A blood transfusion threshold of 7 g/dL of hemoglobin significantly improved outcomes in patients with acute upper gastrointestinal bleeding compared to 9 g/dL, a study found.
Researchers randomly assigned 444 patients with severe acute upper gastrointestinal bleeding to a restrictive transfusion strategy (transfusion when hemoglobin fell below 7 g/dL with a target range post-transfusion of 7 to 9 g/dL) and 445 patients to a liberal strategy (transfusion when hemoglobin fell below 9 g/dL with a target range post-transfusion of 9 to 11 g/dL). Safety and efficacy of both strategies were compared.
Results appeared in the Jan. 3 New England Journal of Medicine.
A total of 225 patients assigned to the restrictive strategy did not receive transfusions compared with 65 assigned to the liberal strategy (51% vs. 15%;P<0.001). The restrictive-strategy group had a higher survival rate at six weeks compared to the liberal-strategy group (95% vs. 91%; hazard ratio [HR] for death with restrictive strategy, 0.55; 95% CI, 0.33 to 0.92; P=0.02).
Deaths attributed to unsuccessfully controlled bleeding occurred in three patients in the restrictive-strategy group and in 14 patients in the liberal-strategy group (0.7% vs. 3.1%; P=0.01). Complications of treatment were the cause of death in one patient in the restrictive-strategy group and two in the liberal-strategy group. Hemorrhage was controlled and death was due to associated diseases in 19 patients in the restrictive-strategy group and 25 in the liberal-strategy group.
Less bleeding occurred in the restrictive-strategy group compared with the liberal-strategy group (10% vs. 16%; P=0.01), and there were fewer adverse events (40% vs. 48%; P=0.02). Further bleeding was significantly lower with the restrictive strategy group after adjustment for baseline risk factors (HR, 0.68; 95% CI, 0.47 to 0.98). Length of hospital stay was shorter in the restrictive-strategy group than in the liberal-strategy group.
Patients who had bleeding associated with a peptic ulcer had a slightly higher probability of survival with the restrictive strategy than with the liberal strategy (HR, 0.70; 95% CI, 0.26 to 1.25). Patients with cirrhosis and Child-Pugh class A or B disease in the restrictive-strategy group had a significantly higher probability of survival (HR, 0.30; 95% CI, 0.11 to 0.85), but those with cirrhosis and Child-Pugh class C disease did not (HR, 1.04; 95% CI, 0.45 to 2.37).
Researchers noted that improvement in survival rates observed with the restrictive transfusion strategy "was probably related to a better control of factors contributing to death, such as further bleeding, the need for rescue therapy, and serious adverse events. All these factors were significantly reduced with the restrictive strategy."
No comments:
Post a Comment