Blood Transfusion Practices in Upper Gastrointestinal Bleeding: Response to a Landmark Study

Abstract

ObjectiveLack of clear evidence in red blood cell (RBC) transfusion during gastrointestinal bleeding has led to varied recommendations over the years. However, studies in broad areas of medicine have provided evidence about appropriate RBC transfusion thresholds, and a ‘landmark’ study published in 2013 provided evidence in patients with upper gastrointestinal (UGI) bleeding. We hypothesized that the response to the evidence would lead to improved RBC transfusion practice. Our aim was to determine the response in RBC transfusion practices at our institution.DesignWe examined RBC transfusion practices in patients with UGI bleeding who presented to the Medical University of South Carolina from January 2010 through December 2013. We abstracted extensive clinical data including demographic, medical history (comorbidities), medications, physical examination findings, laboratory data, endoscopic data, and RBC transfusion practices. We considered appropriate RBC transfusion to have occurred when performed for a hemoglobin level of <70 g/L.Results270 patients hospitalized with UGI bleeding had 606 RBC transfusions; 355 transfusions in 107 patients were appropriate, and 251 transfusions in 163 were inappropriate. In 2010, 2011, and 2012, the rates of appropriate RBC transfusions were 61/124 (49%), 92/172 (53%), and 84/142 (59%), respectively. There was a statistically significant difference in appropriate transfusions in 2013 (118/168 (70%)) compared with 2012 (84/142 (59%), p=0.003), as well as during 2010–2012 (237/438 (54%), p≤0.003).ConclusionsThe data suggest that there was an improvement in RBC transfusion practices after a landmark study. However, the data also highlight that RBC transfusion practices in UGI bleeding remain imperfect.

Analysis of the diagnostic utility of Glasgow-Blatcford Score, Rockall Score, AIMS65 Score, BUN-to-albumin ratio and BUN-to-creatinine ratio for predicting the need for transfusion in upper gastrointestinal bleeding

“…The percentage of patients who received blood transfusions, which is associated with poor outcomes, was found to be 25% in our study. Based on the literature, this rate seems to be lower than that reported in previous studies (16,19). However, when the average age of our participants is examined, it is also noted that this average is lower than that in the literature (5,12).…”

The impact of red blood cell transfusion practices on inpatient mortality in variceal and non‐variceal gastrointestinal bleeding patients: a 20‐year US nationwide retrospective analysis

“…9 Therefore, PRBC transfusion practices remain poorly defined and are highly variable in practice, [10][11][12] and many patients with upper GI bleeding are inappropriately transfused. 13 From a pathophysiological standpoint, over-transfusion is likely to be of greatest concern in patients with variceal upper GI bleeding due to its resultant increase in portal pressure, which in turn may cause re-bleeding. 14,15 Because of the possibility that over-transfusion in patients with variceal upper GI bleeding may increase portal pressure, we hypothesised that patients with variceal upper GI bleeding who are transfused with PRBCs are not only at an increased risk of inpatient mortality compared to patients not transfused but also are at increased risk of inpatient mortality compared to patients with non-variceal bleeding receiving PRBC transfusion during hospitalisation.…”

“…This recommendation remains based on low‐quality evidence and is currently a conditional recommendation per recently published American College of Gastroenterology society guidelines 9 . Therefore, PRBC transfusion practices remain poorly defined and are highly variable in practice, 10–12 and many patients with upper GI bleeding are inappropriately transfused 13 . From a pathophysiological standpoint, over‐transfusion is likely to be of greatest concern in patients with variceal upper GI bleeding due to its resultant increase in portal pressure, which in turn may cause re‐bleeding 14,15 .…”