Lower versus higher hemoglobin threshold for transfusion in septic shock.

Holst LB, Haase N, Wetterslev J, <i>et al.</i>

N Engl J Med 2014;371:1381-1391.
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Review by : J.-F. Hardy
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The authors of this multicentre, randomised trial of transfusion triggers in 998 anaemic patients with septic shock report no difference in outcomes at 90 days whether the trigger is restrictive (7 g/dL) or liberal (9 g/dL). Patients treated with the lower transfusion threshold received a median of 1 unit of red blood cells (RBCs) compared with 4 units of RBCs in the higher transfusion threshold group. Thus, there appears to be no benefit of RBC transfusion to maintain a higher haemoglobin level (10 g/dL) in anaemic, septic ICU patients.

In an accompanying editorial, Paul Hébert and Jeff Carson propose that, in line with TRISS, the TRICC trial and two early goal-directed therapy trials, 7 g/dL be considered the new ‘normal’ transfusion threshold, with the possible exception of patients with an acute coronary syndrome in whom a similar trial is underway. The other recommendation, which has been ours for the past 20 years, is to transfuse one unit at a time, guided by patient evolution/symptoms, as necessary.

While the practice is not universal, we were happy to note that a restrictive transfusion trigger and a one-unit transfusion policy are in place for elderly orthopaedic surgical patients at our institution (Vuille-Lessard E et al. Transfusion 2012;52:261-70). Thus, it appears that transfusion practice is changing, based on high-quality evidence. Unfortunately, old habits (10/30) die hard…

– Jean-François Hardy

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