急性上消化道出血的输血策略

  2013-01-31

 编辑：环球医学 吴晓毅

 关键词： 急性上消化道出血，输血策略

 

 

题目：急性上消化道出血的输血策略（Transfusion strategies for acute upper gastrointestinal bleeding）武警重庆总队医院肝胆胰脾外科李广阔

背景：急性上消化道出血患者是否需输注红细胞对血红蛋白阈值有争议。我们比较限制性输血策略和宽松输血策略的疗效和安全性。

方法：我们共纳入921名重度急性上消化道出血的患者，将其中的461名患者随机分配使用限制性策略（当血红蛋白水平低于7克/分升时输血），另外460名患者采用宽松性策略（当血红蛋白低于9克/分升时输血）。通过是否患有肝硬化对随机化进行分层。

结果：限制性策略中的225名患者（51%）与宽松策略中的65名患者（15%）未接受输血（P＜0.001）。限制策略组的6周生存概率比宽松策略组高（95% vs 91%；限制性策略组的死亡风险比为0.55；95%可信区间[CI] 0.33-0.92；P = 0.02）。限制性策略组有10%的患者进一步发生出血，而宽松策略组发生进一步出血的患者占16%（P = 0.01），且限制性策略组不良事件发生的情况占40%，而宽松策略组为48%（P = 0.02）。伴随消化性溃疡的出血患者，采用限制性策略的存活概率比采用宽松策略高略高（风险比0.70；95% CI 0.26-1.2），且肝硬化和肝功能等级为A或B的疾病患者，采用限制性策略的存活概率明显高于采用宽松策略高（风险比0.30；95% CI 0.11-0.85），但肝硬化和肝功能等级为C类疾病的患者则不同（风险比1.04；95% CI 0.45-2.37）。头5天，宽松策略患者的静脉压梯度显著增加（P = 0.03），限制策略的患者则不同。

结论：与宽松策略输血策略相比，限制性输血策略能显著改善急性上消化道出血患者的结局。（由圣保罗Fundacio Investigacio资助，临床试验政府编号：NCT00414713）。

（选题审校： 任振宇 北京大学第三医院药剂科）

本文由翟所迪教授及其团队选题并审校，环球医学编辑完成。

medline原文：

 

N Engl J Med. 2013 Jan 3;368(1):11-21. doi: 10.1056/NEJMoa1211801.
Transfusion strategies for acute upper gastrointestinal bleeding.
Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M,Muñiz E, Guarner C.
Source
Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Autonomous University, Barcelona, Spain. [e-mail]

Abstract
BACKGROUND:
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.

METHODS:
We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 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.

RESULTS:
A total of 225 patients assigned to the restrictive strategy (51%), as compared with 65 assigned to the liberal strategy (15%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). 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, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.

CONCLUSIONS:
As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).

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