GI tract

Restrictions on transfusion for GI bleeds: putting evidence into practice

A restrictive transfusion strategy may be suitable for many patients presenting with upper GI bleeding though a challenge remains in finding a balance between its risk and benefits.

A South Australian study, comprising an audit of practice at three hospitals in 2014, showed just over half (56%) of patients met the criteria for consideration of restrictive transfusion practice as described in a seminal European trial.

Reasons for exclusions from consideration in the local study of 89 patients included a recent acute ischaemic event and massive bleeding.

However other exclusion criteria applied in the highly regulated RCT setting, such as a previous transfusion in the last 90 days or a Rockall score of 0 with Hb>120 g/L, were not necessarily relevant in the real world.

When those exclusions were removed, the study found 70% of their cohort would have qualified for a restrictive transfusion strategy of <70 g/L.

The audit found of the people who met the inclusion criteria, 58% received a transfusion. Almost half were single unit transfusions.

The study said the majority of patients with upper GI bleeding may be considered suitable for a restrictive transfusion strategy.

“However, concerns regarding overgeneralisation are appropriate and care needs to be taken in assessing which patients are suitable, with transfusion decisions made on the full clinical picture, as under-transfusion may be as damaging as over-transfusion.”

Professor Robert Fraser, head of gastroenterology and hepatology at Finders Medical Centre, said transfusion practice had changed over the last few years from a minimum of two units to the minimum number possible.

“The current practice would be to give one unit and see what the haemoglobin is. There is also a trend to starting the transfusion at a lower haemoglobin level as in some cases there no benefit in transfusing people above the threshold range and in some cases there is harm if you overtransfuse or transfuse too many units.”

He said trying to minimise the amount of blood transfused had benefits for patients as well as the institution in terms of their transfusion requirements.

“The challenge is getting it right and transfusing the right people the right amount at the right level and balancing the risks and benefits.”

He said their audit revealed that in 2014 they probably weren’t matching best practice although there were a number of caveats.

“It showed that at that time we hadn’t taken this on board and … we may have been able to do better and at least consider not transfusing people or transfusing a lower number of units.”

The study said a single haemoglobin threshold was inadequate and other factors such as age and comorbidities had to be taken into account to personalise the treatment.

“Age is an unresolved issue across all specialties. This is a serious intervention and we need to get it right,” Professor Fraser said.

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