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Transfusion Policy

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Variceal Hemorrhage

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Abstract

In acute gastrointestinal bleeding, hypovolemic shock results from the loss of plasma volume and red blood cell (RBC) mass, and can induce an inadequate tissue perfusion of oxygen and substrates. Hypovolemia is managed initially by restoring volume, commonly with infusion of crystalloids through a large-bore intravenous line. Such volume restitution is critical to restore tissue perfusion and optimize oxygen delivery, hemodynamics, and cardiac function rapidly. RBCs are used to improve oxygen delivery to tissues in case of severe anemia and only rarely as part of fluid resuscitation in an actively bleeding patient. RBC transfusion may be lifesaving in patients with massive exsanguinating bleeding. However, in most cases hemorrhage is not so severe and transfusion is aimed to address anemia rather than to fluid resuscitation. Available evidence favors initiating RBC when hemoglobin levels decrease to less than 7 g/dL, with a target level of 7–9 g/dL, in the absence of symptomatic cardiovascular diseases. In a recent RCT such a restrictive transfusion strategy significantly improved survival at 6 weeks and further bleeding as compared with a liberal transfusion strategy in patients with acute upper gastrointestinal bleeding. This is the currently recommended threshold for transfusion in international guidelines. However, the threshold for transfusion may be higher in patients with massive hemorrhage or in those with underlying conditions that preclude an adequate physiological response to acute anemia such as the existence of cardiac disease. A single hemoglobin “trigger” may help to decide transfusion. However, the final decisions regarding RBC transfusion should be made on the basis of the individual patient, and other factors should be considered in addition to hemoglobin level.

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Authors and Affiliations

  1. Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, Barcelona, 08025, Spain

    Càndid Villanueva M.D., Oana Pavel M.D. & Alba Ardèvol Ribalta M.D.

  2. Department of Hepatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

    Oana Pavel M.D. & Alba Ardèvol Ribalta M.D.

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  1. Càndid Villanueva M.D.
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  2. Oana Pavel M.D.
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  3. Alba Ardèvol Ribalta M.D.
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Correspondence to Càndid Villanueva M.D. .

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Editors and Affiliations

  1. Luigi Sacco University Hospital, University of Milan, Milan, Italy

    Roberto de Franchis

  2. Ospedale Universitario Luigi Sacco, Universitá degli Studi di Milano, UOC Gastroenterologia, Milano, Italy

    Alessandra Dell’Era

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Villanueva, C., Pavel, O., Ribalta, A.A. (2014). Transfusion Policy. In: de Franchis, R., Dell’Era, A. (eds) Variceal Hemorrhage. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-0002-2_9

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