RCT

Villanueva

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

NEJM, 2013 · Single-center randomized controlled trial (n=921)

Clinical question

Does a restrictive transfusion strategy improve outcomes compared with a liberal strategy in acute upper GI bleeding?

Population: Adults with severe acute upper gastrointestinal bleeding (hematemesis or melena)
Intervention: Restrictive RBC transfusion (transfuse when Hb < 7.0 g/dL, target 7.0-9.0 g/dL)
Comparator: Liberal RBC transfusion (transfuse when Hb < 9.0 g/dL, target 9.0-11.0 g/dL)
Primary outcome: All-cause mortality at 45 days
Result: 45-day mortality was significantly lower in the restrictive group (5% vs 9%; hazard ratio 0.55; 95% CI, 0.33 to 0.92; P=0.02). Rebleeding was significantly lower (10% vs 16%, P=0.01).

What the trial found

Restrictive transfusion significantly improved 45-day survival and reduced rebleeding, particularly in cirrhotic patients.

Current guideline position

AASLD, ACG, and International Consensus guidelines strongly recommend a restrictive RBC transfusion strategy (target Hb 7.0–8.0 g/dL) in acute upper gastrointestinal bleeding.

Clinical interpretation

Firmly established the restrictive transfusion threshold (Hb < 7.0 g/dL) in acute UGIB.

Clinical Context & Relevant Topics (3)

Disease Reference

Upper Gastrointestinal Bleeding (UGIB)

Risk-stratified non-variceal and variceal hemorrhage care: resuscitation, selective airway protection, individualized transfusion, PPI or portal-pressure therapy, endoscopic hemostasis, and escalation to IR/TIPS/surgery when indicated.

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Blood Product Transfusion in Critical Care

Patient-specific RBC transfusion thresholds, current platelet/procedural thresholds, plasma/cryoprecipitate use, and the TRALI vs TACO diagnostic matrix.

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Major Bleeding, Hemorrhagic Shock, & Damage Control Resuscitation

The trauma lethal diamond (hypothermia, acidosis, coagulopathy, hypocalcemia), 1:1:1 massive transfusion (PROPPR trial), early TXA (CRASH-2), and TEG/ROTEM algorithms.

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