Modern‐day management of upper gastrointestinal haemorrhage

Acute upper gastrointestinal haemorrhage (AUGIH) is a common medical emergency and can present with life threatening haemorrhage. In the UK, there are 70 000 hospital admissions per year. In the majority of cases, the aetiology is non‐variceal in origin, but in other cases it is due to variceal bleeding in patients with cirrhosis. It is also a leading indication for transfusion of blood components. This review explores recent randomised data on the efficacy and safety of red blood cell transfusion for AUGIH. In addition, the evidence base for use of other blood components and pro‐haemostatic pharmacological agents is discussed, including acid suppression, antifibrinolytics and fibrinogen.     

Antifibrinolytic agents and desmopressin as hemostatic agents in cardiac surgery

OBJECTIVE: To review the use of systemic hemostatic medications for reducing bleeding and transfusion requirements with cardiac surgery. DATA SOURCES: Articles were obtained through computerized searches involving MEDLINE (from 1966 to September 2000). Additionally, several textbooks containing information on the diagnosis and management of bleeding associated with cardiac surgery were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION: Due to the large number of randomized investigations involving systemic hemostatic medications for reducing bleeding associated with cardiac surgery, the article selection process focused on recent randomized controlled trials, metaanalyses and pharmacoeconomic evaluations. DATA EXTRACTION: The primary outcomes extracted from the literature were blood loss and associated transfusion requirements, although other outcome measures such as mortality were extracted when available. DATA SYNTHESIS: Although the majority of investigations for reducing cardiac bleeding and transfusion requirements have involved aprotinin, evidence from recent meta-analyses and randomized trials indicates that the synthetic antifibrinolytic agents, aminocaproic acid and tranexamic acid, have similar clinical efficacy. Additionally, aminocaproic acid (and to a lesser extent tranexamic acid) is much less costly. More comparative information of hemostatic agents is needed retative to other outcomes (eg., reoperation rates, myocardial infarction, stroke). There is insufficient evidence to recommend the use of desmopressin for reducing bleeding and transfusion requirements in cardiac surgery, although certain subsets of patients may benefit from its use. CONCLUSIONS: Of the medications that have been used to reduce bleeding and transfusion requirements with cardiac surgery, the antifibrinolytic agents have the best evidence supporting their use. Aminocaproic acid is the least costly therapy based on medication costs and transfusion requirements.     

Systemic hemostatic medications for reducing surgical blood loss

OBJECTIVE: To review randomized trials involving the use of systemic hemostatic medications for reducing surgical blood loss. DATA SOURCES: Articles were obtained through searches of MEDLINE (1966-September 2000). The bibliographies of retrieved publications were reviewed for additional references. STUDY SELECTION: All randomized studies and pharmacoeconomic evaluations that involved medications used for systemic hemostasis in the perioperative period were included. DATA EXTRACTION: Randomized studies involving conjugated estrogens, aminocaproic acid, tranexamic acid, desmopressin, and aprotinin for systemic hemostasis were extracted. Studies of proton-pump inhibitors for upper gastrointestinal bleeding and octreotide for variceal bleeding were excluded, as were trials involving the use of any hemostatic agent for cardiovascular surgery. The primary outcome under review was a reduction in bleeding as defined by reduced transfusion requirements. DATA SYNTHESIS: There is limited efficacy and toxicity information concerning the use of conjugated estrogens for reducing surgery-related bleeding. Similarly, there are a limited number of randomized studies involving aminocaproic acid and tranexamic acid, and with the exception of tranexamic acid for reducing transfusion requirements with knee surgery, the study results are either conflicting or negative. For desmopressin, evidence from a substantial number of randomized trials documents its lack of efficacy. Aprotinin has reduced bleeding and transfusion requirements in a number of randomized studies involving patients undergoing orthopedic surgery, but cost-effectiveness studies are needed to better define its therapeutic role. Trials of aprotinin during hepatic surgery have yielded conflicting results. CONCLUSIONS: Most hemostatic medications used for reducing surgery-related bleeding have limited or contradictory evidence of efficacy.     

Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice

Red blood cell (RBC) transfusion guidelines correctly promote a general restrictive transfusion approach for anemic hospitalized patients. Such recommendations have been derived from evaluation of specific patient populations, and it is important to recognize that engaging a strict guideline approach has the potential to incur harm if the clinician fails to provide a comprehensive review of the patient’s physiological status in determining the benefit and risks of transfusion. We reviewed the data in support of a restrictive or a more liberal RBC transfusion practice, and examined the quality of the datasets and manner of their interpretation to provide better context by which a physician can make a sound decision regarding RBC transfusion therapy. Reviewed studies included PubMed-cited (1974 to 2013) prospective randomized clinical trials, prospective subset analyses of randomized studies, nonrandomized controlled trials, observational case series, consecutive and nonconsecutive case series, and review articles. Prospective randomized clinical trials were acknowledged and emphasized as the best-quality evidence. The results of the analysis support that restrictive RBC transfusion practices appear safe in the hospitalized populations studied, although patients with acute coronary syndromes, traumatic brain injury and patients at risk for brain or spinal cord ischemia were not well represented in the reviewed studies. The lack of quality data regarding the purported adverse effects of RBC transfusion at best suggests that restrictive strategies are no worse than liberal strategies under the studied protocol conditions, and RBC transfusion therapy in the majority of instances represents a marker for greater severity of illness. The conclusion is that in the majority of clinical settings a restrictive RBC transfusion strategy is cost-effective, reduces the risk of adverse events specific to transfusion, and introduces no harm. In anemic patients with ongoing hemorrhage, with risk of significant bleeding, or with concurrent ischemic brain, spinal cord, or myocardium, the optimal hemoglobin transfusion trigger remains unknown. Broad-based adherence to guideline approaches of therapy must respect the individual patient condition as interpreted by comprehensive clinical review.     

Red blood cell transfusion practice in patients presenting with acute upper gastrointestinal bleeding: a survey of 815 UK clinicians

BACKGROUND: Acute upper gastrointestinal bleeding (AUGIB) accounts for 14% of all red blood cell (RBC) transfusions in the United Kingdom, despite little evidence to guide optimal blood transfusion strategies and few data on the variation in practice. We aimed to survey UK clinicians about their RBC transfusion practice in AUGIB. STUDY DESIGN AND METHODS: A survey describing six clinical vignettes of AUGIB was sent to practicing gastroenterologists, acute care physicians, and upper gastrointestinal surgeons. Respondents were asked to select a hemoglobin (Hb) trigger at which they would ordinarily transfuse RBCs. RESULTS: The response rate was 48% (815/1709). Transfusion triggers differed significantly between all six cases (p < 0.001). There was significant variation in the selected Hb trigger between different clinical specialties for five of the six scenarios. Surgeons were more likely to select a lower Hb transfusion trigger than physicians across all six scenarios (p < 0.005), as were clinicians who had graduated more recently (p < 0.05 for Scenarios 1‐3). The responses suggested the belief that restrictive use of RBCs is appropriate, which is in part discordant with actual observed practice. Only 70% of respondents reported familiarity with national guidelines for AUGIB. CONCLUSIONS: There is significant variation in the reported approach to transfusion practice among clinicians caring for patients with AUGIB, with both patient‐ and clinician‐related factors accounting for these differences. Further studies are needed to evaluate the safety and efficacy of differing blood transfusion strategies in patients presenting with AUGIB.     

Restrictive vs Liberal Blood Transfusion for Acute Upper Gastrointestinal Bleeding: Rationale and Protocol for a Cluster Randomized Feasibility Trial

Acute upper gastrointestinal bleeding (AUGIB) is the commonest reason for hospitalization with hemorrhage in the UK and the leading indication for transfusion of red blood cells (RBCs). Observational studies suggest an association between more liberal RBC transfusion and adverse patient outcomes, and a recent randomised trial reported increased further bleeding and mortality with a liberal transfusion policy. TRIGGER (Transfusion in Gastrointestinal Bleeding) is a pragmatic, cluster randomized trial which aims to evaluate the feasibility and safety of implementing a restrictive versus liberal RBC transfusion policy in adult patients admitted with AUGIB. The trial will take place in 6 UK hospitals, and each centre will be randomly allocated to a transfusion policy. Clinicians throughout each hospital will manage all eligible patients according to the transfusion policy for the 6-month trial recruitment period. In the restrictive centers, patients become eligible for RBC transfusion when their hemoglobin is < 8 g/dL. In the liberal centers patients become eligible for transfusion once their hemoglobin is < 10 g/dL. All clinicians will have the discretion to transfuse outside of the policy but will be asked to document the reasons for doing so. Feasibility outcome measures include protocol adherence, recruitment rate, and evidence of selection bias. Clinical outcome measures include further bleeding, mortality, thromboembolic events, and infections. Quality of life will be measured using the EuroQol EQ-5D at day 28, and the costs associated with hospitalization for AUGIB in the UK will be estimated. Consent will be sought from participants or their representatives according to patient capacity for use of routine hospital data and day 28 follow up. The study has ethical approval for conduct in England and Scotland. Results will be analysed according to a pre-defined statistical analysis plan and disseminated in peer reviewed publications to relevant stakeholders. The results of this study will inform the feasibility and design of a phase III randomized trial.     

Pediatric Patient Blood Management Programs: Not Just Transfusing Little Adults

Red blood cell transfusions are a common life-saving intervention for neonates and children with anemia, but transfusion decisions, indications, and doses in neonates and children are different from those of adults. Patient blood management (PBM) programs are designed to assist clinicians with appropriately transfusing patients. Although PBM programs are well recognized and appreciated in the adult setting, they are quite far from standard of care in the pediatric patient population. Adult PBM standards cannot be uniformly applied to children, and there currently is significant variation in transfusion practices. Because transfusing unnecessarily can expose children to increased risk without benefit, it is important to design PBM programs to standardize transfusion decisions. This article assesses the key elements necessary for a successful pediatric PBM program, systematically explores various possible pediatric specific blood conservation strategies and the current available literature supporting them, and outlines the gaps in the evidence suggesting need for further/improved research. Pediatric PBM programs are critically important initiatives that not only involve a cooperative effort between pediatric surgery, anesthesia, perfusion, critical care, and transfusion medicine services but also need operational support from administration, clinical leadership, finance, and the hospital information technology personnel. These programs also expand the scope for high-quality collaborative research. A key component of pediatric PBM programs is monitoring pediatric blood utilization and assessing adherence to transfusion guidelines. Data suggest that restrictive transfusion strategies should be used for neonates and children similar to adults, but further research is needed to assess the best oxygenation requirements, hemoglobin threshold, and transfusion strategy for patients with active bleeding, hemodynamic instability, unstable cardiac disease, and cyanotic cardiac disease. Perioperative blood management strategies include minimizing blood draws, restricting transfusions, intraoperative cell salvage, acute normovolemic hemodilution, antifibrinolytic agents, and using point-of-care tests to guide transfusion decisions. However, further research is needed for the use of intravenous iron, erythropoiesis-stimulating agents, and possible use of whole blood and pathogen inactivation. There are numerous areas where newly formed collaborations could be used to investigate pediatric transfusion, and these studies would provide critical data to support vital pediatric PBM programs to optimize neonatal and pediatric care.     

Evidence Base for Restrictive Transfusion Triggers in High-Risk Patients

Liberal versus restrictive red blood cell (RBC) transfusion triggers have been debated for years. This review illustrates the human body''s physiologic response to acute anemia and summarizes the evidence from prospective randomized trials (RCTs) for restrictive use of RBC transfusions in high-risk patients. During progressive anemia, the human body maintains the oxygen delivery to the tissues by an increase in cardiac output and peripheral oxygen extraction. Seven RCTs with a total of 5,566 high-risk patients compared a restrictive hemoglobin (Hb) transfusion trigger (Hb < 70 or < 80 g/l) with a liberal Hb transfusion trigger (Hb < 90 or < 100 g/l). Unanimously these studies show non-inferiority, safety, and a significant reduction in RBC transfusions in the restrictive groups. In one RCT mortality was higher in the liberal Hb transfusion group, and in two additional RCTs mortality of subgroups or after risk adjustment was significantly higher in the liberal Hb transfusion trigger groups.

Conclusion

Strong RCT evidence suggests the safety of restrictive transfusion triggers. As a consequence, an Hb transfusion trigger of <70 g/l is recommended for high risk patients.Key Words: Red blood cell transfusions, Blood transfusion, Transfusion trigger, Patient blood management     

Current status of blood component therapy in surgical critical care

PURPOSE OF REVIEW: The use of blood component therapy, with transfusion of red cells, plasma, and platelets, is common in critical care. New evidence has emerged documenting the risks associated and lack of efficacy or improvement in clinical outcome with blood transfusion for the treatment of anemia in critically ill patients who are hemodynamically stable. RECENT FINDINGS: The safety of a restrictive transfusion strategy (transfuse only if hemoglobin < 7 g/dL) was reported in 1999. Despite compelling evidence from this prospective randomized clinical trial, clinicians have not substantially changed practice regarding blood transfusion in critical care. The recently published CRIT trial reported that the mean pre-transfusion hemoglobin was 8.6 g/dL in this large multicenter trial that examined transfusion practices in critical care in the US. Furthermore, only 19% of hospitals had an institutional blood transfusion protocol. The Surviving Sepsis Campaign guidelines have also recommended blood transfusion only when hemoglobin falls to 7.0 g/dL, following resolution of tissue hypoperfusion and in the absence of significant coronary artery disease or acute hemorrhage. We have an increased understanding of the pathophysiology of the anemia associated with critical care, related to the inflammatory response, downregulation of erythropoietin, and lack of iron availability due to macrophage sequestration. Clinical trials are underway to confirm the efficacy of recombinant erythropoietin in the treatment of critically ill patients with anemia. SUMMARY: Current data regarding blood transfusion thresholds and risks of blood transfusion have not as yet significantly altered practice patterns. Efforts to reduce blood transfusion rates in critically ill patients are required. These strategies will require education, unit and institutional protocols, and reduction of phlebotomy for diagnostic laboratory testing in the intensive care unit. Further investigations regarding anemia in critical care and new treatment and prevention strategies are required.     

Determinants of empiric transfusion in gastrointestinal bleeding in the emergency department

IntroductionCurrent guidelines for the management of GI bleeding (GIB) recommend restrictive transfusion triggers unless patients have shock or specific comorbidities. However, these studies may not be applicable to Emergency Department (ED) patients. Factors determining transfusion decisions in the ED are poorly understood. We compared baseline characteristics and outcomes between ED patients with GI bleeding transfused at lower or higher empiric hemoglobin levels.MethodsSingle center, retrospective analysis of hospital records from a large tertiary care center of ED patients diagnosed with GIB who underwent red blood cell transfusion in the ED. A pre-transfusion hemoglobin cutoff of 7 g/dl was used to divide patients into restrictive and empirically transfused groups. Demographics, mortality, hospital length-of-stay, and mortality risk estimates were compared between groups.Results175 patients met inclusion criteria, with 120 restrictive patients (68.5%) and 55 liberal patients (31.4%). The sample was 49.7% male, with mean age 67.2 years, similar between groups. Patients in the empiric transfusion group had more acute emergency severity index scores (2.09 vs. 2.3). No difference was found between groups in triage vital signs, pre-endoscopy Rockall scores or mortality estimates, or length of stay. Most common reasons for empiric transfusion from chart review were hypotension and witnessed large hemorrhage.ConclusionsPatients that were empirically transfused had similar presentations to patients meeting restrictive guidelines, based on review of triage data. Transfusions above restrictive thresholds occurred frequently in our population. Additional studies are required to clarify appropriate criteria to guide transfusions for GIB in the ED.     

Is there a place for epoetin alfa in managing anemia during critical illness?

BACKGROUND: Anemia is a common problem in critically ill patients. As a result, blood transfusions are often used in the intensive care unit (ICU) setting. However, mounting evidence shows that blood transfusions may contribute to negative outcomes, such as transfusion-related infections, organ dysfunction, and immunosuppression. Supplementation with epoetin alfa is currently used in some medical centers to manage anemia in critically ill patients. OBJECTIVE: This review discusses the risks with blood transfusions and the clinical evidence supporting the use of epoetin alfa in managing edema during critical illness. METHODS: A search was conducted in MEDLINE and Current Contents (1966-2003) using the terms epoetin alfa, recombinant human erythropoietin, and anemia. Articles addressing anemia and the use of epoetin alfa in critically ill patients were selected and assessed. From this selection, the cited references addressing the etiology of anemia in the ICU and the risks associated with blood transfusions were manually extracted and reviewed. RESULTS: Several reports have shown that critically ill patients display evidence of anemia due to a blunted erythropoietin response. One large, randomized, placebo-controlled study assessed the effect of SC epoetin alfa on blood transfusions in the ICU. In this study, 40, 000 IU administered weekly for up to 4 weeks resulted in an overall transfusion reduction (9.9% absolute risk reduction; P<0.001 ). Other, smaller studies using different dosing regimens in critically ill patients have also demonstrated that epoetin alfa can decrease the need for transfusion. CONCLUSION: The use of epoetin alfa in critically ill patients can decrease the number of blood transfusions required during hospitalization, and potentially result in transfusion avoidance. Because of the scarce amount of evidence and the diversity of dosing regimens used used, no strict recommendations can be drawn from this review.     

Transfusion of Blood Products in Trauma: An Update

Background: Blood transfusion in the management of severely injured patients can be lifesaving. These patients are susceptible to developing early coagulopathy, thus perpetuating bleeding. Objectives: This article presents recent advances in both the civilian and military clinical arena to improve the treatment of trauma patients with severe hemorrhage, the use of agents to support coagulation, perspectives on restrictive transfusion strategies, and transfusion-related risks. Discussion: Massive blood transfusion is an adjunct to surgical care. The volume of blood products transfused and the ratio of blood components have been associated with increased morbidity and mortality rates. The adverse clinical effects of transfusion and the limited supply of blood products have resulted in modern resuscitation protocols to limit the volume of blood transfused. Conclusion: A restrictive blood transfusion strategy and the use of hemostatic agents may decrease morbidity and mortality in trauma patients, but insufficient data are available for their use in trauma patients. Massive transfusion should reflect an equal ratio of packed red cells and plasma to limit coagulopathy. Prospective randomized trials are needed to standardize an effective protocol.     

The evidence for the use of recombinant factor VIIa in massive bleeding: development of a transfusion policy framework

summary .  A review of the recent randomized control trial evidence of the use of recombinant factor VIIa (rFVIIa) in massive bleeding. rFVIIa is a recombinant genetically engineered clotting factor that has been used for the management of haemophilia patients with inhibitors. There has been increasing use in patients with massive bleeding, even when there is no underlying coagulation disorder present. In November 2006, the Canadian National Advisory Committee on Blood and Blood Products engaged in a consultation and review process with several leading Canadian experts to review and discuss the current evidence up to November 2006. There is little evidence to support the routine use of rFVIIa in massive bleeding on review of 13 randomized controlled trials. rFVIIa should only be considered as part of a transfusion policy framework for massive bleeding after all other transfusion and supportive measures are considered. An example of a policy framework is presented.     

How low is too low? Cardiac risks with anemia

Despite the increasing availability of data supporting more restrictive transfusion practices, the risks and benefits of transfusing critically ill patients continue to evoke controversy. Past retrospective and observational studies suggested that liberal transfusion strategies were more beneficial in patients whose hematocrit levels fell below 30%. An expanding body of literature suggests that an arbitrary trigger for transfusion (the '10/30 rule') is ill advised. A recent randomized controlled trial provided compelling evidence that similar, and in some cases better, outcomes result if a restrictive transfusion strategy is maintained. The impact of this accumulating evidence on clinical practice is evident in large reports, which show that the average transfusion trigger in critically ill patients was a hemoglobin level in the range 8-8.5 g/dl. Based on the available evidence, transfusion in the critically ill patient without active ischemic heart disease should generally be withheld until the hemoglobin level falls to 7 g/dl. Transfusions should be administered as clinically indicated for patients with acute, ongoing blood loss and those who have objective signs and symptoms of anemia despite maintenance of euvolemia. The hemoglobin level at which serious morbidity or mortality occurs in critically ill patients with active ischemic heart disease is a subject of continued debate but it is likely that a set transfusion trigger will not provide an optimal risk-benefit profile in this population.     

Factors involved in gastrointestinal bleeding in advanced cancer patients followed at home

There is a lack of information on the frequency of symptomatic gastrointestinal bleeding in patients with advanced cancer. This group of patients presents several risk factors for developing gastrointestinal bleeding. The aim of this multicenter longitudinal survey was to assess the frequency of gastrointestinal bleeding and possible factors implicated in advanced cancer patients followed at home. A consecutive sample of 439 patients who referred to home palliative care program entered the study. Age, gender, primary cancer and known metastases, possible associated pathologies, history of peptic disease, use of previous or actual nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids, drugs used to prevent gastric complications, the occurrence of hematemesis or melena, significant anemia requiring blood transfusion, and mortality associated with the hemorrhagic event were recorded. Of 377 patients who completed the study, 18 reported gastrointestinal bleeding, and five had significant anemia requiring blood transfusion in three cases. Death was found to be related to bleeding in three patients. NSAIDs, steroids, and gastroprotectors were frequently used, either before or during home care. However, no clear relationship between age, gender, and the use of offender drugs with gastrointestinal bleeding was found. Liver involvement was frequently associated with the risk of developing gastrointestinal bleeding.     

Reversal of drug-induced anticoagulation: old solutions and new problems

Anticoagulant drugs are taken by millions of patients throughout the world. Warfarin has been the most widely prescribed anticoagulant for decades. In recent years, new oral anticoagulants have been approved for use, are being positioned as alternatives to warfarin, and represent an enormous market opportunity for pharmaceutical companies. Requests for urgent reversal of anticoagulants are not uncommon especially in the setting of critical bleeding. This review summarizes information on reversal of warfarin by vitamin K, plasma, prothrombin complex concentrates, and recombinant VIIa. In addition, we emphasize the lack of current evidence supporting reversibility of the new oral direct thrombin inhibitors and Factor Xa inhibitors. This review is presented to assist transfusion medicine specialists, hematologists, and other clinicians who prescribe blood components for reversal of drug-induced anticoagulation.     

Plasma transfusion for bedside, radiologically guided, and operating room invasive procedures

Frozen plasma (FP) is commonly used in an attempt to correct coagulation defects before performing bedside, radiologically guided, or operating room procedures. Use of FP prophylactically is closely linked to results for standard coagulation tests in the laboratory, including prothrombin time, but there is a general lack of evidence supporting the predictive value of abnormalities of these tests for bleeding. Use of FP has little effect on correcting abnormal coagulation tests when mild and moderate results are recorded. There is no support for evidence of effectiveness for the prophylactic use of FP when reviewing the wider randomized controlled trial literature. When the lack of clinical effectiveness is combined with the risks of FP transfusion, such as transfusion-related acute lung injury and transfusion-associated circulatory overload, the need to challenge continued preprocedure prophylactic use of FP becomes pressing. In clinical practice, abnormalities of standard coagulation tests should not be interpreted in isolation, but alongside review of clinical bleeding history and other hemostatic markers such as platelet count. A more appropriate transfusion strategy may be one that emphasizes the therapeutic use of FP.     

New diagnostic imaging technologies in nonvariceal upper gastrointestinal bleeding

This article covers new endoscopic imaging modalities in nonvariceal upper gastrointestinal bleeding, such as Doppler ultrasound probe technology, endoscopic ultrasonography, color Doppler optical coherence tomography, and magnification endoscopy. A more in-depth discussion of these modalities and the published evidence supporting their use are included. Furthermore, the shift in focus from identification of conventional visual surface stigmata of recent hemorrhage to an assessment and understanding of subsurface blood flow as it relates to the bleeding lesion is discussed.     

Low utility of endoscopy for suspected upper gastrointestinal bleeding occurring in hospitalized patients

OBJECTIVES: To determine the clinical utility of upper endoscopy in patients who have upper gastrointestinal bleeding after hospitalization. METHODS: Patients were studied who underwent upper endoscopy for an indication of suspected upper gastrointestinal bleeding that developed more than 48 hours after hospitalization. Demographic, clinical, and endoscopic data were extracted by chart review. Bleeding was characterized as clinically important (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion) or non-clinically important. RESULTS: Eighty-six patients met inclusion criteria. Clinically important bleeding occurred in 17%. Peptic ulcer disease and gastritis were the most common sources of bleeding in the clinically important and non-clinically important groups, respectively. The bleeding source was not found in 24% of patients. Endoscopic therapy was required in 11% (all of whom had clinically important bleeding). Upper endoscopy prompted no treatment changes in the non-clinically important bleeding group. CONCLUSIONS: Endoscopic therapy was needed only in the few patients with clinically important bleeding. Nonendoscopic treatment can be recommended for upper gastrointestinal bleeding developing in hospitalized patients who do not meet established criteria for a clinically important bleed.     

Do blood transfusions make a difference when you are dying?

Recent blood transfusion guidelines published by the UK National Institute for Health and Care Excellence (2015) recommend restrictive single unit transfusion practices with a threshold haemoglobin level of 70?g/l. While these guidelines do not specifically relate to palliative care patients, neither do they exclude them. Prompted by these guidelines, and studies questioning the costs and benefits of red cell transfusions, a retrospective review of the electronic patient records was undertaken to explore the use and impact of blood transfusions over a 54-month period on the in-patient unit of a 14-bedded hospice in the UK. The objective was to identify the reasons for transfusion and documented evidence of benefit and outcome. Results showed that transfusions were infrequent, the reason given for transfusion was fatigue in 84% of cases, benefit was reported in 39%, and 50% died within 4 weeks of transfusion. These findings are similar to those of other studies highlighting the low level of benefit and short survival time post-transfusion. Anaemia is common in the palliative population and fatigue is increasingly prevalent in the final weeks of life. It has been postulated that fatigue may provide protection from suffering at this time, suggesting that appropriate selection of patients for transfusion is important to prevent the potential to do harm. The use of validated tools, goal setting conversations, and an algorithm for the management of fatigue have now been implemented to support more rational transfusion decisions in the hospice.