Transfusion Strategy in Upper GI Bleeding


A 55-year aged male presents to a Emergency Department, diseased and drunken following 3 episodes of dark, blood-streaked emesis.

He’s a long-time drinker with hepatitis C and peptic ulcer disease. Knowing a risk of an top gastrointestinal bleed, we fast place dual large-bore IV’s and start volume resuscitation with fluids.

Labs lapse with a hemoglobin turn of 8 g/d. You reflexively pierce to call a blood bank to sequence a transfusion, though afterwards pause.

Does this studious indeed need a transfusion?

You know that limiting transfusion strategies have been proven profitable in a critically ill, though these studies generally released patients with strident draining from a gastrointestinal source.  When it comes to your studious and a doubt during hand, a jury is still out.

Until now. In this week’s emanate of NEJM, Candide Villanueva and colleagues news their results: even in GI bleeding, reduction is more.

To residence a argumentative question, a authors enrolled scarcely 1,000 patients with serious strident top GI bleeds. Half perceived transfusions with a aim hemoglobin of 7 g/dL and a other half were transfused to a hemoglobin of 9 g/dL.

All enclosed in a examine had transparent justification of top GI bleeding, possibly from queasiness blood or from melena.  The meant hemoglobin during acknowledgment was identical in both groups; 9.6 g/dL in a organisation with a limiting plan and 9.4 g/dL in a other group.

All patients underwent emergent top endoscopy, as is customary use to examine draining source. Peptic ulcers were identified as a source of drain in scarcely half those enrolled, and esophageal varices in 20 percent.

Those with “massive exsanguinating bleeding” – for whom transfusions could be life-saving – were excluded, as were those with consequent heart attacks. Patients both with and but liver illness were included, and a groups were stratified according to a participation or deficiency of cirrhosis.

The formula were striking. Mortality during 45 days was significantly reduce in a organisation with fewer transfusions.  Furthermore, a patients with a reduce transfusion idea were reduction expected to re-bleed and were liberated from a sanatorium sooner.

What competence explain these findings?

In their discussion, a authors privately residence because assertive transfusion competence be damaging for patients with cirrhosis and portal hypertension, by augmenting portal vigour and heading to some-more bleeding.  Indeed, those with cirrhosis who were incidentally reserved to magnanimous transfusion parameters had aloft portal pressures – leading, perhaps, to a aloft rates of serve draining celebrated in this group.

But limiting transfusions also benefited those with bleeds from non-variceal sources – such as ulcers. To residence this point, a authors note that transfused blood itself competence be harmful, by altering a coagulation cascade and interfering with a body’s possess response to blood loss.

How germane are these results?

In an concomitant editorial, Loren Laine, M.D. writes that dual groups – specifically, patients in hypovolemic shock, and those with cardiovascular illness – competence still advantage from aloft transfusion thresholds. But for a infancy of patients, a study’s formula are clinically directive: “Most patients with top gastrointestinal bleeding, with or but portal hypertension, should have blood transfusions funded until a hemoglobin turn drops next 7 grams per deciliter,” Laine writes.

For a patient, then?

Rethink that automatic and put down a phone.

Tags: endoscopy, gastrointestinal bleed, GI bleeding, hemoglobin level, large exsanguinating bleeding, Peptic ulcers, transfusion
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Via: Health Medicine Network