Transfusion thresholds Flashcards
(8 cards)
Restrictive vs Liberal targets
1.TRICC
2.TRISS
3.TRICS
4.REALITY
5.SAHARA
6.HEMOTION
7.TRAIN
Rationale:
Increased O2 carrying capacity of blood
resolution of tissue hypoxia with higher Hb conc and improvement in circulating blood volume
leading to early resolution of shock
Summary for TRICC
Restrictive strategy is at least as effective and possibly superior to liberal strategy.
Lower targets will lead to less transfusions, lower adverse reactions and costs related to tx
TRICC-2014
In ICU patients -does a restrictive vs. liberal blood transfusion strategy alter mortality?
Restrictive- <7
Liberal -<10
*Primary outcome- overall 30day mortality similar in both groups
*Hospital mortality significantly higher in Liberal group
*Subgroup- mortality significantly lower in restrictive group in patients with lesser severity of illness and in <55yrs
*Non leucodeplete RBCs were used in those days.
UGI bleed
Summary:
Restrictive strategy can be standard in pts with UGI bleed provided early endoscopy and source control achieved
VILLANEUVA:
RCT- NEJM in 2013
Restrictive vs liberal in UGI bleed-effect on mortality
*Excluded patients with massive GI bleed
*All had endoscopy <6hrs
*Mortality significantly reduced in Restrictive group
*Reduced RBC transfusions, transfusion reactions and pulmonary oedema in restrictive group
Lower vs higher threshold in Septic shock
TRISS:-2014
Liberal vs restrictive strategy- in pts with septic shock- effect on mortality
Results:
*No significant diff in mortality between two groups
*Lower tx req in restrictive group
Pts with ACS excluded
Patients undergoing cardiac surgery
TRICS 3-2017
In patients undergoing cardiac surgery with moderate risk of death- does restrictive vs liberal Tx strategy affect composite outcome of - Death, MI, Stroke and AKI
Tx threshold- 7.5 vs 9.5
Results: Restrictive Tx NONINFERIOR to liberal
Continued to be noninferior 6months after surgery.
Patients with Acute MI
Anaemia is associated with major adverse cardiovascular events in patients with acute coronary syndrome
It is not known if transfusing patients with anaemia and AMI ameliorates this risk and often patients with acute coronary syndromes are excluded from trials comparing liberal and restrictive transfusion strategies
Summary:
Restrictive strategy noninferior with a statistically non significant trend towards superiority- larger trials needed
REALITY -2021
In Patients with Acute MI and Anaemia- restrictive Tx strategy- is it NONINFERIOR to major cardiovascular adverse outcomes at 30 days when compared to liberal
*The outcome was a composite MACE (major acute cardiovascular event) at 30 days-
all-cause death, recurrent myocardial infarction, emergency revascularisation prompted by ischaemia, stroke
*Exclusions:
Shock with signs of low COP
Recent PCI/CABG
Haem malignancy
Life threatening bleeding
Results:
Restrictive strategy noninferior to liberal with regards to 30 day MACE outcomes.
Transfusion thresholds in SAH
The TRICC study, published over 20 years go, led to the widespread adoption of restrictive thresholds for blood transfusion in critically ill patients
However, few neurocritically unwell patients were included in that study
observational data suggests Hb<9 g/l is linked with poorer outcomes in patients with traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH)
Mixed evidence from Prospective RCTs in this setting - however, these had methodological differences including single centre design, higher liberal transfusion thresholds and the definition of unfavourable neurological outcome
SAHARA Multicentre RCT including ANZ-2024 Dec
Pts with acute aneurysmal SAH
Does a liberal Tx strategy reduce unfavourable neurological outcomes when compared to liberal
Liberal- Hb>10
Restrictive-Tx permitted when Hb <8
Results:
No diff in neurological outcomes as assessed by modified Rankin scores but
Reduced Radiological evidence of vasospasm in Liberal group without any significant difference in DCI or CT evidence of infarction in both groups
No difference in adverse reactions with transfusion including thrombotic events, cardiovascular events/ARDS
Acute TBI
Summary:
-Large, multi-center RCT
-Excellent generalisability
-Demonstrates improved neurological outcomes for survivors of a range of acute brain injury
There are some limitations and unanswered questions, which in view of the scarcity of blood and dogma of restrictive transfusion practices in critically unwell patients, may be a barrier to implementation
In view of TRAIN and HEMOTION( where difference among two groups did not reach a statistical significance, but there was no increase in adverse effects)- I will target a more liberal transfusion threshold in acute brain injury
HEMOTION-2024 june
Moderate-severe TBI
Thresholds-<7 vs <10
Does liberal strategy reduce unfavourable neurological outcomes as measured by Glasgow outcome scale Extended (GOSE) at 6months
Results:
No statistically significant difference in GOSE at 6 months between those with liberal or restrictive transfusion following moderate or severe traumatic brain injury
TRAIN-2024 oct
Patients with acute brain injury (TBI,SAH, ICH included) does a liberal strategy improve neurological outcomes at 180 days when compared to restrictive
*ICH sec to brain tumour or AVM excluded
Results:
Patients with anemia and acute brain injury in liberal arm had a lower probability of unfavourable neurological outcome at 180 days as compared to restrictive arm.
Oncology patients
TRICOP-2017
In cancer patients, with Septic Shock- will liberal strategy reduce mortality at 28days
Single centre RCT
Haematological malignancy excluded
Results:
No difference in 28day mortality but 90 day mortality reduced in Liberal group.
Needs to be interpreted with caution as only one of their secondary outcomes reported a benefit,
Very low fragility index
larger studies needed to confirm findings
