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Erschienen in:
01.10.2013 | Journal club critique
Blood transfusion for upper gastrointestinal bleeding: is less more again?
Erschienen in: Critical Care | Ausgabe 5/2013
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Background
The hemoglobin threshold for transfusion of red blood cells in patients withacute gastrointestinal (GI) bleeding is controversial. We compared theefficacy and safety of a restrictive transfusion strategy with those of aliberal transfusion strategy.
Methods
Objective: The objective was to prove that the restrictivethreshold for red blood cell transfusion in patients with acute upper GIbleeding (UGIB) was safer and more effective than a liberal transfusionstrategy.
Design: A single-center, randomized controlled trial wasconducted.
Setting: Patients with GI bleeding were admitted to the de la SantaCreu i Sant Pau hospital in Barcelona, Spain.
Subjects: The subjects were adult intensive care unit patientsadmitted with high clinical suspicion of UGIB (hematomemesis, melena, orboth). Patients were excluded if they had massive exsanguinating bleeding,acute coronary syndrome, symptomatic peripheral vascular disease,stroke/transient ischemic attack, transfusion within the previous 90 days,recent trauma or surgery, lower GI bleeding, or a clinical Rockall score of0 with hemoglobin higher than 12 g/dL.
Intervention: A total of 921 patients with severe acute UGIB wereenrolled. Of these, 461 were randomly assigned to a restrictive strategy(transfusion when the hemoglobin level fell to below 7 g/dL) and 460 to aliberal strategy (transfusion when the hemoglobin fell to below 9 g/dL).Random assignment was stratified according to the presence or absence ofliver cirrhosis.
Outcomes: The primary outcome was rate of death from any causewithin the first 45 days. Secondary outcomes were further bleeding, definedas hematemesis or melena with hemodynamic instability or hemoglobin decreaseof 2 g/dL or more, and in-hospital complications.
Results
In total, 225 patients assigned to the restrictive strategy (51%) and 65assigned to the liberal strategy (15%) did not receive transfusions(P <0.001). The probability of survival at 6 weeks washigher in the restrictive-strategy group than in the liberal-strategy group(95% versus 91%; hazard ratio (HR) for death with restrictive strategy,0.55; 95% confidence interval (CI) 0.33 to 0.92; P = 0.02). Furtherbleeding occurred in 10% of the patients in the restrictive-strategy groupand in 16% of the patients in the liberal-strategy group (P =0.01), and adverse events occurred in 40% and 48%, respectively (P= 0.02). The probability of survival was slightly higher with therestrictive strategy than with the liberal strategy in the subgroup ofpatients who had bleeding associated with a peptic ulcer (HR 0.70, 95% CI0.26 to 1.25) and was significantly higher in the subgroup of patients withcirrhosis and Child-Pugh class A or B disease (HR 0.30, 95% CI 0.11 to 0.85)but not in those with cirrhosis and Child-Pugh class C disease (HR 1.04, 95%CI 0.45 to 2.37). Within the first 5 days, the portal-pressure gradientincreased significantly in patients assigned to the liberal strategy(P = 0.03) but not in those assigned to the restrictivestrategy.
Conclusions
Compared with a liberal transfusion strategy, a restrictive strategysignificantly improved outcomes in patients with acute UGIB.