A 52-year-old man with a history of peptic ulcer disease presents to the emergency department with haematemesis and melaena. On examination, he is pale, diaphoretic, with blood pressure 95/58 mmHg and heart rate 118 bpm. His haemoglobin is 7.2 g/dL, and he has active bleeding on upper GI endoscopy. After two large-bore IV lines are established and aggressive fluid resuscitation is initiated, what is the most appropriate next step regarding blood transfusion?

Explanation

## Indications for Transfusion in Acute Haemorrhage **Key Point:** In acute surgical bleeding with haemodynamic instability and active ongoing blood loss, transfusion should not be delayed to achieve an arbitrary haemoglobin threshold. Immediate transfusion is indicated when there is evidence of shock and ongoing bleeding. ### Clinical Context This patient has: - **Haemodynamic instability:** BP 95/58, HR 118 (tachycardia) - **Active ongoing bleeding:** Haematemesis, melaena, endoscopic confirmation - **Moderate anaemia:** Hb 7.2 g/dL (though not critically low in isolation) ### Transfusion Trigger in Acute Bleeding | Scenario | Transfusion Trigger | | --- | --- | | **Stable, chronic anaemia** | Hb < 7 g/dL (restrictive strategy) | | **Acute bleeding with shock** | Hb < 8–9 g/dL OR haemodynamic instability | | **Active ongoing bleeding** | Transfuse early; do not wait for further drop | | **Massive transfusion protocol** | Initiate when >4 units needed in 1 hour | **High-Yield:** The **restrictive transfusion strategy** (Hb trigger 7 g/dL) applies to stable patients with chronic anaemia or controlled bleeding. In **acute uncontrolled bleeding with shock**, a **liberal strategy** (Hb 8–9 g/dL) is safer because ongoing blood loss will worsen anaemia and oxygen delivery. ### Why Immediate Transfusion Here 1. **Haemodynamic compromise:** Systolic BP <100 mmHg, tachycardia >100 bpm 2. **Ongoing active bleeding:** Endoscopically confirmed; will worsen if transfusion is delayed 3. **Oxygen delivery at risk:** Hb 7.2 g/dL + shock = inadequate tissue perfusion **Clinical Pearl:** In acute bleeding, do not apply the "Hb < 7" rule. Transfuse based on **haemodynamic status and ongoing blood loss**, not a single lab value. [cite:Harrison 21e Ch 113]