Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials

Odutayo, Ayodele; Desborough, Michael; Trivella, Marialena; Stanley, Adrian J.; Dorée, Carolyn; Collins, Gary S.; Hopewell, Sally; Brunskill, Susan J; Kahan, Brennan C; Logan, Richard F.; Barkun, Alan N.; Murphy, Michael; Jairath, Vipul

doi:10.1016/s2468-1253(17)30054-7

Cited by 155 publications

(113 citation statements)

References 27 publications

(68 reference statements)

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“…26 In the meta-analysis, a restrictive transfusion strategy was associated with a reduction in all-cause mortality at 30 days (26 fewer deaths per 1000; 95% CI 2 to 42); rebleeding (57 fewer rebleeding episodes per 1000; 95% CI 21 to 81), transfusion requirement (mean difference −1.73 RBC units; 95% CI −2.36 to −1.11); number of people who required a transfusion (276 fewer per 1000; 95% CI 164 to 361) and LOS (mean difference −1.9 days; 95% CI 3.34 to 0.46). 30 No difference was found between the variceal and nonvariceal subgroups. No RCTs included participants with exsanguinating haemorrhage, where haemoglobin may not be an accurate measure of blood loss.…”

Section: We Recommend That Red Blood Cell (Rbc) Transfusion Should Fomentioning

confidence: 91%

“…Five RCTs have assessed the use of different transfusion thresholds; [25][26][27][28][29] these were summarised in a systematic review (n=1965). 30 Ninety-three per cent of patients were derived from two RCTs which included both variceal and non-variceal AUGIB. 26 27 Only one RCT included participants regardless of age, comorbidity or history of ischaemic heart disease.…”

Section: We Recommend That Red Blood Cell (Rbc) Transfusion Should Fomentioning

confidence: 99%

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British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Siau¹,

Hearnshaw

Stanley

et al. 2020

Frontline Gastroenterol

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Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed to develop a multisociety care bundle centred on the early management of AUGIB.Commissioned by the British Society of Gastroenterology (BSG), a UK multisociety task force was assembled to produce an evidence-based and consensus-based care bundle detailing key interventions to be performed within 24 hours of presentation with AUGIB. A modified Delphi process was conducted with stakeholder representation from BSG, Association of Upper Gastrointestinal Surgeons, Society for Acute Medicine and the National Blood Transfusion Service of the UK. A formal literature search was conducted and international AUGIB guidelines reviewed. Evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation tool and statements were formulated and subjected to anonymous electronic voting to achieve consensus. Accepted statements were eligible for incorporation into the final bundle after a separate round of voting. The final version of the care bundle was reviewed by the BSG Clinical Services and Standards Committee and approved by all stakeholder groups.Consensus was reached on 19 statements; these culminated in 14 corresponding care bundle items, contained within 6 management domains: Recognition, Resuscitation, Risk assessment, Rx (Treatment), Refer and Review.A multisociety care bundle for AUGIB has been developed to facilitate timely delivery of evidence-based interventions and drive quality improvement and patient outcomes in AUGIB.

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Section: We Recommend That Red Blood Cell (Rbc) Transfusion Should Fomentioning

confidence: 91%

Section: We Recommend That Red Blood Cell (Rbc) Transfusion Should Fomentioning

confidence: 99%

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Siau¹,

Hearnshaw

Stanley

et al. 2020

Frontline Gastroenterol

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“…Further bleeding was also less frequent in the restrictive transfusion strategy group (10 vs. 16%, P = 0·01), and the observed difference in mortality remained when considering only patients with cirrhosis . Although other research is in progress to confirm the results of this single centre trial, restrictive transfusion strategy appears to be safe and beneficial compared to a liberal transfusion strategy in patients with acute upper gastrointestinal bleeding and is now recommended .…”

Section: When To Transfuse Critically Ill Patients?mentioning

confidence: 67%

Making transfusion decisions in critical care

Aubron

2017

ISBT Science Series

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Transfusion triggers and parameters to consider in the decision to transfuse depend on the setting. In cases of massive bleeding, transfusion decision is made on haemodynamic parameters, vital signs and when possible on bleeding volume estimation. In anaemic haemodynamically stable patients, haemoglobin remains the primary trigger for transfusion. In the less severe or in the youngest critically ill patients, transfusion for a haemoglobin threshold of 7 g/dl has been shown to be associated with higher survival in comparison with a haemoglobin threshold of 10 g/dl. This lower threshold of 7 g/dl appears to be also safe in patients with upper gastrointestinal bleeding. In patients with acute ischaemic heart disease, where anaemia may worsen myocardial ischaemia, pathophysiology and findings from large observational studies support the benefit of a higher haemoglobin threshold (between 9 and 10 g/dl). Elderly and cardiovascular patients should be monitored for cardiac tolerance of anaemia and transfused accordingly. In haematology–oncology patients and in neuro critically ill patients, the optimal strategy for red blood cell (RBC) transfusion remains unknown. Transfusion practices have shifted from liberal towards restrictive strategy, making the monitoring of anaemia tolerance an important element in the decision to transfuse. Substantial comorbidities and conditions that influence anaemia tolerance should be integrated into clinicians’ transfusion decision‐making process. Research evaluating the benefit to consider additional triggers in the decision to transfuse RBC in critically ill patients is warranted.

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“…In a metaanalysis of four randomised controlled trials that examined this issue, restrictive transfusion was associated with a lower risk of all-cause mortality (relative risk [RR]=0.65, 95% CI=0.44-0.97; P=0.03) and a lower overall re-bleeding rate (RR=0.58, 95% CI=0.40-0.80; P=0.004). 21 It has become clear that a restrictive transfusion strategy should be adopted for acute GIB; this is currently recommended in many international guidelines. [22][23][24][25] The above recommendation includes exceptions where a more liberal transfusion strategy should be adopted.…”

Section: Transfusion Strategiesmentioning

confidence: 99%

Joint recommendations on management of anaemia in patients with gastrointestinal bleeding in Hong Kong

Mak¹,

Wallis

Hui

et al. 2018

Hong Kong Med J

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The demand for blood products continues to grow in an unsustainable manner in Hong Kong. While anaemia associated with gastrointestinal bleeding (GIB) is the leading indication for transfusion, there is no local recommendation regarding best practices for transfusion. We aimed to provide evidence-based recommendations regarding management of anaemia in patients with acute and chronic GIB. We reviewed all original papers, meta-analyses, systematic reviews, or guidelines that were available in PubMed. For acute GIB, a restrictive transfusion strategy, targeting a haemoglobin threshold of 7 to 8 g/dL, should be adopted because overtransfusion is associated with significantly higher all-cause mortality and re-bleeding. A liberal transfusion strategy should only be considered in patients with co-existing symptomatic coronary artery disease, targeting a haemoglobin threshold of 9 to 10 g/dL. When acute GIB settles, patients should be prescribed iron supplements if iron deficiency is present. For chronic GIB, iron stores should be replenished aggressively via iron supplementation before consideration of blood transfusion, except in patients with symptoms of severe anaemia. Oral iron replacement is the preferred first-line therapy, while intravenous iron is indicated for patients with inflammatory bowel disease, poor response or poor tolerability to oral iron, and in whom a rapid correction of iron deficit is preferred. Intravenous iron is underutilised and the risk of anaphylactic reaction to current preparations is extremely low. These recommendations are provided to local clinicians to facilitate judicious and appropriate use of red cell products and iron replacement therapy in patients with GIB.

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Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials

Abstract: None.

Cited by 155 publications

References 27 publications

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Making transfusion decisions in critical care

Joint recommendations on management of anaemia in patients with gastrointestinal bleeding in Hong Kong

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