EBQ:Transfusion strategies for acute upper gastrointestinal bleeding: Difference between revisions
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==Clinical Question== | ==Clinical Question== | ||
*Is a restrictive transfusion strategy superior to a liberal transfusion strategy in patients with upper GI bleeds? | |||
==Conclusion== | ==Conclusion== | ||
*Lower mortality in the restrictive transfusion group (hemoglobin threshold 7) 5% vs 9% (p=0.02) | |||
==Major Points== | ==Major Points== | ||
*Transfusion threshold of hemoglobin 7g/deciliter if hemodynamically stable | |||
*Study excluded unstable patients | |||
==Inclusion Criteria== | ==Inclusion Criteria== | ||
*Age >18 | |||
*Melena or hematemasis | |||
*Consent to blood transfusion | |||
==Exclusion Criteria== | ==Exclusion Criteria== | ||
*Massive GI bleed | |||
*Lower GI bleeding | |||
*ACS | |||
*Stroke/TIA | |||
*Symptomatic PVD | |||
*Transfusion in the previous 90 days | |||
*Recent trauma or surgery | |||
*Decision by attending physician that patient should not get a specific therapy | |||
*Rockall score (assessment of future bleeding risk) of 0 with hemoglobin > 12 | |||
==Interventions== | ==Interventions== | ||
*Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11 | |||
==Outcome== | ==Outcome== | ||
*Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02) | |||
===Primary Outcomes=== | ===Primary Outcomes=== | ||
*Death from any cause in the first 45 days | |||
**Lower with restrictive strategy | |||
===Secondary Outcomes=== | ===Secondary Outcomes=== | ||
*Rate of in hospital hematemasis or melena with hemodynamic instability | |||
*2 point fall in hemoglobin in 6 hours | |||
*Number of patients requiring transfusion in each group | |||
===Subgroup analysis=== | ===Subgroup analysis=== | ||
*Cirrhotic patients | |||
**Lower mortality with restrictive strategy in Child's class A and B | |||
**No difference in Child's class C | |||
**No significant difference when all cirrhotics taken as a group | |||
*Peptic ulcer disease | |||
**No significant difference | |||
==Criticisms== | ==Criticisms== | ||
*1 unit of pRBCs was transfused up front in both groups. Therefore, there was no true conservative transfusion group. The study suggests that a transfusion threshold of hgb 7 is superior, but cannot definitively answer the question as all patients in the study received a transfusion. | |||
*All patients received an EGD within 6 hours. This may not be always be achievable. The study findings may not be generalizable. | |||
*Massive GI bleeds, which were excluded from the trial, are not defined | |||
==Funding== | ==Funding== | ||
*No external funding | |||
==Sources== | ==Sources== | ||
Revision as of 04:35, 26 March 2014
incomplete Journal Club Article
Villanueva C. et al. "Transfusion strategies for acute upper gastrointestinal bleeding". NEJM. 2013. 368(1):11-21.
PubMed Full text PDF
PubMed Full text PDF
Clinical Question
- Is a restrictive transfusion strategy superior to a liberal transfusion strategy in patients with upper GI bleeds?
Conclusion
- Lower mortality in the restrictive transfusion group (hemoglobin threshold 7) 5% vs 9% (p=0.02)
Major Points
- Transfusion threshold of hemoglobin 7g/deciliter if hemodynamically stable
- Study excluded unstable patients
Inclusion Criteria
- Age >18
- Melena or hematemasis
- Consent to blood transfusion
Exclusion Criteria
- Massive GI bleed
- Lower GI bleeding
- ACS
- Stroke/TIA
- Symptomatic PVD
- Transfusion in the previous 90 days
- Recent trauma or surgery
- Decision by attending physician that patient should not get a specific therapy
- Rockall score (assessment of future bleeding risk) of 0 with hemoglobin > 12
Interventions
- Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11
Outcome
- Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02)
Primary Outcomes
- Death from any cause in the first 45 days
- Lower with restrictive strategy
Secondary Outcomes
- Rate of in hospital hematemasis or melena with hemodynamic instability
- 2 point fall in hemoglobin in 6 hours
- Number of patients requiring transfusion in each group
Subgroup analysis
- Cirrhotic patients
- Lower mortality with restrictive strategy in Child's class A and B
- No difference in Child's class C
- No significant difference when all cirrhotics taken as a group
- Peptic ulcer disease
- No significant difference
Criticisms
- 1 unit of pRBCs was transfused up front in both groups. Therefore, there was no true conservative transfusion group. The study suggests that a transfusion threshold of hgb 7 is superior, but cannot definitively answer the question as all patients in the study received a transfusion.
- All patients received an EGD within 6 hours. This may not be always be achievable. The study findings may not be generalizable.
- Massive GI bleeds, which were excluded from the trial, are not defined
Funding
- No external funding