Major Literature
- Villanueva. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2013;368:11-21
- In adult patients with UGI bleed, transfusion threshold of 7 vs. 9 g/dl Hgb resulted in higher probability of survival
2013 - Transfusion Strategies for Acute Upper GI Bleeding (NEJM) - Methods
- >18 yrs with hematemsis, melena, or both
- All pts underwent emergency gastroscopy within 6 hrs
- 31% had cirrhosis
- 49% with PUD, 21% with EV
- Exclusion criteria: massive exsanguinating bleeding, acute coronary syndrome, symptomatic PVD, CVA/TIA, recent h/o trauma/surgery, or lower GIB
- RCT, 1 center: transfusion threshold 7 with goal 7-9 (444 pts, restrictive) vs. transfusion threshold 9 with goal 9-11 (445 pts, liberal)
- Baseline characteristics were similar
- Results
- Transfusion outcome
- Lower daily hgb until discharge in restrictive, but hgb at 45 days was similar
- Lower proportion of pts without any transfusion in restrictive (51% vs. 14%)
- Lower mean units transfused in restrictive (1.5 units vs. 3.7 units)
- No difference in percentage of pts receiving FFP and platelets
- No difference in amount of fluids administered
- Primary outcome
- Lower all cause mortality at 45 days in restrictive (5% vs. 9%)
- Lower mortality in pts with cirrhosis w/ Child-Pugh class A or B in restrictive
- No difference in subgroup mortality for pts with EV or PUD
- Secondary outcome
- Lower rate of further bleeding in restrictive (10% vs. 16%), even after adjustment for baseline risk for further bleeding
- Lower hospital length of stay in restrictive (9.6 days vs. 11.5 days)
- Lower all cause adverse events in restrictive (40% vs. 48%)
- Lower transfusion reactions and cardiac complications (mainly pulm edema) in restrictive when analyzed separately
- No difference in pulmonary complications, AKI, CVA/TIA, or bacterial infection rate
- Conclusion
- Restrictive strategy significantly improved outcomes in pts with acute UGIB
2013 - Approach to a Child with UGIB (Indian Journal of Pediatrics) - Review paper on UGIB
- Introduction
- Definition of UGIB: bleeding proximal to the ligament of Treitz
- Hematemesis, melena, and even hematochezia seen
- Esophageal varices (EV) one of the most common causes in children
- Also keep in mind esophagitis, gastritis, ulcers, and "unknown"
- Less common are Dieulafoy's, AVM, Mallory Weiss, tumors, IBD, vasculitis (HSP)
- Orthostatic BP if able, cap refill, etc.
- Can use Gastroccult test to see if it becomes positive for blood (do not use Hemoccult test...the pH of gastric fluid leads to false results)
- Is it GI vs pulmonary, oral, or ENT source?
- Assess for sore throat, epistaxis, cough, etc
- Is it truly "upper" GI bleed?
- Use NG lavage to determine if blood coming from stomach and/or above
- CBC, coags, LFTs, T/S, consider H. pylori testing if indicated
- Abd U/S w/ doppler if clinically indicated
- Endoscopy for diagnostic and therapeutic measures
- Make sure to have at least 2 large bore IVs
- Indicated in all pts, but if pt has a h/o esophageal banding (like in our pt), hold off (per our GI team, but not sure if this is standard of care)
- I've been taught to use ice water for its vasoconstrictive effect, but no data to back this up
- Correct coagulopathies and severe thrombocytopenia
- Meta-analysis comparing emergency sclerotherapy and pharmacotherapy shows similar efficacy with fewer side effects with the latter (so pharmacotherapy is 1st line therapy)
- Octreotide
- Reduces splanchnic blood flow
- Controls UGIB in 70% of kids
- Bolus 1mcg/kg followed by 1mcg/kg/hr titrated up to 4mcg/kg/hr
- Infusions continued for 24-48hrs after the bleeding has stopped
- Can cause hyperglycemia as a side effect
- As effective as octreotide, and its use has largely been replaced by octreotide
- Perform asap after initial stabilization
- Variceal ligation, sclerotherapy, argon plasma coagulation
- Blakemore tube can be placed in esophagus (do not use longer than 12hrs in kids)
- <40kg --> 1mg/kg IV qday
- >40kg --> 20-40mg IV qday
- BID dosing also commonly used
- Infusion also can be used, but no evidence that infusion is better than intermittent (per GI team, see the paper below)
- Epi injection, clips, thermocoagulation
2009 - Continuous Infusion of Pantoprazole with Octreotide Does Not Improve Management of Variceal Hemorrhage (Pharmacotherapy) - Retrospective cohort study done in adults to assess the effect of a prolonged continuous infusion of pantoprazole vs. short-term infusion vs. intermittent injection with octreotide
- 130 adults with variceal bleed (most were esophageal, some were gastric)
- 53 pts (cohort group): octreotide + prolonged continuous infusion of PPI (>24 hrs)
- 77 pts (control group): octreotide alone vs. octreotide with short-term (<24 hrs) infusion of PPI vs. octreotide with intermittent PPI
- pRBC and platelet transfusion rates not different in cohort vs. control group
- No difference in mortality, hgb level at end of therapy, rate of recurrent variceal bleed, or need for endoscopic interventions
- Prolonged infusion of PPI with octreotide did not offer clinical benefit compared to octreotide with or without short-term infusion or intermittent injection of PPI
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