A new trial shows that among patients with upper GI bleeding, withholding transfusion until the hemoglobin level falls below 7 g per deciliter results in better outcomes than using 9 g per deciliter as the trigger for transfusion.
Acute upper gastrointestinal bleeding is a common emergency condition associated with high morbidity and mortality. It is a frequent indication for red-cell transfusion, because acute blood loss can decrease tissue perfusion and the delivery of oxygen to tissues. Transfusion may be lifesaving in patients with massive exsanguinating bleeding. However, in most cases hemorrhage is not so severe, and in such circumstances the safest and most effective transfusion strategy is controversial.
• What were the hemoglobin thresholds for transfusion in the restrictive- versus liberal-strategy group in this study?
In the restrictive-strategy group, the hemoglobin threshold for transfusion was 7 g per deciliter, with a target range of 7 to 9 g per deciliter. In the liberal-strategy group, the hemoglobin threshold for transfusion was 9 g per deciliter, with a target range of 9 to 11 g per deciliter.
• Were there mortality differences observed between restrictive-strategy and liberal-strategy groups of patients with acute GI bleeding?
Mortality at 45 days was significantly lower in the restrictive-strategy group than in the liberal-strategy group: 5% (23 patients) as compared with 9% (41 patients) (P=0.02). Among all patients with cirrhosis, the risk of death was slightly lower in the restrictive-strategy group than in the liberal-strategy group. In the subgroup of patients with cirrhosis and Child-Pugh class A or B, the risk of death was significantly lower among patients in the restrictive-strategy group than among those in the liberal-strategy group, whereas in the subgroup of patients with cirrhosis and Child-Pugh class C, the risk was similar in the two groups. Among patients with bleeding from a peptic ulcer, the risk of death was slightly lower with the restrictive strategy than with the liberal strategy.
Morning Report Questions
Q: What were the findings concerning the rate of further bleeding in patients in the restrictive-versus liberal-transfusion strategies in this study?
A: The rate of further bleeding was significantly lower in the restrictive-strategy group than in the liberal-strategy group: 10% (45 patients), as compared with 16% (71 patients) (P=0.01). In the subgroup of patients with cirrhosis, the risk of further bleeding was lower with the restrictive transfusion strategy than with the liberal transfusion strategy among patients with Child-Pugh class A or B and was similar in the two groups among patients with Child-Pugh class C. Among patients with bleeding from esophageal varices, the rate of further bleeding was lower in the restrictive-strategy group than in the liberal-strategy group (11% vs. 22%, P=0.05). Among patients with bleeding from a peptic ulcer, there was a trend toward a lower risk of further bleeding in the restrictive-strategy group.
Q: What do the authors postulate as a potential reason for a harmful effect of transfusion?
A: According to the authors, the harmful effect of transfusion may be related to an impairment of hemostasis. Transfusion may counteract the splanchnic vasoconstrictive response caused by hypovolemia, inducing an increase in splanchnic blood flow and pressure that may impair the formation of clots. Transfusion may also induce abnormalities in coagulation properties. In patients with cirrhosis and portal hypertension, experimental studies have shown that restitution of blood volume can induce rebound increases in portal pressure that may precipitate portal hypertensive-related bleeding.