EBQ:Transfusion strategies for acute upper gastrointestinal bleeding

From WikEM
Jump to: navigation, search
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

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
  • All patients had emergency gastroscopy within the first 6 hours with appropriate techniques to mitigate bleeding.

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
  • Emergency gastroscopy within the first 6 hours to perform appropriate treatment
    • Injection of adrenaline and multipolar electrocoagulation or application of endoscopic clips for
      • Nonvariceal lesion with active arterial bleeding
      • Nonbleeding visible vessel
      • Adherent clot
    • Omeprazole bolus of 80mg followed by a continuous IV infusion of 80 mg per 10 hour period for next 72 hours
      • Peptic ulcer
    • Continuous intravenous infusion of somatostatin 250 micrograms per hour and prophylactic antibiotic therapy with norfloxacin or ceftriaxone were administered at the time of admission and continued for 5 days.
      • portal hypertension suspected
    • band ligation with sclerotherapy
      • bleeding esophageal varices
    • injection of cyanoacrylate
      • Bleeding gastric varices

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 (SBP<100 mmHg and/or HR>100)
  • 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
  • Low risk of rebleeding were not included
  • Massive exsanguinating hemorrhage were also excluded
  • Study was not blinded and could have introduced bias

See Also

External Links

Funding

  • No external funding

References