Should packed red blood cells (PRBC) be transfused in a patient with upper gastrointestinal (UGI) bleed, hemoglobin (Hb) level of 8.5 g/dl, and international normalized ratio (INR) of 2.2?

Blood Transfusion Decision in UGI Bleeding with Hb 8.5 g/dL and INR 2.2

In this patient with UGI bleeding, hemoglobin of 8.5 g/dL (85 g/L), and INR 2.2, you should NOT transfuse PRBCs unless the patient has underlying cardiovascular disease or signs of hemodynamic instability. The hemoglobin is above the restrictive transfusion threshold of 8.0 g/dL (80 g/L) recommended for most patients with acute UGI bleeding 1.

Transfusion Threshold Algorithm

For Patients WITHOUT Cardiovascular Disease:

• **Transfuse when Hb falls to <8.0 g/dL (80 g/L)** with a target of maintaining Hb >8.0 g/dL 1
• The 2019 International Consensus Guidelines specifically recommend this restrictive threshold based on evidence showing reduced mortality and rebleeding with restrictive versus liberal transfusion strategies 1
• At Hb 8.5 g/dL, this patient is above the threshold and does not require transfusion unless actively bleeding with hemodynamic compromise 1

For Patients WITH Cardiovascular Disease:

• Use a higher threshold of 8.0-10.0 g/dL depending on cardiac risk 1, 2
• The American College of Cardiology recommends maintaining Hb ≥8.0 g/dL in patients with coronary artery disease 2
• Hemoglobin levels <8.2 g/dL predict elevated cardiac troponin I levels in UGI bleeding patients 1, 3
• Transfuse immediately regardless of Hb level if cardiac ischemia symptoms develop (chest pain, orthostatic hypotension unresponsive to fluids, tachycardia, heart failure) 2

Critical Modifying Factors:

• Active exsanguinating bleeding: Transfusion should not be dictated by current Hb alone but must account for predicted Hb drop and clinical status 1
• Hemodynamic instability: Initiate resuscitation and transfusion regardless of Hb level 1
• Hemodilution effect: In acute blood loss, Hb may remain unchanged initially due to plasma equilibrium times 1

Management of INR 2.2

The INR of 2.2 requires correction but should NOT delay endoscopy 1.

Key Evidence on Coagulopathy:

• INR between 1.3-2.7 does not predict rebleeding, transfusion requirement, surgery, or length of stay in nonvariceal UGI bleeding 1
• Endoscopic therapy can be safely performed with INR <2.5 1
• However, correcting INR to <1.8 as part of intensive resuscitation reduces mortality and myocardial infarctions 1, 3
• Proceed with endoscopy while simultaneously correcting coagulopathy with fresh frozen plasma or prothrombin complex concentrate 1

Important Caveat:

• An INR ≥1.5 at presentation is a significant predictor of mortality (not rebleeding), likely reflecting comorbidity burden rather than bleeding risk 1

Evidence Supporting Restrictive Transfusion Strategy

The 2019 meta-analysis of 5 randomized trials (n=1,965 patients) demonstrated that restrictive transfusion in UGI bleeding was associated with 1:

• Lower all-cause mortality (RR 0.65,95% CI 0.45-0.97)
• Lower rebleeding risk (RR 0.58,95% CI 0.40-0.84)
• No increase in myocardial infarction, stroke, or acute kidney injury

The landmark single-center trial showed reductions in mortality and rebleeding with Hb threshold of 7.0 g/dL versus 9.0 g/dL 1. The consensus group recommended the more conservative 8.0 g/dL threshold for practical clinical application 1.

Common Pitfalls to Avoid

• Do not use the older 7.0 g/dL threshold from critical care literature - the 2019 guidelines updated this to 8.0 g/dL for UGI bleeding specifically 1
• Do not delay endoscopy for INR correction unless INR is supratherapeutic 1
• Do not ignore cardiovascular comorbidities - elderly patients with UGI bleeding often have undiagnosed cardiac disease requiring higher transfusion thresholds 1, 3
• Do not rely solely on Hb during active bleeding - assess hemodynamic parameters and clinical trajectory 1
• Transfuse one unit at a time and reassess before giving additional units to avoid unnecessary blood product exposure 2

Clinical Decision Summary for This Patient

With Hb 8.5 g/dL and INR 2.2:

1. Assess for cardiovascular disease - if present, consider transfusion to maintain Hb ≥8.0 g/dL 2
2. Assess hemodynamic stability - if unstable, initiate resuscitation including transfusion 1
3. If hemodynamically stable without cardiac disease: Hold transfusion, monitor closely, transfuse if Hb drops below 8.0 g/dL 1
4. Correct INR with FFP or PCC while preparing for endoscopy 1
5. Proceed with early endoscopy (within 24 hours) without delay 1