January 16, 2013
Volume 8 - Issue 3   

DynaMed Weekly Update

For the week ending January 11, 2013

Last week 559 articles were evaluated via DynaMed's Systematic Literature Surveillance and 185 were added to DynaMed content.   


Based on the editors' criteria of selecting "articles most likely to change clinical practice," one article of significant interest was selected for the DynaMed Weekly Update.

Feature Article

Use of Restrictive Transfusion Threshold May Reduce Mortality Compared to Liberal Threshold in Patients with Upper GI Bleeding


Blood transfusions are common in patients hospitalized with acute upper gastrointestinal bleeding, but the optimal hemoglobin threshold for administering blood products remains unclear. For critically ill patients in general, use of lower, more restrictive transfusion thresholds is associated with reduced transfusion rates and decreased in-hospital mortality (but not longer-term mortality) compared to more liberal thresholds (Cochrane Database Syst Rev 2012 Apr 18;(4):CD002042). Current guidelines recommend the use of a restrictive threshold (7 g/dL) in patients with upper GI bleeding (Am J Gastroenterol 2012 Mar;107(3):345, Ann Intern Med 2010 Jan 19;152(2):101), but little of the evidence supporting these guidelines comes from studies in this specific population.


A recent randomized trial compared restrictive vs. liberal transfusion protocols in 921 adults with acute upper GI bleeding (49% with peptic ulcer, 21% with esophageal varices). Patients were randomized to have blood transfusion when hemoglobin reached < 7 g/dL with a target range 7-9 g/dL (restrictive strategy) or when hemoglobin reached < 9 g/dL with target range 9-11 g/dL (liberal strategy). Patients reaching the threshold initially received 1 unit of red blood cells and had a second unit if hemoglobin fell below the target range. Exclusion criteria included exsanguinating bleeding and low risk of rebleeding.


A total of 889 patients (96.5%) were included in the analysis following exclusions for ineligibility, major protocol violations, or withdrawal. The rates of transfusion were 49% with the restrictive strategy and 85% with the liberal strategy (p < 0.001). All-cause mortality at 45 days was significantly reduced in the restrictive group (5% vs. 9%, p = 0.02, NNT 25) (level 2 [mid-level] evidence). The restrictive threshold was also associated with a lower rate of death due to uncontrolled bleeding (0.7% vs. 3.1%, p = 0.01, NNT 42) and of severe adverse events (12% vs. 18%, p = 0.01, NNT 17) (N Engl J Med 2013 Jan 3;368(1):11).


For more information see the Acute upper gastrointestinal bleeding and Blood products administration topics in DynaMed.

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About DynaMed Weekly Update

Prepared by the clinician members of the DynaMed Editorial Team, DynaMed Weekly Update is a compilation of one to five articles selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice.

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CME Information


0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
Release Date: January 16, 2013
Expiration Date: January 16, 2014
Estimated Completion Time:
15 minutes
There is no fee for this activity.

To Receive Credit 
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives


Upon successful completion of this educational program, the reader should be able to:


1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.


Faculty Information
Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.


No commercial support has been received for this activity.

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AAFP: Enduring Material activity, DynaMed Weekly Update, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each Weekly Update is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.


Program ID: 1210392T

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