Strategija primene transfuzije krvi u lečenju akutnog krvarenja iz gornjih partija gastrointestinalnog trakta

Abstract

Akutno krvarenje iz gornjih partija gastrointestinalnog trakta, koje se najčešće javlja kao komplikacija peptičke ulkusne bolesti, je urgentno stanje povezano sa visokim morbiditetom i mortalitetom. Bez obzira na značajna poboljšanja u terapiji i načinu zbrinjavanja obolelih, eradikaciji Helikobakter pilori infekcije, mortalitet nije značajno opao u poslednjih 50 godina. Stariji pacijenti kao i osobe sa uznapredovalim hroničnim bolestima podnose krvarenje značajno teže, te su i izloženi većem riziku od smrtnog ishoda. Za pravilnu trijažu pacijenata sa akutnim gornjim gastrointestinalnim krvarenjem upotrebljavaju se bodovni sistemi poput Glasgow-Blatchford skora i Rockall preendoskopskog skora za procenu rizika od lošeg kliničkog toka bolesti. Transfuzija eritrocitnih krvnih produkta predstavlja vid alogene transplantacije tkiva koja je povezana sa određenim rizikom. Kod hemodinamski stabilnih pacijenata sa krvarenjem iz gornjih partija gastrointestinalnog trakta optimalnu graničnu vrednost hematokrita, kod koje je indikovana transfuzija eritrocita, potrebno je pažljivije definisati. Smatra se da restriktivna transfuzijska strategija značajno smanjuje mortalitet i morbiditet kod pacijenta sa krvarenjem iz gornjih partija gastrointestinalnog trakta. Metodologija: Ispitivanjem je obuhvaćeno 339 bolesnika, oba pola, starosti 18 godina i starijih. Retrospektivno, od 01.01.2015. do 31.12.2016. su analizirani bolesnici hospitalizovani zbog akutnog nevariksnog krvarenja iz gornjih partija gastrointestinalnog trakta u Odeljenju urgentne interne medicine Kliničkog Centra Vojvodine. Prospektivno su ispitani bolesnici koji su iz istog razloga hospitalizovani od 01.01.2017 do 31.06. 2017. Podaci koji su bili od značaja za inicijanu epizodu krvarenja, uključujući i narednih 30 dana lečenja, su prikupljeni iz istorija bolesti i kartona pacijenata. Potom su bolesnici podeljeni u grupu urgentne endoskopije, kod koje je načinjena ezofagogastroduodenoskopija unutar 12 časova od prijema i grupu rane endoskopije koja je načinjena nakon više od 12 časova od prijema. Potom je grupa urgentne endoskopije podeljena u grupu restriktivne strategije primene transfuzije (bez trasnfuzije ili transfuzija kada je vrednost hemoglobina u krvi, iznosila 70 g/L ili niže) i liberalne (transfuzija kada je vrednost hemoglobina u krvi, iznosila više od 70 g/L). Upoređivali smo endoskopske, kliničke parametre i ishod lečenja između ovih grupa bolesnika. Rezultati: Na našem uzorku dokazali smo da je liberalna strategija primene transfuzije eritrocita (primenjena transfuzija kada je vrednost hemoglobina u krvi veća od 70 g/L) u poređenju sa restriktivnom strategijom (primenjena transfuzija kada je vrednost hemoglobina u krvi manja od 70 g/L) povezana sa češćim otkrivanjem aktivnog krvarenja tokom endoskopije (p=0,010). Verovatnoća otkrivanja Forrest I a i I b lezija je veća u grupi liberalne nego u grupirestriktivne strategije primene transfuzije (3,935 puta). Nije bilo značajnih razlika u učestalosti recidiva krvarenja, mortalitetu ili potrebi za hiruškom intervencijom sa ciljem zbrinjavanja krvarenja između onih sa urgentnom i endoskopijom koja je načinjena nakon 12 časova od prijema. Stariji bolesnici, sa većim brojem komorbiditeta i nižom koncentracijom hemoglobina u krvi na prijemu, su u proseku najduže čekali na endoskopski pregled. Vrednost količnika uree (izražene u mmol/L) i koncentracije hemoglobina u krvi (izražene u g/dl) je bolja u predviđanju potrebe za primenom transfuzije krvi kod bolesnika sa akutnim gornjim nevaricealnim krvarenjem u poređenju sa Glasgow-Blatchford skorom. Zaključili smo da restriktivna strategija primene transfuzije eritrocita povoljno utiče na klinički tok akutnog gornjeg GI krvarenja. Granična vrednost koncentracije hemoglobina u krvi, kod koje je indikovana transfuzija eritrocita, kod bolesnika sa akutnim gornjim GI krvarenjem, trebalo bi da bude značajno niža od one sada ustaljene u našoj kliničkoj praksi.

Acute bleeding from the upper parts of the gastrointestinal tract, which most often occurs as a complication of peptic ulcer disease, is an urgent condition associated with high morbidity and mortality. Despite significant improvements in therapy and the patient care, as well as the eradication of Helicobacter pylori infection, mortality has not decreased significantly in the last 50 years. Elderly patients, as well as patients with late stages of chronic diseases, have a significantly reduced tolerability towards bleeding and are thus at higher risk of death. In order to properly triage patients with acute upper gastrointestinal bleeding, scoring systems such as the Glasgow-Blatchford score and the Rockall preendoscopic score are used to assess the risk of poor clinical course of the disease. Transfusion of erythrocyte blood products represents a type of allogenic tissue transplantation, which is associated with a certain risk. In hemodynamically stable patients with acute upper gastrointestinal bleeding, the optimal limit value of hematocrit, in which erythrocyte transfusion is indicated, needs to be defined more carefully. A restrictive transfusion strategy is considered to have significantly reduced mortality and morbidity in s patients with upper gastrointestinal bleeding. Methodology: The study included 339 patients, male and female, aged 18 years and older. Retrospective analysis was performed, and included patients who were admitted in the period of 01.01.2015. to 31.12.2016. to the Department of Emergency Internal Medicine, Clinical Center of Vojvodina, due to acute non-varicose bleeding from the upper lobes of the gastrointestinal tract. Patients who were hospitalized for the same reason from 01.01.2017 to 31.06.2017 were prospectively examined. Data that were relevant to the initial bleeding episode, including the following 30 days of treatment, were collected from medical histories and patient records. The patients were afterwards split into two groups: first on being emergency endoscopy group, in which an esophagogastroduodenoscopy was performed within 12 hours of admission, and the second one being the early endoscopy group, which was performed more than 12 hours after admission. The emergency endoscopy group was then further divided into a group of restrictive transfusion strategies (no transfusion or transfusion when the hemoglobin value in the blood was 70 g / L or lower) and liberal (transfusion when the hemoglobin value in the blood was more than 70 g / L). ). We compared endoscopic, clinical parameters and treatment outcome between these groups of patients. Results: Our study demonstrated that the liberal strategy of erythrocyte transfusion (applied transfusion when the value of hemoglobin in the blood is greater than 70 g / L) compared to the restrictive strategy (applied transfusion when the value of hemoglobin in the blood is less than 70 g / L) ) is associated with more frequent detection of active bleeding during endoscopy (p = 0.010). The probability of detecting Forrest I a and I b lesions is higher in the group of liberal than in the group of restrictive transfusion application strategies (3,935 times). There were no statistically significant differences in the frequency of bleeding recurrence, mortality, or the need for surgical intervention to manage bleeding between those with emergency endoscopy and endoscopy performed 12 hours after admission. Elderly patients, who have a greater number of comorbidities and a lower concentration of hemoglobin in the blood at admission, waited on average the longest for an endoscopic examination. The value of urea quotient (expressed in mmol / L) and hemoglobin concentration in blood (expressed in g / dl) is better in predicting the need for blood transfusion in patients with acute upper nonvariceal hemorrhage compared to the Glasgow-Blatchford score. We concluded that the restrictive strategy of erythrocyte transfusion has a favorable effect on the clinical course of acute upper GI bleeding. The cut-off value of hemoglobin concentration in the blood, in which erythrocyte transfusion is indicated, in patients with acute upper GI bleeding, should be significantly lower than the one established and used today in our clinical practice.