What hemoglobin level is safe for admitting a patient with Upper Gastrointestinal Bleeding (UGIB) to the floor?

Hemoglobin Thresholds for Floor Admission in Upper Gastrointestinal Bleeding

Patients with UGIB can be safely admitted to the floor if they have a hemoglobin level greater than 100 g/L (10 g/dL), normal vital signs, and minimal comorbidities. 1

Risk Stratification for Floor vs. ICU Admission

Floor Admission Criteria:

• Hemoglobin >100 g/L (10 g/dL)
• Hemodynamically stable (pulse <100 beats/min, systolic BP >100 mmHg)
• Age <60 years (preferably)
• No significant comorbidities
• No active hematemesis

ICU/High-Dependency Unit Admission Criteria:

• Hemoglobin <100 g/L (10 g/dL)
• Hemodynamic instability (pulse >100 beats/min, systolic BP <100 mmHg)
• Age >60 years with comorbidities
• Active bleeding with shock
• Significant comorbidities (cardiac failure, renal failure, liver disease)

Transfusion Thresholds

The transfusion strategy should be guided by the following parameters:

• For most patients: Transfuse when hemoglobin <70-80 g/L (7-8 g/dL) 1, 2
• For patients with cardiovascular disease: Consider a higher threshold (e.g., 80-90 g/L) 1
• For actively bleeding patients with shock: Immediate transfusion regardless of hemoglobin level

The evidence strongly supports a restrictive transfusion strategy, as demonstrated in a landmark study by Villanueva et al. showing improved survival with a hemoglobin threshold of 70 g/L versus 90 g/L 2.

Risk Assessment Tools

The Rockall scoring system can help determine the risk of rebleeding and mortality:

Total Rockall Score	Risk Level	Floor vs. ICU Decision
<3	Low risk	Floor appropriate
3-7	Moderate	Floor with monitoring
>8	High risk	ICU recommended

Monitoring Requirements for Floor Patients

For patients admitted to the floor with UGIB:

• Hourly vital signs (pulse, BP)
• Urine output measurement
• Endoscopy within 24 hours
• IV access with fluid resuscitation as needed
• Serial hemoglobin measurements

Special Considerations

Coagulopathy

• Correction of coagulopathy is recommended but should not delay endoscopy 1
• Endoscopic treatment can be safely performed with INR <2.5

Elderly Patients

• Lower threshold for ICU admission
• More vigilant monitoring even with stable parameters

Liver Disease

• Special consideration required as prognosis relates to severity of liver disease rather than magnitude of bleeding 1
• May require specialized management protocols

Common Pitfalls to Avoid

1. Relying solely on hemoglobin level: Initial hemoglobin may not reflect acute blood loss due to delayed hemodilution
2. Overlooking tachycardia: A compensatory tachycardia may be the only sign of significant bleeding
3. Underestimating comorbidities: Cardiac, renal, or liver disease significantly increases mortality risk
4. Delaying endoscopy: Patients admitted to the floor still need timely endoscopy (within 24 hours)
5. Inadequate monitoring: Even stable-appearing patients need regular vital sign checks

Algorithm for Admission Decision

1. Assess hemoglobin level and vital signs
2. Calculate Rockall score
3. Evaluate comorbidities
4. If hemoglobin >100 g/L, vital signs normal, and Rockall score <3: Floor admission
5. If hemoglobin <100 g/L, abnormal vital signs, or Rockall score >8: ICU admission
6. For intermediate cases: Consider high-dependency unit or floor with enhanced monitoring

This approach ensures that patients with UGIB are appropriately triaged based on their risk profile, optimizing resource utilization while maintaining patient safety.