EBQ:Transfusion strategies for acute upper gastrointestinal bleeding

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

• Lower mortality in the restrictive transfusion group (hemoglobin threshold 7) 5% vs 9% (p=0.02)

Major Points

• Transfusion threshold of hemoglobin 7g/deciliter if hemodynamically stable
• Study excluded unstable patients

Inclusion Criteria

• Age >18
• Melena or hematemasis
• 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

Outcome

• 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

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

• 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

Funding

• No external funding