What is the target hemoglobin (Hb) level in patients with upper gastrointestinal (GI) bleeding?

Target Hemoglobin in Upper GI Bleeding

In patients with upper gastrointestinal bleeding, blood transfusions should be administered when the hemoglobin level falls below 70 g/L, with a target range of 70-90 g/L, unless the patient has cardiovascular disease, in which case a higher threshold of 80 g/L and target of 80-100 g/L is recommended. 1

General Transfusion Strategy

• Blood transfusions should be administered when hemoglobin falls below 70 g/L in most patients with upper GI bleeding 1
• Red blood cell transfusion is almost always indicated when hemoglobin is less than 60 g/L 1
• Transfusion is rarely indicated when hemoglobin is greater than 100 g/L 1
• The target hemoglobin range after transfusion should be 70-90 g/L in most patients 1

Special Considerations

Patients with Cardiovascular Disease

• In patients with acute or chronic cardiovascular disease, use a more liberal transfusion strategy with a hemoglobin threshold of ≤80 g/L 2, 3
• For these patients, aim for a post-transfusion target hemoglobin of 80-100 g/L 2, 3
• Patients with UGIB are often elderly with comorbid cardiovascular conditions and may have poor tolerance for anemia 1
• Hemoglobin levels less than 82 g/L in patients with UGIB have been associated with elevated cardiac troponin I levels 1

Individualized Assessment

• The threshold for transfusion should be based on the patient's underlying condition, hemodynamic status, and markers of tissue hypoxia 1
• Consider the following factors when determining transfusion needs:
  • Hemodynamic instability 1
  • Presence of continued or recurrent bleeding 1
  • Comorbidities, especially cardiac disease 1, 2

Evidence Supporting Restrictive Transfusion

• A restrictive transfusion strategy (Hb <70 g/L) compared to a liberal strategy (Hb <90 g/L) has been associated with: 4
  • Higher probability of survival at 6 weeks (95% vs 91%) 4
  • Lower rate of further bleeding (10% vs 16%) 4
  • Fewer adverse events (40% vs 48%) 4
• The restrictive strategy is particularly beneficial in patients with cirrhosis and Child-Pugh class A or B disease 4
• Patients discharged with hemoglobin between 8-10 g/dL have shown favorable outcomes with recovery from anemia within 45 days without critical complications 5

Clinical Approach

1. Assess hemodynamic status and severity of bleeding immediately 1
2. Initiate fluid resuscitation as needed 1
3. Check hemoglobin level and determine if transfusion is needed based on:
   • Hemoglobin <70 g/L for most patients 1
   • Hemoglobin <80 g/L for patients with cardiovascular disease 2, 3
4. After transfusion, aim for target hemoglobin of 70-90 g/L (or 80-100 g/L in cardiovascular disease) 1, 2
5. Proceed with endoscopy within 24 hours of admission (earlier for high-risk patients) without delaying for mild to moderate coagulopathy 2

Common Pitfalls

• Delaying endoscopy to reach an arbitrary hemoglobin level is unnecessary and not supported by evidence 6
• Over-transfusion can lead to increased portal pressure in cirrhotic patients, potentially increasing rebleeding risk 4
• Transfusion has been associated with higher risks of death, nosocomial infection, multiorgan dysfunction, and acute respiratory distress syndrome in some studies 1
• Waiting for the hematocrit to reach a certain level before endoscopy is not necessary and may delay appropriate care 6