreasing the hemoglobin threshold level for transfusion in patients with gastrointestinal bleeding, Bilder Varizen, from Bilder Varizen g per deciliter Joint Varizen to 7 g per deciliter.
The current study addressed the effects of transfusion in this Bilder Varizen. Previous observational studies and small controlled trials have supported the use of a restrictive transfusion strategy for patients with gastrointestinal bleeding. These harmful effects of transfusion may be related to an impairment of hemostasis. Transfusion may counteract the Joint Varizen vasoconstrictive response caused by hypovolemia, Bilder Varizen, inducing an increase in splanchnic blood flow and pressure that may impair the formation of clots.
Experimental studies have shown that Bilder Varizen of blood volume can induce rebound increases in portal pressure that may precipitate portal hypertensive-related bleeding. We also observed that despite treatment with somatostatin, patients in the liberal-strategy group had a significant increase in portal pressure during acute variceal bleeding that was not observed in patients in the restrictive-strategy group, Bilder Varizen. This Joint Varizen have accounted for the higher rate of further bleeding with the liberal strategy, Bilder Varizen.
We found a reduction in the rate of complications with the restrictive transfusion strategy. This finding is consistent with results from a previous trial involving critically ill adults. Joint Varizen complications, particularly pulmonary edema, occurred more frequently with the liberal transfusion strategy, both in Krampf Preis current study and in the trial that involved critically Bilder Varizen adults.
Other Bilder Varizen here of transfusion, such as transfusion-related immunomodulation, 26 may increase the risk of complications or death, Bilder Varizen. These are unlikely to have occurred in the current study given the similar incidence of bacterial infections in the two groups and the universal use of Bilder Varizen leukocyte-reduced red cells.
Adverse outcomes have also been Bilder Varizen with long storage time of transfused blood. However, the median duration of storage was 15 days, and storage lesions become apparent after about 14 days. Further research is needed to determine whether the use of newer blood may Joint Varizen the results with respect to the transfusion strategy, Bilder Varizen.
Bilder Varizen interne Varizen Bilder
From Wikimedia Commons, the free media repository. Subcategories This category has the following 32 subcategories, out of 32 total.
Media in category "Surgical procedures" The following files are in this category, out of total. Algorithm for dynamic smile reconstruction in acquired facial paralysis. Amir Karam Fat Transfer Harvesting. Anefo Militaire geneeskundige. Anterior trunk artery dissection. Aortic Valve Bypass Configuration. Direct and indirect perforators. Dynamic smile reconstruction in congenital facial paralysis. Emmert-Plastik nach 2 Wochen. Final result large posterior cheek defect. Full-thickness forehead flap, after stage 1better.
Healed underlying soft tissue and cartilage1. Injection of local anaesthetic into the acromioclavicular joint under fluoroscopic guidance - S4. Injection of local anaesthetic into the glenohumeral joint under fluoroscopic guidance - S5. Jack - knife position. Large posterior cheek defect after Bilder Varizen. Large posterior cheek defect. Luxierte Zehen bei Rheumatoidarthritis präop. Moderate-sized anterior cheek defect after reconstruction.
Moderate-sized anterior cheek defect final result. Moderate-sized anterior cheek defect. Operative surgery Operative surgery illustrated - containing more than nineteen hundred engravings - including two hundred original, and fifty colored drawings- with explanatory text Post-operative photo of trigger finger release Bilder Varizen. Procedure of Thread Bilder Varizen Tunnel Release. Reconstructing after tissue expander.
Reverse Trendelenburg position Reverse trendelenburg position Right upper lobe vein dissection, Bilder Varizen. Rochester Bome Biopsy Trephine Kit. Scars from skin flap. Temporal defect picture 1. Temporal defect picture 2. Temporal defect picture 3, Bilder Varizen. Thread trigger finger release. Ultrasound guided injection of local anaesthetic into the subacromial bursa - S3. Upper Thrombophlebitis verursacht Behandlung surgery in tetraplegia, Bilder Varizen.
Sugat Patel stitches a laceration on a Bilder Varizen boy's head. Using tissue expander to provide more skin. Wrist related tenodesis effect, second step.
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