Recent Evidence Challenges Four Inpatient Management Habits
The evidence behind the AABB recommendation is only of moderate quality because there are only the three studies. Although the literature generally favors a restrictive versus a liberal approach, there’s no robust evidence for any particular transfusion threshold, said Dr. Daniel S. VanderEnde, a hospitalist and member of the joint transfusion committee at Emory University, Atlanta.
Pointing to the limited amount of research, the AABB itself calls the recommendation’s quality of evidence "very low" and the strength of the recommendation "uncertain."
"Subpar" evidence is one reason that Dr. VanderEnde’s institution leaves transfusion decisions to individual clinicians, he said in an interview. One ICU may transfuse at a hemoglobin threshold "in the mid-7s, and another ICU will have a transfusion threshold in the mid-8s."
Emory is starting a computer order entry protocol requiring physicians to tell why they’re transfusing blood, compared with no previous oversight. "It doesn’t stop them from transfusing for any reason. It is just trying to collect data, in the hopes that maybe they will be more restrictive in their use rather than liberal," he said.
Anecdotally, transfusion practices do seem to be shifting, at least among newly-trained physicians, Dr. VanderEnde added. Five years ago when he would ask medical students about transfusion thresholds, many hewed to "the old 10/30 rule," but far fewer do so today, he said. "The younger orthopedists tend to not transfuse as much as the older orthopedists."
Nasogastric Lavage
Few procedures performed in emergency departments are more painful for patients than nasogastric intubation, and there’s a study to prove that (Ann. Emerg. Med. 1999;33:652-8).
"Patients think nasogastric lavage and nasogastric intubation really stink, so we need to have a good reason to do it," Dr. Feldman said.
And, like all invasive procedures, there are risks involved, Dr. Chad T. Whelan said in an interview. There are only modestly convincing data suggesting that nasogastric lavage can provide some prognostic or "localizing" information (such as differentiating upper vs. lower bleed). "Therefore, the risk/benefit ratio of routinely performing them for all patients has shifted with our increasing understanding of their risks and benefits," said Dr. Whelan, a hospitalist at the University of Chicago.
International consensus recommendations on the management of patients with nonvariceal upper GI bleeding suggest that physicians consider placing a nasogastric tube in selected patients because the findings may have prognostic value – not very helpful advice in decision making, Dr. Feldman said. (Ann. Intern. Med. 2010;152:101-13).
The rationale until now has been that patients with bloody aspirate on nasogastric lavage are significantly more likely to have high-risk GI lesions on endoscopy, compared with patients with clear or bilious aspirates on lavage. But does knowing this improve outcomes?
One review of the literature on how to determine if a patient has a severe upper GI bleed confirmed that a bloody aspirate on nasogastric lavage increases the likelihood of an upper GI bleed but there’s only a mildly increased likelihood of a severe bleed, "and the negative likelihood ratio is not unimpressive," Dr. Feldman said (JAMA 2012;307:1072-19).
Results of a separate propensity-matched retrospective analysis of data on 632 patients admitted with GI bleeding are "as good as we’re going to get on this topic," he said. The study found that getting or not getting nasogastric lavage did not change 30-day mortality, mean length of stay, transfusion requirements, or emergency surgery rates (Gastrointest. Endosc. 2011;74:971-80).
The only things that nasogastric lavage did change were an increase in the rate of patients undergoing endoscopy, a shorter interval to endoscopy, and a shorter length of stay among patients who had endoscopy.
That suggests that there was an individual-provider confounder that the study could not measure. Perhaps emergency physicians or gastroenterologists who order nasogastric lavage are simply more aggressive, Dr. Feldman said. "This is information that you might want to take to your emergency department," he said.
In a joint editorial accompanying the study, an emergency physician and an endoscopist concluded that the practice of nasogastric lavage in patients with acute upper GI bleeding is "antiquated."
Dr. Whelan said the role of nasogastric lavage "is in transition rather than antiquated." As upper GI bleeding epidemiology evolves and endoscopic interventions improve, "the widespread use of nasogastric lavage as a universal piece of the upper GI bleed protocol should decrease. Whether nasogastric lavage ultimately becomes a completely unnecessary procedure remains to be seen," he said.
Physicians at his institution no longer routinely perform nasogastric lavage when evaluating suspected upper GI bleeding, but "it has not completely disappeared from practice, either," he said. That’s less a factor of "aggressive" physicians and more a result of how practice changes and environmental factors, Dr. Whelan added. "Not all emergency rooms have access to full-service endoscopy on site, so emergency room physicians may have a different set of risk/benefit tradeoffs to consider."
