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