Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

Summarized by Trevor Pour MD

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding, N Engl J Med. 2013 Jan 3;368(1):11-21

Background
Upper GI bleed is a common emergency condition with wide ranging severity. There is some controversy regarding hemoglobin transfusion thresholds in acute upper GI bleed, with previous studies (which excluded GI bleeds) showing that a restrictive transfusion strategy were at least as effective as more liberal transfusion strategies in treating critically ill patients. This study was conducted to determine whether a restrictive transfusion strategy was associated with improved patient survival.

Methods
Randomized controlled trial
Single center, enrolled from 2003-2009
921 patients underwent randomization
No commercial support
Analyzed with intention to treat

Inclusion criteria

  • 18 years or older
  • Hematemesis, melena, or both


Exclusion criteria

  • Patient declined blood transfusion
  • Massive exsanguinating bleeding
  • Acute coronary syndrome
  • Symptomatic peripheral vasculopathy
  • Stroke/TIA
  • Transfusion within the previous 90 days
  • Recent history of trauma or surgery
  • Lower gastrointestinal bleeding
  • Previous decision on the part of the attending physician that the patient should avoid specific medical therapy
  • Clinical Rockall score of 0 with a hemoglobin level higher than 12 g per deciliter

 

Intervention
Restrictive arm received transfusion of PRBC for Hgb <7 g/dL
Liberal arm received transfusion of PRBC for Hgb <9 g/dL
Both groups received one unit PRBCs at a time followed by a post-transfusion Hgb level

Primary Endpoint
Rate of death by any cause within 45 days

Secondary Endpoint
Rate of further bleeding
Rate of in-hospital complications

Results

  • Mortality at 45 days was significantly lower in restrictive-strategy group (5% compared to 9%, Hazard Ratio 0.55 [0.33-0.92], P=0.02)
  • Further bleeding was significantly lower in restrictive-strategy group (10% vs 16%, Hazard Ratio 0.62 [0.43-0.91], P=0.01)
  • Restrictive-strategy patients spent fewer days in-hospital (9.6+/-8.7 vs. 11.5+/-12.8)
  • Adverse events were less common in restrictive-strategy group (40% vs 48%, Hazard Ratio 0.73 [0.56-0.95] P=0.02)
    • Adverse events included transfusion reactions, cardiac/pulmonary complications, AKI, stroke/TIA, or bacterial infections.
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