A 40-year-old man comes to the emergency department after 2 episodes of coffee-ground vomiting. He reports black, tarry stools for 1 day. He has had no previous episodes and has no history of liver disease, jaundice, weight loss, ascites, edema, dysphagia, or illicit drug use. He has been taking ibuprofen for lower back pain for the past 2 weeks. He is otherwise in good general health and takes no prescription medications.
His supine blood pressure is 120/80 mm Hg and pulse is 84/min; after 1 minute of standing they are 118/76 mm Hg and 90/min. There is no jaundice or scleral icterus. Cardiopulmonary examination is normal. There is mild epigastric tenderness on palpation. There is no hepatomegaly or stigmata of chronic liver disease. The remainder of the examination is within normal limits.
A nasogastric tube is inserted, with return of coffee ground material and some bright red blood with clots.
Laboratory results are as follows:

Urgent gastrointestinal endoscopy is scheduled.
Which of the following values for hemoglobin represents the optimal threshold for initiating blood transfusion in this patient?

Question

A 40-year-old man comes to the emergency department after 2 episodes of coffee-ground vomiting.  He reports black, tarry stools for 1 day.  He has had no previous episodes and has no history of liver disease, jaundice, weight loss, ascites, edema, dysphagia, or illicit drug use.  He has been taking ibuprofen for lower back pain for the past 2 weeks.  He is otherwise in good general health and takes no prescription medications.
His supine blood pressure is 120/80 mm Hg and pulse is 84/min; after 1 minute of standing they are 118/76 mm Hg and 90/min.  There is no jaundice or scleral icterus.  Cardiopulmonary examination is normal.  There is mild epigastric tenderness on palpation.  There is no hepatomegaly or stigmata of chronic liver disease.  The remainder of the examination is within normal limits.
A nasogastric tube is inserted, with return of coffee ground material and some bright red blood with clots.
Laboratory results are as follows:

Urgent gastrointestinal endoscopy is scheduled.
Which of the following values for hemoglobin represents the optimal threshold for initiating blood transfusion in this patient?

Quizplus · Accepted Answer

Patients with gastrointestinal bleeding require adequate fluid and colloidal resuscitation prior to endoscopy to minimize complications. A 2013 landmark study showed better outcomes for patients (without comorbid illnesses) when blood transfusion was initiated when the hemoglobin level was < 7 g/dL (restrictive transfusion group) than when it was < 9 g/dL (liberal transfusion group). The restrictive transfusion group patients had fewer complications and fewer further episodes of bleeding, as well as decreased mortality. However, for patients at risk for morbidity in the setting of severe anemia, such as those with unstable coronary artery disease, goal hemoglobin level should be maintained at > 9 g/dL (rather than > 10 g/dL). Similarly, patients with hypovolemia and active bleeding may require blood transfusion despite normal hemoglobin values. Patients with suspected variceal bleeding may have worsening of the bleed if they are overtransfused to hemoglobin > 10 g/dL. Most patients included in the study, however, underwent endoscopy within 5 hours of admission. If such patients have evidence of coagulopathy (INR > 1.5 or platelets < 50000/µL), they should be transfused with fresh frozen plasma (FFP) or platelets as appropriate. The target INR is < 3 prior to endoscopy. Endoscopy can safely be performed with mild to moderate coagulopathy provided patients receive FFP during the procedure. Educational objective: The threshold for blood transfusion in patients with gastrointestinal bleeding (without comorbidity) who are hemodynamically stable is hemoglobin of < 7 g/dL. This results in fewer complications, fewer further episodes of bleeding, and decreased mortality. __________ References: Transfusion strategies for acute upper gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/23281973) Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/23205554) Risk factors for in-hospital mortality in cirrhotic patients with oesophageal variceal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/22356784)

A 40-Year-Old Man Comes to the Emergency Department After 2