Hematemesis in the ED: When to Transfuse?

Sylvie Sontheimer

MS-4, UAB School of Medicine

Johns Hopkins Virtual Clinical Elective in EM & Equitable Healthcare

10 October 2020

Case Presentation:

History

- 37 YOM with Hx of heavy alcohol use (1 L whiskey/day) and heroin use (last use 2 days ago) presents with 3 episodes of hematemesis that began this morning, and 1 episode of melena the day before.

- No PMHx or PSHx. No daily or OTC medication use. No prior episodes of melena or hematemesis.

- ROS notable for vomiting, abdominal pain, melena. Negative for syncope, CP, dyspnea, constipation, diarrhea, weight loss, easy bruising.

Physical Exam

- Vitals on arrival: BP 100/72, P 115, RR 16, T 98.6, O2Sat 98% on RA.

- Patient is pale and ill-appearing but is A&Ox4 and able to speak in full sentences. Dried blood caked around lips and blood stains visible on shoes and lower legs.

- Tachycardic, no M/R/G. Radial and pedal pulses 2+ and symmetric.

- LCTAB, no increased WOB. No chest wall tenderness or crepitus.

- Mild TTP in epigastric region, no rebound or guarding.

ED Management

- 2 large bore IV (18 G) access obtained. Resuscitation began with NS. O+ blood ordered to have pending Hg. Pt NPO.

- PPI (Esomeprazole, pantoprazole; 80 mg IV bolus + infusion 8 mg/hour for 72 hours OR intermittent boluses) for possible PUD, the number one cause of hematemesis (1).

- Octreotide (50 mcg IV bolus + 50 mcg/hour for 2-5 days) due to concern for variceal bleeding given patient’s Hx of alcohol use (2).

- Antibiotics (1 gram Rocephin IV daily) for prophylaxis against SBP (3,4).

- Pt’s Hg came back at 6.8. Started O+ pRBC.

- Pt had an episode of large volume, projectile, grossly bloody emesis ~30 minutes after arrival. Pt intubated and sent to ICU for urgent endoscopic evaluation by GI. Mallory-Weiss tear diagnosed, no evidence of esophageal rupture or varices. D/c 3 days after arrival.

Clinical Question

- Is there an optimum hemoglobin level for transfusion of packed red blood cells for individuals presenting with a suspected acute upper GI bleed? Is there a difference in clinical outcomes or mortality rates in individuals presenting with a suspected acute GI bleed who are transfused at higher hemoglobin levels compared to lower hemoglobin levels?

Summary of the Evidence

- Villanueva et al. (2013) conducted a randomized controlled trial which randomized individuals with acute upper GI bleeds into either a restrictive transfusion group (transfuse when Hg < 7 g/dL (target range 7-9 g/dL) or a liberal transfusion group (transfuse when Hg < 9 g/dL (target range 9-11 g/dL). This study excluded individuals with ischemic heart disease. Clinical outcomes were better for those in the restrictive group vs. the liberal group.

o Higher probability of 6-week survival in the restrictive group.

o Shorter length of hospital stay in the restrictive group.

o Increased risk of further bleeding in the liberal group.

- A recent meta-analysis of 5 randomized controlled trials investigated the benefit and harm of liberal vs. restrictive red blood cell transfusion strategies in acute upper GI bleeding. The restrictive groups transfused when Hg < 7-8 g/dL (3 of 5 trials transfused when Hg < 8, 2 when Hg < 7) (6).

o The restrictive group was associated with a lower mortality risk and lower rebleeding rates overall and in the sub-group of people with cirrhosis. There was a 35% lower all-cause mortality overall in the restrictive vs. liberal transfusion group. Those with cirrhosis had the highest mortality benefit, with a 48% reduction in risk of death, if in the restrictive transfusion group.

o No difference in mortality between transfusion groups in those with non-variceal upper GI bleeding and those with known ischemic heart disease. Notably, there was no increase in the risk of ischemic events or acute kidney injury between groups.

- A meta-analysis of 41 randomized controlled trials analyzing restrictive (Hg < 8 g/dL) vs. liberal transfusion strategies in the hospital setting found that there was an increased risk of acute coronary syndrome (ACS) in the restrictive group (risk ratio 1.78, p = 0.01); however, there was no difference in 30 day mortality between groups (7).

Recommendations

- For individuals presenting to the emergency department with concern for an acute upper gastrointestinal bleed and no history of ischemic heart disease, a restrictive transfusion strategy (transfuse when Hg < 7-8 g/dL) should be employed. This is especially important for those with a known history of cirrhosis.

- The evidence for using a restrictive transfusion strategy in individuals with a history of ischemic heart disease is conflicting (6,7). The decision of when to transfuse in these patients should be made on an individual basis.

Sources:

1. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755.

2. Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.

3. Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.

4. Noveloso, B., Bastiampillai, B., Perni, N., & Waterman, A. (2017). Antibiotic Prophylaxis in Patients with Cirrhosis and Upper Gastrointestinal Bleeding. American family physician, 95(9), 582-582.

5. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C. Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine. 2013 Jan 3;368(1):11-21.

6. Odutayo, Ayodele, et al. "Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials." The Lancet Gastroenterology & Hepatology 2.5 (2017): 354-360.

7. 7. Docherty AB, O’Donnell R, Brunskill S, Trivella M, Doree C, Holst LB, Parker M, Gregersen M, de Almeida JP, Walsh TS, Stanworth SJ. Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis. Bmj. 2016 Mar 29;352.