A 55 year old male presented with acute upper abdominal pain and haematemesis. He had admitted drinking alcohol to excess. Following admission, he had a further significant episode of haematemesis associated with haemorrhagic shock. An emergency oesophagogastrectomy (OGD) was arranged in theatre. His pre-procedure haemoglobin was 60g/L. OGD revealed large amounts of fresh blood in the stomach, which prevented identification of the bleeding point. The patient had a number of oesophageal varices, attempts were made to band these but this did not stop the bleeding. A partial gastrectomy was undertaken. The patient received a total of 18 units of red blood cells, 14 units of flesh frozen plasma and 2 units of platelets and cryoprecipitate before being taken to Intensive Care intubated and ventilated.
On the Intensive Care Unit he was warmed and repeat blood tests were sent to ensure correction of his coagulopathy. Haemoglobin was recorded as 9.4g/dL and the APTTr was normal. The following day when he was normothermic and cardiovascularly stable he was woken and extubated. He was discharged to the ward the following day.
When should we transfuse in upper gastro-intestinal haemorrhage? Are there any adjunctive therapies that can help?
Blood transfusion policies are becoming more restrictive, and vary from hospital to hospital. At the same time it is difficult to assess volume depletion from single laboratory results such as a haemoglobin level, as in acute haemorrhage this may not be representative. Latest trials in trauma patients have shown evidence that tranexamic acid is beneficial in major haemorrhage.
A recent study looking at transfusion thresholds of 7g/dL (restrictive) versus 9g/dL (liberal) in patients with peptic uler, cirrhosis or liver disease showed an increased survival at 6 weeks (peptic ulcer, cirrhosis and Child-Pugh class A or B disease) in the patients who were in the restrictive group. Other benefits included a lower increase in portal-pressure gradient in these patients, and a lower incidence of re-bleeding. However those patients with Child-Pugh class C disease had no difference in mortality.1
A review of the literature by Wang et al suggests that initial liberal fluid resuscitation may be associated with higher mortality in trauma patients.2 However the authors do not define the definitions of liberal or restrictive fluid resuscitation, so it is difficult to quantify this.
Pham et al state that adequate circulation and haemostasis should be the end points for massive haemorrhage and major transfusion. Effective preparation and communication between laboratory services and clinical teams are essential and blood products should be administered early in the resuscitation. Current data may suggest that improved outcomes are seen in those patients treated aggressively for coagulopathy, with higher plasma and platelet to red cell transfusion ratios. They also emphasize the evidence for tranexamic acid, and suggest that greater use of cryoprecipitate and fibrinogen concentrate might be beneficial in obstetric major haemorrhage. The use of other therapies including prothrombin complex concentrate and recombinant activated factor VII are less well defined and should be balanced against risk in individual circumstances.3
The American College of Physicians have produced guidelines recommending a restrictive red blood cell transfusion strategy, with trigger haemoglobin levels of 7 to 8g/dL in hospitalised patients with coronary heart disease, however this doesn’t cover massive transfusion.4 Mitra et al look more closely at the use of recombinant factor VII, suggesting that in patients with acidosis, coagulopathy and hypothermia in refractory bleeding, recombinant factor VII may improve survival by approximately 30%, but appears to be futile if patients are severely acidotic (pH <6.91).5
Major haemorrhage requires a multi-disciplinary team approach in order to manage the patient. The current evidence suggests early blood products and correction of coagulopathy, with restrictive fluid resuscitation and red blood cell transfusion over the level of 7g/dL, even in patients with ischaemic heart disease. Tranexamic acid is best given early and recombinant factor VII should be reserved for the patients who continue to bleed once all other apparent factors have been replaced or corrected.
- Rockey DC. To transfuse or not to transfuse in upper gastrointestinal haemorrhage? That is the question. Hepatology. 2014 jan 4. Doi:10.1002/hep.26994 (epub ahead of print)
- Wang CH, Hsieh WH, Chou HC et al. Liberal Versus Restricted Fluid Resuscitation Strategies In Trauma patients: A systematic review and meta-analysis of randomized controlled trials and observational studies. Crit Care Med 2013 Dec 11.
- Pham HP, Shaz BH. Update on massive transfusion. Br J Anaesth 2013 Dec; 111 Suppl 1:i71-i82
- Qaseem A, Humphrey LL, Fitterman N et al. Treatment of anaemia in patients with heart disease: a clinical practice guideline from the American college of physicians. Ann Intern Med. 2013 Dec 3;159(11):770-9.
- Mitra B, Cameron PA, Parr MJ et al. Recombinant factor VIIa in trauma patients with the ‘triad of death’. Injury 2012 Sep;43 (9):1409-14.
One thought on “Massive Transfusion in Upper Gastrointestinal Haemorrhage”
The 2012 NICE guidelines focus on replacing blood products although the coagulation targets recommended are based on expert opinion rather than trial evidence. A meta-analysis of four RCT showed lower mortality, lower risk of rebleeding, and shorter length of stay for patients undergoing a restrictive rather than a liberal transfusion strategy. One study however makes up 90% of patients in the meta-analysis. Villanueva et al (2013) looked at 889 patients in a randomised single centre study in Barcelona. This found a restrictive transfusion threshold (Hb >70) was associated with reduced mortality at 45 days compared with a liberal transfusion threshold (Hb >100). However the study excluded both those with exsanguinating bleeding and those with a low risk of rebleeding (Rockall score 0 with Hb >120). All patients underwent upper GI endoscopy within an average of 5 hours of admission- a timeframe possibly unrealistic outside of a research facility. Finally transfusion of packed red cells was not linked to corresponding replacement of platelets or plasma and it is possible that the liberal transfusion strategy may have led to a coagulopathy in that group. This aside, the results echo the 1999 TRICC study (which excluded actively bleeding patients) in demonstrating improved survival with a restrictive transfusion trigger.
Gluud LL Klingeberg SL, Langhloz E., Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2012
This meta- analysis of 7 available RCT has so far failed to prove the effectiveness of Tranexamic acid (TXA) on bleeding, surgery or transfusion requirements . This may be due to the heterogeneity and under powering of available studies , currently 2 large scale randomised control trials of TXA are underway, the South Korean TAUGIB which aims to recruit 400 patients by July 2015 and the UK HALT-IT trial aiming to recruit 8000 patients by March 2019. These should be powered enough to show any effect.
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