Liberal Versus Restrictive Transfusion Strategy in Critically Ill Oncologic Patients: The Transfusion Requirements in Critically Ill Oncologic Patients Randomized Controlled Trial*

Objective: Anemia is very common in critical care patients, on admission (affecting about two-thirds of patients), but also during and after their stay, due to repeated blood loss, the effects of inflammation on erythropoiesis, a decreased red blood cell life span, and haemodilution. Anemia is associated with severity of illness and length of stay. Methods: A committee composed of 16 experts from four scientific societies, SFAR, SRLF, SFTS and SFVTT, evaluated three fields: (1) anemia prevention, (2) transfusion strategies and (3) non-transfusion treatment of anemia. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE ® methodology. Results: The SFAR-SRLF guideline panel provided ten statements concerning the management of anemia in adult critical care patients. Acute haemorrhage and chronic anemia were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for ten recommendations. Three of these recommendations had a high level of evidence (GRADE 1±) and four had a low level of evidence (GRADE 2±). No GRADE recommendation could be provided for two questions in the absence of strong consensus. Conclusions: The experts reached a substantial consensus for several strong recommendations for optimal patient management. The experts recommended phlebotomy reduction strategies, restrictive red blood cell transfusion and a single-unit transfusion policy, the use of red blood cells regardless of storage time, treatment of anaemic patients with erythropoietin, especially after trauma, in the absence of contraindications and avoidance of iron therapy (except in the context of erythropoietin therapy).

Section: Field 2: Which Transfusion Strategies Can Reduce Red Blood Cmentioning

confidence: 99%

Management and prevention of anemia (acute bleeding excluded) in adult critical care patients

Lasocki

Pène

Ait‐Oufella

et al. 2020

“…The reasons for this finding remain intriguing, but possibly related to a lower incidence of both cardiovascular complications and superinfections. The same team reported a benefit from a liberal transfusion strategy applied throughout the ICU stay in solid cancer patients with septic shock [26]. A multicenter randomized Scandinavian study addressed the transfusion policy in septic shock patients, of whom 7.5% had hematological malignancies and 9.5% had metastatic cancer.…”

Section: Discussionmentioning

confidence: 99%

Red blood cell transfusion in the resuscitation of septic patients with hematological malignancies

Mirouse

Resche-Rigon

Lemiale

et al. 2017

BackgroundIndications for red blood cell (RBC) transfusion in septic acute circulatory failure remain unclear. We addressed the practices and the prognostic impact of RBC transfusion in the early resuscitation of severe sepsis and septic shock in patients with hematological malignancies.MethodsWe performed a retrospective analysis of a prospectively collected database of patients with hematological malignancies who required intensive care unit (ICU) admission in 2010–2011. Patients with a main admission diagnosis of severe sepsis or septic shock were included in the present study. We assessed RBC transfusion during the first two days as part of initial resuscitation.ResultsAmong the 1011 patients of the primary cohort, 631 (62.4%) were admitted to the ICU for severe sepsis (55%) or septic shock (45%). Among them, 210 (33.3%) patients received a median of 2 [interquartile 1–3] packed red cells during the first 48 h. Hemoglobin levels were lower in transfused patients at days 1 and 2 and became similar to those of non-transfused patients at day 3. Early RBC transfusion was more likely in patients with myeloid neoplasms and neutropenia. Transfused patients displayed more severe presentations as assessed by higher admission SOFA scores and blood lactate levels and the further requirements for organ failure supports. RBC transfusion within the first two days was associated with higher day 7 (20.5 vs. 13.3%, p = 0.02), in-ICU (39 vs. 25.2%, p < 0.001) and in-hospital (51 vs. 36.6%, p < 0.001) mortality rates. RBC transfusion remained independently associated with increased in-hospital mortality in multivariate logistic regression (OR 1.52 [1.03–2.26], p = 0.03) and propensity score-adjusted (OR 1.64 [1.05–2.57], p = 0.03) analysis.ConclusionsRBC transfusion is commonly used in the early resuscitation of septic patients with hematological malignancies. Although it was preferentially provided to the most severe patients, we found it possibly associated with an increased risk of death.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0292-3) contains supplementary material, which is available to authorized users.

“…The clinical impact of the adverse effects on morbidity and mortality of transfusion of RBCs in sepsis has been investigated in randomized controlled trials (RCT) [ 7 – 9 ]. In the subgroup analyses of septic patients in the TRICC trail [ 7 ] and in the TRISS trail [ 8 ], a liberal RBC transfusion strategy (hemoglobin level > 90–100 g/L) did not confer a benefit as compared to a restrictive strategy (hemoglobin level > 70 g/L).…”

Section: Introductionmentioning

confidence: 99%

Mortality and morbidity of low-grade red blood cell transfusions in septic patients: a propensity score-matched observational study of a liberal transfusion strategy

Nilsson

Bentzer

Andersson

et al. 2020

Background: Red blood cell (RBC) transfusions are associated with risks including immunological reactions and volume overload. Current guidelines suggest a restrictive transfusion strategy in most patients with sepsis but based on previous randomized controlled trials and observational studies, there are still uncertainties about the safety in giving low-grade RBC transfusions to patients with sepsis. Methods: Critically ill patients with severe sepsis or septic shock admitted to a university hospital intensive care unit between 2007 and 2018 that received less or equal to 2 units of RBCs during the first 5 days of admission were propensity score matched to controls. Outcomes were 90-and 180-day mortality, highest acute kidney injury network (AKIN) score the first 10 days, days alive and free of organ support the first 28 days after admission to the intensive care unit and highest sequential organ failure assessment score (SOFA-max). Results: Of 9490 admissions, 1347 were diagnosed with severe sepsis or septic shock. Propensity-score matching resulted in two well-matched groups with 237 patients in each. The annual inclusion rate in both groups was similar. The median hemoglobin level before RBC transfusion was 95 g/L (interquartile range 88-104) and the majority of the patients were transfused in first 2 days of admission. Low-grade RBC transfusion was associated with increased 90-and 180-day mortality with an absolute risk increase for death 9.3% (95% confidence interval: 0.6-18%, P = 0.032) and 11% (95% confidence interval: 1.7-19%, P = 0.018), respectively. Low-grade RBC transfusion also correlated with increased kidney, circulatory and respiratory failure and higher SOFA-max score. Conclusions: Low-grade RBC transfusion during the first 5 days of admission was associated with increased mortality and morbidity in a liberal transfusion setting. The results support the current practice of a restrictive transfusion strategy in septic critically ill patients.