EBQ:Transfusion strategies for acute upper gastrointestinal bleeding - Revision history

Ostermayer: Prepared the page for translation

2026-01-05T00:01:04Z

Prepared the page for translation

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	{{JC info		{{JC info
	\| title= Transfusion strategies for acute upper gastrointestinal bleeding		\| title= Transfusion strategies for acute upper gastrointestinal bleeding
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	\|status=Under Review		\|status=Under Review
	}}		}}
			<translate>


	==Clinical Question==		==Clinical Question==

	*Is a restrictive transfusion strategy superior to a liberal transfusion strategy in patients with upper GI bleeds?		*Is a restrictive transfusion strategy superior to a liberal transfusion strategy in patients with upper GI bleeds?


	==Conclusion==		==Conclusion==

	*Compared to a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper GI bleeding.		*Compared to a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper GI bleeding.

	==Major Points==
			==Major Points==


	*The restrictive strategy required significantly less transfusions, had a higher probability of survival at 6 weeks, less further bleeding, less adverse effects, and lower mortality compared to the liberal strategy group.		*The restrictive strategy required significantly less transfusions, had a higher probability of survival at 6 weeks, less further bleeding, less adverse effects, and lower mortality compared to the liberal strategy group.
	*Restrictive strategy= transfusion threshold of hemoglobin 7g/deL if hemodynamically stable		*Restrictive strategy= transfusion threshold of hemoglobin 7g/deL if hemodynamically stable


	==Study Design==		==Study Design==

	*Randomized prospective trial		*Randomized prospective trial
	*Patients admitted to Barcelona hospital between June 2003 and December 2009		*Patients admitted to Barcelona hospital between June 2003 and December 2009
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	**Hb levels assessed when further bleeding suspected		**Hb levels assessed when further bleeding suspected
	*All patients had emergency gastroscopy within the first 6 hours with appropriate techniques to mitigate bleeding.		*All patients had emergency gastroscopy within the first 6 hours with appropriate techniques to mitigate bleeding.


	==Population==		==Population==


	===Patient Demographics===		===Patient Demographics===

	===Inclusion Criteria===
			===Inclusion Criteria===


	*Age >18		*Age >18
	*Melena and/or hematemasis (or bloody nasogastric aspirate)		*Melena and/or hematemasis (or bloody nasogastric aspirate)
	*Consent to blood transfusion		*Consent to blood transfusion


	===Exclusion Criteria===		===Exclusion Criteria===

	*Massive GI bleed		*Massive GI bleed
	*Lower GI bleeding		*Lower GI bleeding
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	*Rockall score (assessment of future bleeding risk) of 0 with hemoglobin > 12		*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		*Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11
	*Emergency gastroscopy within the first 6 hours to perform appropriate treatment		*Emergency gastroscopy within the first 6 hours to perform appropriate treatment
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	**injection of cyanoacrylate		**injection of cyanoacrylate
	***Bleeding gastric varices		***Bleeding gastric varices

	==Outcomes==		==Outcomes==

	*Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02)		*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		*Death from any cause in the first 45 days
	**Lower with restrictive strategy		**Lower with restrictive strategy
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	strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02)		strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02)

	===Secondary Outcomes===
			===Secondary Outcomes===


	*Rate of in hospital hematemasis or melena with hemodynamic instability (SBP<100 mmHg and/or HR>100)		*Rate of in hospital hematemasis or melena with hemodynamic instability (SBP<100 mmHg and/or HR>100)
	*2 point fall in hemoglobin in 6 hours		*2 point fall in hemoglobin in 6 hours
	*Number of patients requiring transfusion in each group		*Number of patients requiring transfusion in each group



	===Subgroup analysis===		===Subgroup analysis===

	*Cirrhotic patients		*Cirrhotic patients
	**Lower mortality with restrictive strategy in Child's class A and B		**Lower mortality with restrictive strategy in Child's class A and B
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	**No significant difference		**No significant difference



	==Criticisms & Further Discussion==		==Criticisms & Further Discussion==

	*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.		*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.		*All patients received an EGD within 6 hours. This may not be always be achievable. The study findings may not be generalizable.
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	*Massive exsanguinating hemorrhage were also excluded		*Massive exsanguinating hemorrhage were also excluded
	*Study was not blinded and could have introduced bias		*Study was not blinded and could have introduced bias


	==See Also==		==See Also==


	==External Links==		==External Links==
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	==Funding==		==Funding==

	*No external funding		*No external funding


	==References==		==References==

	<references/>		<references/>

	[[Category:EBQ]][[Category:GI]]		[[Category:EBQ]][[Category:GI]]
			</translate>

Panosiaa at 21:21, 5 July 2017

2017-07-05T21:21:38Z

← Older revision		Revision as of 21:21, 5 July 2017
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	*Hb measured after admission and again q8h during the first 2 days and every day thereafter		*Hb measured after admission and again q8h during the first 2 days and every day thereafter
	**Hb levels assessed when further bleeding suspected		**Hb levels assessed when further bleeding suspected
			*All patients had emergency gastroscopy within the first 6 hours with appropriate techniques to mitigate bleeding.

	==Population==		==Population==
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	==Interventions==		==Interventions==
	*Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11		*Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11
			*Emergency gastroscopy within the first 6 hours to perform appropriate treatment
			**Injection of adrenaline and multipolar electrocoagulation or application of endoscopic clips for
			***Nonvariceal lesion with active arterial bleeding
			***Nonbleeding visible vessel
			***Adherent clot
			**Omeprazole bolus of 80mg followed by a continuous IV infusion of 80 mg per 10 hour period for next 72 hours
			***Peptic ulcer
			**Continuous intravenous infusion of somatostatin 250 micrograms per hour and prophylactic antibiotic therapy with norfloxacin or ceftriaxone were administered at the time of admission and continued for 5 days.
			***portal hypertension suspected
			**band ligation with sclerotherapy
			***bleeding esophageal varices
			**injection of cyanoacrylate
			***Bleeding gastric varices
	==Outcomes==		==Outcomes==
	*Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02)		*Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02)
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	===Secondary Outcomes===		===Secondary Outcomes===
	*Rate of in hospital hematemasis or melena with hemodynamic instability		*Rate of in hospital hematemasis or melena with hemodynamic instability (SBP<100 mmHg and/or HR>100)
	*2 point fall in hemoglobin in 6 hours		*2 point fall in hemoglobin in 6 hours
	*Number of patients requiring transfusion in each group		*Number of patients requiring transfusion in each group
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	*All patients received an EGD within 6 hours. This may not be always be achievable. The study findings may not be generalizable.		*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		*Massive GI bleeds, which were excluded from the trial, are not defined
			*Low risk of rebleeding were not included
			*Massive exsanguinating hemorrhage were also excluded
			*Study was not blinded and could have introduced bias

	==See Also==		==See Also==

Catierey: study design

2015-09-24T23:25:24Z

study design

← Older revision		Revision as of 23:25, 24 September 2015
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	==Conclusion==		==Conclusion==
	*~~Lower mortality~~ in ~~the restrictive transfusion group (hemoglobin threshold 7) 5% vs 9% (p=0~~.~~02)~~		*Compared to a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper GI bleeding.

			==Major Points==
			*The restrictive strategy required significantly less transfusions, had a higher probability of survival at 6 weeks, less further bleeding, less adverse effects, and lower mortality compared to the liberal strategy group.
			*Restrictive strategy= transfusion threshold of hemoglobin 7g/deL if hemodynamically stable

	==~~Major Points~~==		==Study Design==
	*~~Transfusion~~ threshold of hemoglobin ~~7g/deciliter if hemodynamically stable~~		*Randomized prospective trial
	*~~Study excluded unstable patients~~		*Patients admitted to Barcelona hospital between June 2003 and December 2009
			*Patients randomized by computer, randomization stratified based on presence or absence of liver cirrhosis
			**In the restrictive group, Hb threshold for transfusion was 7 g/dL, with target range for post-transfusion of 7-9 g/dL
			**In the liberal-strategy group, Hb threshold for transfusion was 9 g/dL, with target range for post-transfusion of 9-11 g/dL
			*In both groups, 1 unit of red cells was transfused initially and the hemoglobin level was assessed after transfusion
			*Transfusion protocol applied until discharge or death
			*Transfusion allowed any time symptoms or signs related to anemia developed, massive bleeding occurred during follow-up, or surgical intervention was required.
			*Only pRBCs were used
			*Hb measured after admission and again q8h during the first 2 days and every day thereafter
			**Hb levels assessed when further bleeding suspected

			==Population==
			===Patient Demographics===

	==Inclusion Criteria==		===Inclusion Criteria===
	*Age >18		*Age >18
	*Melena or hematemasis		*Melena and/or hematemasis (or bloody nasogastric aspirate)
	*Consent to blood transfusion		*Consent to blood transfusion

	==Exclusion Criteria==		===Exclusion Criteria===
	*Massive GI bleed		*Massive GI bleed
	*Lower GI bleeding		*Lower GI bleeding
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	*Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11		*Transfusion threshold set at hgb 7 with target range 7-9 vs hgb 9 with target range 9-11

			==Outcomes==
	==~~Outcome~~==
	*Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02)		*Lower mortality with restrictive transfusion strategy 5% vs 9% (p=0.02)

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	*Death from any cause in the first 45 days		*Death from any cause in the first 45 days
	**Lower with restrictive strategy		**Lower with restrictive strategy
			95% vs. 91%; hazard ratio for death with restrictive
			strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02)

	===Secondary Outcomes===		===Secondary Outcomes===
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	==Criticisms==		==Criticisms & Further Discussion==
	*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.		*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.		*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		*Massive GI bleeds, which were excluded from the trial, are not defined

	==~~Funding==~~		==See Also==
	*No external funding

	~~==Sources~~==

			==External Links==


			==Funding==
			*No external funding

			==References==
	<references/>		<references/>

	[[Category:EBQ]][[Category:GI]]		[[Category:EBQ]][[Category:GI]]

Ostermayer: /* External Links */

2015-09-23T13:29:51Z

External Links

← Older revision		Revision as of 13:29, 23 September 2015
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	~~==External Links==~~
	*[http://www.smartem.org/podcasts/upper-gi-bleed-2 SMART EM - PPI]
	*[http://www.smartem.org/podcasts/upper-gi-bleed-ppi SMART EM - PPI #2]

	<references/>		<references/>

	[[Category:EBQ]][[Category:GI]]		[[Category:EBQ]][[Category:GI]]

Ostermayer: /* External Links */

2015-09-23T13:29:12Z

External Links

← Older revision		Revision as of 13:29, 23 September 2015
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	==External Links==		==External Links==
	*[[http://www.smartem.org/podcasts/upper-gi-bleed-2 SMART EM - PPI]]		*[http://www.smartem.org/podcasts/upper-gi-bleed-2 SMART EM - PPI]
	*[[http://www.smartem.org/podcasts/upper-gi-bleed-ppi SMART EM - PPI #2]]		*[http://www.smartem.org/podcasts/upper-gi-bleed-ppi SMART EM - PPI #2]

	<references/>		<references/>

	[[Category:EBQ]][[Category:GI]]		[[Category:EBQ]][[Category:GI]]

Ostermayer: /* External Links */

2015-09-23T13:28:52Z

External Links

← Older revision		Revision as of 13:28, 23 September 2015
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	==External Links==		==External Links==
	*[[http://www.smartem.org/podcasts/upper-gi-bleed-2 SMART EM - PPI]]		*[[http://www.smartem.org/podcasts/upper-gi-bleed-2 SMART EM - PPI]]
	*[[http://www.smartem.org/podcasts/upper-gi-bleed-ppi SMART EM - PPI]]		*[[http://www.smartem.org/podcasts/upper-gi-bleed-ppi SMART EM - PPI #2]]

	<references/>		<references/>

	[[Category:EBQ]][[Category:GI]]		[[Category:EBQ]][[Category:GI]]

Ostermayer at 13:28, 23 September 2015

2015-09-23T13:28:33Z

← Older revision		Revision as of 13:28, 23 September 2015
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	==Sources==		==Sources==


			==External Links==
			*[[http://www.smartem.org/podcasts/upper-gi-bleed-2 SMART EM - PPI]]
			*[[http://www.smartem.org/podcasts/upper-gi-bleed-ppi SMART EM - PPI]]

	<references/>		<references/>

	[[Category:EBQ]][[Category:GI]]		[[Category:EBQ]][[Category:GI]]

Ostermayer at 13:20, 23 September 2015

2015-09-23T13:20:39Z

← Older revision		Revision as of 13:20, 23 September 2015
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	\| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMoa1211801		\| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMoa1211801
	\| pdfurl= http://www.nejm.org/doi/pdf/10.1056/NEJMoa1211801		\| pdfurl= http://www.nejm.org/doi/pdf/10.1056/NEJMoa1211801
	\|status=~~Complete~~		\|status=Under Review
	}}		}}

Ostermayer at 02:51, 3 April 2015

2015-04-03T02:51:03Z

← Older revision		Revision as of 02:51, 3 April 2015
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	\| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMoa1211801		\| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMoa1211801
	\| pdfurl= http://www.nejm.org/doi/pdf/10.1056/NEJMoa1211801		\| pdfurl= http://www.nejm.org/doi/pdf/10.1056/NEJMoa1211801
	\|status=~~Completed~~		\|status=Complete
	}}		}}

Ostermayer at 02:50, 3 April 2015

2015-04-03T02:50:55Z

← Older revision		Revision as of 02:50, 3 April 2015
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	\| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMoa1211801		\| fulltexturl= http://www.nejm.org/doi/full/10.1056/NEJMoa1211801
	\| pdfurl= http://www.nejm.org/doi/pdf/10.1056/NEJMoa1211801		\| pdfurl= http://www.nejm.org/doi/pdf/10.1056/NEJMoa1211801
	\|status=~~Under Review~~		\|status=Completed
	}}		}}