Transfusion targets in acute GI bleed.
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Transcript of Transfusion targets in acute GI bleed.
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding
The New England Journal of Medicine
n engl j med 368;1 nejm.org January 3, 2013
Study Design
RandomisedControlledNot blinded
18yrs + with upper Gi bleed Exclusions
Restrictive vs. Liberal
<7g/dL<9g/dL
Outcomes
Death rate at 45 daysFurther bleedingHospital complications
Measure 1 point 2 points 3 points
Total bilirubin, μmol/l (mg/dl) <34 (<2) 34-50 (2-3) >50 (>3)
Serum albumin, g/dl >3.5 2.8-3.5 <2.8
PT INR <1.7 1.71-2.30 > 2.30
Ascites None Mild Moderate to Severe
Hepatic encephalopathy None Grade I-II (or suppressed with medication)
Grade III-IV (or refractory)
Child Pugh Prognostic Score
Points Class One year survival
Two year survival
5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%
Discussion Increased survival
5% vs 9% Mortality Reduced rebleeding, rescue therapies and adverse
complications Reduced length of hospital stay
9.6 vs 11.5 days
Explanation Less harmful effects of transfusion. Less negative effect on haemostasis and clot
formation. Transfusion may counteract splanchnic
vasoconstrictive response caused by hypovolemia. Precipitation of coagulation abnormalities
Explanation Increasing blood volume can induce rebound
increases in portal pressure that may precipitate portal hypertensive- related bleeding.
Increase in portal pressure found, even with somatostatin
May account for increase in rebleeding.
Explanation The higher level of cardiac complications may
indicate a higher risk of circulatory overload associated with a liberal transfusion strategy.
Transfusion immunomodulation Blood storage time
Mean 15 days Protocol violations- less than 10% (R > L)
Limitations Specific group Exclusion of extreme groups Allowed deviation from protocol Not blinded
Summary A restrictive transfusion strategy improved the
outcomes among patients with acute upper gastrointestinal bleeding.
The risk of further bleeding The need for rescue therapy The rate of complications
The rate of survival was increased. A strategy of not performing transfusion until the
hemoglobin concentration falls below 7 g/dL is a safe and effective approach.
All significantly reduced
How will this change our practice? “Less is more”
What about other patient groups? Massive bleeding? Acute coronary syndrome?
Thank you... Questions? References:
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. Villanueva et al. The New England Journal of Medicine; n engl j med 368;1 nejm.org January 3, 2013
Wikipaedia (Child Pugh Score) Blood transfusion for upper gastrointestinal
bleeding: is less more again? Al-Jaghbeer and Yende. Critical Care 2013, 17:325