The role of blood transfusion in the management of upper and lower intestinal tract bleeding

Indications and hemoglobin thresholds for red blood cell transfusion and iron replacement in adults with gastrointestinal bleeding: An algorithm proposed by gastroenterologists and patient blood management experts

Gastrointestinal (GI) bleeding is associated with considerable morbidity and mortality. Red blood cell (RBC) transfusion has long been the cornerstone of treatment for anemia due to GI bleeding. However, blood is not devoid of potential adverse effects, and it is also a precious resource, with limited supplies in blood banks. Nowadays, all patients should benefit from a patient blood management (PBM) program that aims to minimize blood loss, optimize hematopoiesis (mainly by using iron replacement therapy), maximize tolerance of anemia, and avoid unnecessary transfusions. Integration of PBM into healthcare management reduces patient mortality and morbidity and supports a restrictive RBC transfusion approach by reducing transfusion rates. The European Commission has outlined strategies to support hospitals with the implementation of PBM, but it is vital that these initiatives are translated into clinical practice. To help optimize management of anemia and iron deficiency in adults with acute or chronic GI bleeding, we developed a protocol under the auspices of the Spanish Association of Gastroenterology, in collaboration with healthcare professionals from 16 hospitals across Spain, including expert advice from different specialties involved in PBM strategies, such as internal medicine physicians, intensive care specialists, and hematologists. Recommendations include how to identify patients who have anemia (or iron deficiency) requiring oral/intravenous iron replacement therapy and/or RBC transfusion (using a restrictive approach to transfusion), and transfusing RBC units 1 unit at a time, with assessment of patients after each given unit (i.e., “don’t give two without review”). The advantages and limitations of oral versus intravenous iron and guidance on the safe and effective use of intravenous iron are also described. Implementation of a PBM strategy and clinical decision-making support, including early treatment of anemia with iron supplementation in patients with GI bleeding, may improve patient outcomes and lower hospital costs.

Can old dogs learn new "transfusion requirements in critical care": a survey of packed red blood cell transfusion practices among members of The American Association for the Surgery of Trauma

BACKGROUND

The objective of this study was to characterize variations in packed red blood cell (PRBC) transfusion practices in critically ill patients and to identify which factors influence such practices. We hypothesized that significant variation in transfusion triggers exists among acute care surgeons.

METHODS

A survey of PRBC transfusion practices was administered to the American Association for the Surgery of Trauma members. The scenarios examined hemoglobin thresholds for which participants would transfuse PRBCs.

RESULTS

A hemoglobin threshold of less than or equal to 7 g/dL was adopted by 45% of respondents in gastrointestinal bleeding, 75% in penetrating trauma, 66% in sepsis, and 62% in blunt trauma. Acute care surgeons modified their transfusion trigger significantly in the majority of the modifications of these scenarios, often inappropriately so.

CONCLUSIONS

This study documents continued evidence-practice gaps and wide variations in the PRBC transfusion practices of acute care surgeons. Numerous clinical factors altered such patterns despite a lack of supporting evidence (for or against).

[Predictive factors of organ failure in patients admitted in intensive care unit for acute gastrointestinal bleeding]

INTRODUCTION

Gastrointestinal hemorrhage is an emergency requiring usually an admission in intensive care unit (ICU), which may prove abusive secondarily. The aim of this study was to identify predictive risk factors of organ failure in patients admitted for GH in our ICU.

DESIGN

Retrospective and observational

METHODS AND MEASUREMENTS

Between January 2008 and December 2011, all patients admitted in our ICU for gastrointestinal hemorrhage were consecutively included. The primary endpoint was the occurrence of at least an organ failure. We realized an univariate analysis then a backward regression to identify independent risk factors associated with the occurrence of at least one organ failure during the ICU hospitalization.

RESULTS

During this period study, 441 consecutive patients with a mean age of 67±15years were included. The median ICU length of stay was of 4 (3-7) days and 116 (26% [IC95%: 22-30]) patients presented at least one organ failure. The multivariate analysis identified predictive risk factors of organ failure: history of cirrhosis (OR=3.5 [IC95%: 1.9-6.7], P<0.001) and an increase in troponin at the admission above the 99th percentile (OR=3.1 [IC95%: 1.8-5.5], P<0.001).

CONCLUSION

Our results confirmed that a large proportion of patients admitted in ICU for the primary diagnosis of gastrointestinal hemorrhage developed any organ failure. The history of cirrhosis and the systemic consequences of the hemorrhagic syndrome as myocardial damage represents important risk factors of morbidity and mortality and thus should be considered during the management.

Frozen blood products: clinically effective and potentially ideal for remote Australia

The development of effective cryopreservation techniques for both red blood cells and platelets, which maintain ex vivo biological activity, in combination with frozen plasma, provides for a unique blood banking strategy. This technology greatly enhances the storage life of these products. The rationale and potential advantages of using cryopreservation techniques for the provision of blood products to remote and military environments have been effectively demonstrated in several conflicts over the last decade. Current haemostatic resuscitation doctrine for the exsanguinating patient supports the use of red blood cells, platelets and frozen plasma early in the resuscitation. We believe an integrated fresh-frozen blood bank inventory could facilitate provision of blood products, not only in the military setting but also in regional Australia, by overcoming many logistic and geographical challenges. The processes involved in production and point of care thawing are sufficiently well developed and achievable to make this technology a viable option. The potential limitations of cryopreservation and subsequent product thawing need to be considered if such a strategy is to be developed. A substantial body of international experience using cryopreserved products in remote settings has already been accrued. This experience provides a template for the possible creation of an Australian integrated fresh-frozen blood bank inventory that could conceivably enhance the care of patients in both regional Australia and in the military setting.

Fixed rate of blood component improves the survival rate of patients in massive transfusion

The aim of this study was to examine the manner in which varying proportions of serum and red blood cells (RBC) in massive blood transfusion affect the survival rates of patients with severe blood loss. Massive transfusion (MT) was determined as receiving ≥10 units of red blood cells in 24 h. The electronic medical records and blood transfusion information for the period January, 2002 to December, 2011 of patients with MT were examined. Moreover, we calculated the ratio of blood components and examined their correlation with survival. In total, 1,658 patients underwent MT during the period 2002-2011, with an overall of 28,030 units RBC, accounting for 2.8% of the total blood transfusion. In conclusion, fixing blood-component ratios has the potential to help improve survival rate in MT.

Resuscitation and monitoring in gastrointestinal bleeding

INTRODUCTION

Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately.

MATERIALS AND METHODS

Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards.

RESULTS

Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. "Functional hemodynamic monitoring" requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding.

CONCLUSIONS

Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

Blood banking in a malaria-endemic area: evaluating the problem posed by malarial parasitaemias

The emergence and wide dissemination of drug-resistant malarial parasites underscore the need to prevent post-transfusion malaria. In Nigeria, as in most of sub-Saharan Africa, however, blood donors are not routinely screened for malarial infection. Recently, 391 consecutive potential blood donors in a malaria-endemic area of south-western Nigeria were each checked for malarial parasitaemia using three methods: microscopy (all samples), OptiMAL (315 samples) and/or the Clinotech Malaria Cassette (142 samples). OptiMAL detects parasite-specific lactate dehydrogenase whereas the Clinotech test detects the surface proteins of merozoites and sporozoites. Microscopy revealed parasitaemias in 79 (20.2%) of the potential donors, the levels of parasitaemia varying from 34 to 6289 asexual parasites/microl (mean=445/microl). The prevalence of malarial parasitaemia, as detected by microscopy, was significantly higher during the rainy season than in the dry season (27.3% v. 5.5%; P<0.0001). There was no significant association between patent parasitaemia and fever (i.e. an axillary temperature > or =37.5 degrees C), blood group, gender or anaemia. The corresponding prevalences of malarial parasitaemia detected using the rapid diagnostic tests were 3.8% (12/315) for OptiMAL and 57.8% (82/142) for the Clinotech. With the results of the microscopy used as the 'gold standard', OptiMAL gave a sensitivity of only 16.0% but a specificity of 98.5%. The corresponding values for the Clinotech tests were 69.2% and 50.0%, respectively. It would clearly be beneficial to include screening for malaria parasitaemia in the routine investigation of potential blood donors in Nigeria, especially during the rainy season, when the risk of transfusion-transmitted malaria appears relatively high.

Massive transfusion: new insights

Massive transfusion (MT) is used for the treatment of uncontrolled hemorrhage. Earlier definitive control of life-threatening hemorrhage has significantly improved patient outcomes, but MT is still required. A number of recent advances in the area of MT have emerged, including the use of "hypotensive" or "delayed" resuscitation for victims of penetrating trauma before hemorrhage is controlled and "hemostatic resuscitation" with increased use of plasma and platelet transfusions in an attempt to maintain coagulation. These advances include the earlier use of hemostatic blood products (plasma, platelets, and cryoprecipitate), recombinant factor VIIa as an adjunct to the treatment of dilutional and consumptive coagulopathy, and a reduction in the use of isotonic crystalloid resuscitation. MT protocols have been developed to simplify and standardize transfusion practices. The authors of recent studies have advocated a 1:1:1 ratio of packed RBCs to fresh frozen plasma to platelet transfusions in patients requiring MT to avoid dilutional and consumptive coagulopathy and thrombocytopenia, and this has been associated with decreased mortality in recent reports from combat and civilian trauma. Earlier assessment of the exact nature of abnormalities in hemostasis has also been advocated to direct specific component and pharmacologic therapy to restore hemostasis, particularly in the determination of ongoing fibrinolysis.

Dedicated bleed units: should they be advocated?

BACKGROUND

Upper gastrointestinal haemorrhage (UGIH) is a common emergency, however, dedicated bleed units only exist in selected hospitals in the UK.

OBJECTIVE

To evaluate the rebleeding and mortality rate of patients admitted with UGIH to a tertiary centre bleed unit in comparison with the current national standards and earlier unit performance in 1995-1998.

METHODS

A retrospective case note review of demographics, the Rockall scores and final outcome was conducted for all patients admitted to the bleed unit over 24 months.

RESULTS

Two hundred and fifty-five cases were identified with a mean age of 62 years and a median Rockall score of 3. Eighty-two percent of gastroscopies were performed within 24 h. Of these, 29% were undertaken after 5 p.m. Peptic ulcer and varices (15%) were the commonest diagnosis. The rebleeding (12%) and mortality rate (9%) were comparable with that of the units previous audit (P=0.47, 0.51, respectively) and the current national audit (P=0.58, 0.76, respectively). The number of patients requiring surgery has reduced from 6 to 0.4% in our unit over the last 8 years. Preendoscopy and postendoscopy Rockall scores were predictive of rebleeding (P=0.013, 0.045) and mortality (P=0.003, 0.01).

CONCLUSION

This study has shown a consistently low rebleeding and mortality rate in patients with UGIH in a dedicated bleed unit. However there are limitations to the degree of improvements which can be demonstrated due to factors such as age and comorbidity.