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EBQ:Transfusion strategies for acute upper gastrointestinal bleeding
From WikEM
Under Review Journal Club Article
Villanueva C. et al. "Transfusion strategies for acute upper gastrointestinal bleeding". NEJM. 2013. 368(1):11-21.
PubMed Full text PDF
PubMed Full text PDF
Contents
Clinical Question
- Is a restrictive transfusion strategy superior to a liberal transfusion strategy in patients with upper GI bleeds?
Conclusion
- Compared to a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper GI bleeding.
Major Points
- The restrictive strategy required significantly less transfusions, had a higher probability of survival at 6 weeks, less further bleeding, less adverse effects, and lower mortality compared to the liberal strategy group.
- Restrictive strategy= transfusion threshold of hemoglobin 7g/deL if hemodynamically stable
Study Design
- Randomized prospective trial
- Patients admitted to Barcelona hospital between June 2003 and December 2009
- Patients randomized by computer, randomization stratified based on presence or absence of liver cirrhosis
- In the restrictive group, Hb threshold for transfusion was 7 g/dL, with target range for post-transfusion of 7-9 g/dL
- In the liberal-strategy group, Hb threshold for transfusion was 9 g/dL, with target range for post-transfusion of 9-11 g/dL
- In both groups, 1 unit of red cells was transfused initially and the hemoglobin level was assessed after transfusion
- Transfusion protocol applied until discharge or death
- Transfusion allowed any time symptoms or signs related to anemia developed, massive bleeding occurred during follow-up, or surgical intervention was required.
- Only pRBCs were used
- Hb measured after admission and again q8h during the first 2 days and every day thereafter
- Hb levels assessed when further bleeding suspected
Population
Patient Demographics
Inclusion Criteria
- Age >18
- Melena and/or hematemasis (or bloody nasogastric aspirate)
- Consent to blood transfusion
Exclusion Criteria
- Massive GI bleed
- Lower GI bleeding
- ACS
- Stroke/TIA
- Symptomatic PVD
- Transfusion in the previous 90 days
- Recent trauma or surgery
- Decision by attending physician that patient should not get a specific therapy
- Rockall score (assessment of future bleeding risk) of 0 with hemoglobin > 12
Interventions
- Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11
Outcomes
- Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02)
Primary Outcomes
- Death from any cause in the first 45 days
- Lower with restrictive strategy
95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02)
Secondary Outcomes
- Rate of in hospital hematemasis or melena with hemodynamic instability
- 2 point fall in hemoglobin in 6 hours
- Number of patients requiring transfusion in each group
Subgroup analysis
- Cirrhotic patients
- Lower mortality with restrictive strategy in Child's class A and B
- No difference in Child's class C
- No significant difference when all cirrhotics taken as a group
- Peptic ulcer disease
- No significant difference
Criticisms & Further Discussion
- 1 unit of pRBCs was transfused up front in both groups. Therefore, there was no true conservative transfusion group. The study suggests that a transfusion threshold of hgb 7 is superior, but cannot definitively answer the question as all patients in the study received a transfusion.
- All patients received an EGD within 6 hours. This may not be always be achievable. The study findings may not be generalizable.
- Massive GI bleeds, which were excluded from the trial, are not defined
See Also
External Links
Funding
- No external funding
References
Authors
Alex Linker, Catie Reynolds, Daniel Ostermayer, Ross Donaldson