Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial

Jairath, Vipul; Kahan, Brennan C; Gray, Alasdair; Doré, Caroline J; Mora, Ana Sabrina; James, Martin; Stanley, Adrian J.; Everett, Simon; Bailey, Adam; Dallal, Helen; Greenaway, John; Jeune, Ivan Le; Darwent, Melanie; Church, Nicholas I.; Reckless, Ian; Hodge, Renate; Dyer, Claire; Meredith, Sarah; Charlotte, Llewelyn; Palmer, K R; Logan, Richard F.; Travis, Simon; Walsh, Timothy; Murphy, Michael

doi:10.1016/s0140-6736(14)61999-1

Cited by 211 publications

(220 citation statements)

References 28 publications

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“…A recent multicenter study from the UK also assessed the benefits and harms of targeting different hemoglobin levels in patients with gastrointestinal bleeding. 30 The case-mix of this study was, however, very different from the Spanish study discussed earlier. When variceal bleeding is not the dominant cause of gastrointestinal bleeding, as in the UK study (9%, 81 out of 936), a liberal transfusion strategy (10 g/dL) was not associated with different clinical outcomes, including 28-day mortality (7% in the liberal vs 5% in the restricted group), compared to a more restricted transfusion target (8 g/dL).…”

Section: Risks Of a Liberal Rbc Transfusion Strategymentioning

confidence: 61%

“…When variceal bleeding is not the dominant cause of gastrointestinal bleeding, as in the UK study (9%, 81 out of 936), a liberal transfusion strategy (10 g/dL) was not associated with different clinical outcomes, including 28-day mortality (7% in the liberal vs 5% in the restricted group), compared to a more restricted transfusion target (8 g/dL). 30 As such, depending on the underlying cause of gastrointestinal bleeding, it is biologically plausible for a liberal RBC transfusion strategy to have diverse effects on patient outcomes compared to a restricted strategy even between different patients with gastrointestinal bleeding.…”

Section: Risks Of a Liberal Rbc Transfusion Strategymentioning

confidence: 99%

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Context-dependent risks and benefits of transfusion in the critically ill

Harahsheh¹,

Ho²

2017

IJCTM

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Transfusion of red blood cells (RBCs) and other blood products to critically ill patients is common. Blood products are expensive, and not without risks. Recent evidence from high-quality multicenter randomized controlled trials confirmed the safety of allogeneic RBC transfusions, including the use of aged RBCs, and mild to moderate anemia for most stable and nonbleeding critically ill patients. Emerging evidence suggests that a liberal RBC transfusion target may have potential divergent effects on patient outcomes depending on their clinical context, with possible harms for patients with gastrointestinal bleeding due to portal hypertension and, conversely, benefits for patients with severe underlying cardiovascular diseases. Despite an apparent increased risk of bleeding in critically ill patients with deranged coagulation parameters and thrombocytopenia, recent studies suggested that fresh frozen plasma (FFP) and platelet transfusions may not be beneficial and, indeed, also not very effective in correcting these abnormalities. As for patients who have active severe critical bleeding, use of empirical 1:1:1 RBC: platelets: FFP transfusion appears justifiable in an attempt to reduce deaths as a result of exsanguination. In conjunction with platelet count and fibrinogen concentration, whole blood viscoelastic and platelet function tests are particularly useful to assist clinicians to rationalize FFP and platelet transfusions, when imminent death from exsanguination is not anticipated. Because the risks and benefits of blood product transfusion are heavily context-dependent, a thorough consideration of the characteristics and clinical status of the patients, in conjunction with viscoelastic and platelet function tests, is needed to rationalize the decision to transfuse (or withhold) blood products -very much in line with the move toward the practice of individualized or personalized medicine.

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Section: Risks Of a Liberal Rbc Transfusion Strategymentioning

confidence: 61%

Section: Risks Of a Liberal Rbc Transfusion Strategymentioning

confidence: 99%

Context-dependent risks and benefits of transfusion in the critically ill

Harahsheh¹,

Ho²

2017

IJCTM

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“…Two recent systematic reviews in cardiac surgery [19] and in perioperative transfusion practice (including cardiac surgery) [20] reported higher mortality with a restrictive transfusion threshold. Our systematic review [21] found only 11 blood transfusion threshold randomized controlled trials (RCTs) that included patients with co-existing CVD, either as the whole population [10,[22][23][24], as a pre-defined subgroup [9,11,25] or as a high proportion of patients [14,[26][27][28]. We found no evidence of a difference in 30-day mortality between restrictive and liberal transfusion thresholds.…”

Section: Evidence In Patients With Co-existing Cardiovascular Diseasementioning

confidence: 80%

Anemia and Blood Transfusion in the Critically Ill Patient with Cardiovascular Disease

Docherty¹,

Walsh²

2017

Annual Update in Intensive Care and Emergency Medicine

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“…40 The ongoing bleeding may have contributed to the increased mortality. Jairath et al 41 examined RBC transfusion strategies in 936 patients in the TRIGGER study. They found no difference in clinical outcomes.…”

Section: Upper Gastrointestinal Bleedingmentioning

confidence: 99%

“…They found no difference in clinical outcomes. 41 In a meta-analysis concerning only patients with upper gastrointestinal bleeding (4 RCTs), the mortality was lower in patients treated according to a restrictive transfusion strategy. Also, the patients had a shorter LOS in the restrictive group based on two of the four trials.…”

Section: Upper Gastrointestinal Bleedingmentioning

confidence: 99%