Blood ‘n Guts: hold the blood, save the patient?

One of the trends of recent trauma literature has been the use of “minimal volume” or “permissive hypotension” strategies in the face of bleeding.

Now there is a new study from the New England Journal that compared 2 transfusion strategies in acute upper GI bleeding. And guess what?  It looks like less is more in he upper GI bleed  as well – if you but the data.

The reference is:

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding by Càndid Villanueva, M.D., Alan Colomo, M.D., Alba Bosch, M.D. et al

NEJM, Jan 3 2013

IN Summary:

• It is an RCT of 921 patients with acute, severe upper GI bleed presenting to ED (this was done in Spain)
• The strategies being compared for transfusion of blood were:
  • Liberal = transfusion trigger at 90 g/L, with a target of 110  vs.
  • Restrictive = transfusion trigger of 70, with a target of 90 g/L

[In Australia (at least when I was in a big hospital) the magic number for transfusion was 80g/L – which is painfully in the middle of these study groups.]

• In he restrictive group only about 50% got any blood, compared with 85% in the “liberal” arm.
• Not many patients bled to death in either group – mortality was largely due to the underlying disease eg. cirrhosis
• There was a significant mortality improvement in the “restrictive” arm.
  • This was more apparent in the patients with milder underlying liver disease
  • Those with severe hepatic disease all did about the same regardless of strategy
  • There was no mention of INR or other coagulopathy parameters that I could see
  • In peptic ulcer bleeds the trend was there but did not reach significance

So how does this translate into our ED practice?  Should we use more restrictive transfusion triggers?

Can we start generalizing? Can we now say that blood products are probably a bit poisonous if infused into sick patients?

Should blood be considered an intervention we utilise only when all else has failed, or if the cardiac output is crashing?  My guess is that a lot of the upper GI bleeders are still perfusing their brains and hearts with Hbs of 70 – 90.

We covered PPIs in acute GI bleeding a while back. They also seem to be not so great in the acute, pre-endoscopy period of resuscitation.

Like trauma, the best option seems to be to get in and plug the hole, stop the bleeding – rather than transfuse or medicate until the Hb looks pretty.

Love to hear your point of view and critique of the trial above.

Hit me on the comments or join the twitter conversation @broomedocs

Casey