Transfusion targets in acute GI bleed
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Transfusion Strategies for Acute Upper Gastrointestinal BleedingThe New England Journal of Medicine
n engl j med 368;1 nejm.org January 3, 2013
Study DesignRandomisedControlledNot blinded
18yrs + with upper Gi bleedExclusions
- Restrictive vs. Liberal
OutcomesDeath rate at 45 daysFurther bleedingHospital complications
Child Pugh Prognostic Score
Measure1 point2 points3 pointsTotal bilirubin, mol/l (mg/dl)3)Serum albumin, g/dl>3.52.8-3.5
DiscussionIncreased survival5% vs 9% Mortality Reduced rebleeding, rescue therapies and adverse complicationsReduced length of hospital stay9.6 vs 11.5 days
ExplanationLess 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
ExplanationIncreasing blood volume can induce rebound increases in portal pressure that may precipitate portal hypertensive- related bleeding.Increase in portal pressure found, even with somatostatinMay account for increase in rebleeding.
ExplanationThe higher level of cardiac complications may indicate a higher risk of circulatory overload associated with a liberal transfusion strategy.Transfusion immunomodulationBlood storage timeMean 15 daysProtocol violations- less than 10% (R > L)
LimitationsSpecific groupExclusion of extreme groupsAllowed deviation from protocolNot blinded
SummaryA restrictive transfusion strategy improved the outcomes among patients with acute upper gastrointestinal bleeding. The risk of further bleedingThe need for rescue therapyThe rate of complicationsThe 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, 2013Wikipaedia (Child Pugh Score)Blood transfusion for upper gastrointestinal bleeding: is less more again? Al-Jaghbeer and Yende. Critical Care 2013, 17:325