There is now very convincing evidence to support a restrictive transfusion threshold — hemoglobin, <7 g/dL — for most critically ill patients that is supported by guidelines from the American Association of Blood Banks and the TRICC and FOCUS trials. However, oncology patients have been poorly represented in previous trials.
This single-center study from Brazil, investigators randomized 300 adults with solid-organ malignancies and septic shock to either a restrictive (hemoglobin, <7 g/dL) or a liberal (hemoglobin, <9 g/dL) transfusion strategy. In 60% of patients, the source of sepsis was pneumonia. Transfusions were performed in 61% of patients in the liberal group and in 41% of patients in the restrictive group.
At 28 days, mortality was 45% in the liberal group and 56% in the restrictive group (P=0.08). At 90 days, mortality was 59% in the liberal group and 70% in the restrictive group (P=0.03). Thus, an 11-percentage-point difference was noted at both 1 and 3 months (statistically significant at 90 days).
This is a single center trial and further studies are needed to confirm or refute these findings. Nevertheless, it does suggest that not all critically ill patients should be treated equally. Similarly, it has been suggested that we should be using a more liberal transfusion threshold for patients with acute coronary syndrome and traumatic brain injury. The jury is still out. Stay tuned.
Bergamin FS et al. Liberal versus restrictive transfusion strategy in critically ill oncologic patients: The Transfusion Requirements in Critically Ill Oncologic Patients randomized controlled trial. Crit Care Med2017 May; 45:766.