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Debate: transfusing to normal haemoglobin levels will not improve outcome.

Alvarez G, Hébert PC, Szick S - Crit Care (2001)

Bottom Line: Recent evidence suggests that critically ill patients are able to tolerate lower levels of haemoglobin than was previously believed.It is our goal to show that transfusing to a level of 100 g/l does not improve mortality and other clinically important outcomes in a critical care setting.In addition, a restrictive transfusion strategy will reduce exposure to allogeneic transfusions, result in more efficient use of red blood cells (RBCs), save blood overall, and decrease health care costs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada.

ABSTRACT
Recent evidence suggests that critically ill patients are able to tolerate lower levels of haemoglobin than was previously believed. It is our goal to show that transfusing to a level of 100 g/l does not improve mortality and other clinically important outcomes in a critical care setting. Although many questions remain, many laboratory and clinical studies, including a recent randomized controlled trial (RCT), have established that transfusing to normal haemoglobin concentrations does not improve organ failure and mortality in the critically ill patient. In addition, a restrictive transfusion strategy will reduce exposure to allogeneic transfusions, result in more efficient use of red blood cells (RBCs), save blood overall, and decrease health care costs.

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Related in: MedlinePlus

Kaplan-Meier estimates of survival in the 30 days after admission to the ICU in the restrictive and liberal transfusion strategy groups (patients with APACHE II score ≤ 20). Data from Hébert et al [10].
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Figure 2: Kaplan-Meier estimates of survival in the 30 days after admission to the ICU in the restrictive and liberal transfusion strategy groups (patients with APACHE II score ≤ 20). Data from Hébert et al [10].

Mentions: In 1999, Hebert et al [10] reported the results of the TRICC trial. Patients (n = 838) were randomized either to a restrictive strategy (haemoglobin concentration maintained between 70 and 90 g/l, with a trigger set at 70 g/l) or to a liberal strategy (haemoglobin concentration maintained between 100 and 120 g/l, with a trigger at 100 g/l). To date, the TRICC trial is the only large study that has investigated these parameters. The groups were comparable at baseline. The average daily haemoglobin concentration ranged from 85 ± 7.2 g/l in the restrictive group to 107 ± 7.3 g/l in the liberal group (P < 0.01). The average number of transfusions was reduced by 52% in the restrictive group (2.6 ± 4.1 versus 5.6 ± 5.3 RBCs/patient; P < 0.01). Cardiac events, primarily pulmonary oedema and myocardial infarction, were more frequent in the liberal strategy (P < 0.01; Table 1). On examination of composite outcomes, the number of patients with multiorgan failure was found to be substantially increased in both groups, with the results being marginally better in the restrictive strategy group (20.6% versus 26.0%; P = 0.07; Table 2). Overall, the restrictive transfusion group showed a lower 30-day mortality (18.7% versus 23.3%; P = 0.11; Fig. 1). Kaplan-Meier survival curves, however, were significantly different in the subgroup of patients with an Acute Physiology and Chronic Health Evaluation II score of 20 or less (P = 0.02; Fig. 2). In addition, although 60-day mortality (22.8% versus 26.5%; P = 0.23) and ICU mortality (13.9% versus 16.2%; P = 0.29) were not statistically significant, they did show a consistent trend in terms of absolute values that favoured the restrictive strategy. The key observation from the TRICC trial is not that the restrictive strategy is better, but rather that it is at worst equivalent to the liberal strategy and at best superior to the liberal strategy.


Debate: transfusing to normal haemoglobin levels will not improve outcome.

Alvarez G, Hébert PC, Szick S - Crit Care (2001)

Kaplan-Meier estimates of survival in the 30 days after admission to the ICU in the restrictive and liberal transfusion strategy groups (patients with APACHE II score ≤ 20). Data from Hébert et al [10].
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC137267&req=5

Figure 2: Kaplan-Meier estimates of survival in the 30 days after admission to the ICU in the restrictive and liberal transfusion strategy groups (patients with APACHE II score ≤ 20). Data from Hébert et al [10].
Mentions: In 1999, Hebert et al [10] reported the results of the TRICC trial. Patients (n = 838) were randomized either to a restrictive strategy (haemoglobin concentration maintained between 70 and 90 g/l, with a trigger set at 70 g/l) or to a liberal strategy (haemoglobin concentration maintained between 100 and 120 g/l, with a trigger at 100 g/l). To date, the TRICC trial is the only large study that has investigated these parameters. The groups were comparable at baseline. The average daily haemoglobin concentration ranged from 85 ± 7.2 g/l in the restrictive group to 107 ± 7.3 g/l in the liberal group (P < 0.01). The average number of transfusions was reduced by 52% in the restrictive group (2.6 ± 4.1 versus 5.6 ± 5.3 RBCs/patient; P < 0.01). Cardiac events, primarily pulmonary oedema and myocardial infarction, were more frequent in the liberal strategy (P < 0.01; Table 1). On examination of composite outcomes, the number of patients with multiorgan failure was found to be substantially increased in both groups, with the results being marginally better in the restrictive strategy group (20.6% versus 26.0%; P = 0.07; Table 2). Overall, the restrictive transfusion group showed a lower 30-day mortality (18.7% versus 23.3%; P = 0.11; Fig. 1). Kaplan-Meier survival curves, however, were significantly different in the subgroup of patients with an Acute Physiology and Chronic Health Evaluation II score of 20 or less (P = 0.02; Fig. 2). In addition, although 60-day mortality (22.8% versus 26.5%; P = 0.23) and ICU mortality (13.9% versus 16.2%; P = 0.29) were not statistically significant, they did show a consistent trend in terms of absolute values that favoured the restrictive strategy. The key observation from the TRICC trial is not that the restrictive strategy is better, but rather that it is at worst equivalent to the liberal strategy and at best superior to the liberal strategy.

Bottom Line: Recent evidence suggests that critically ill patients are able to tolerate lower levels of haemoglobin than was previously believed.It is our goal to show that transfusing to a level of 100 g/l does not improve mortality and other clinically important outcomes in a critical care setting.In addition, a restrictive transfusion strategy will reduce exposure to allogeneic transfusions, result in more efficient use of red blood cells (RBCs), save blood overall, and decrease health care costs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada.

ABSTRACT
Recent evidence suggests that critically ill patients are able to tolerate lower levels of haemoglobin than was previously believed. It is our goal to show that transfusing to a level of 100 g/l does not improve mortality and other clinically important outcomes in a critical care setting. Although many questions remain, many laboratory and clinical studies, including a recent randomized controlled trial (RCT), have established that transfusing to normal haemoglobin concentrations does not improve organ failure and mortality in the critically ill patient. In addition, a restrictive transfusion strategy will reduce exposure to allogeneic transfusions, result in more efficient use of red blood cells (RBCs), save blood overall, and decrease health care costs.

Show MeSH
Related in: MedlinePlus