Liberal versus restrictive transfusion strategy in critically ill oncologic patients: the Transfusion Requirements in Critically Ill Oncologic Patients randomized controlled trial.

Liberal red blood cell (RBC) transfusion in critically ill oncology patients – Is liberal better in this population or is this another chance finding to be further evaluated?

Bergamin and colleagues performed an randomised controlled trial comparing a liberal RBC strategy (haemoglobin threshold <9 g/dL) or a restrictive strategy (haemoglobin threshold <7 g/dL) in 300 adult cancer patients with septic shock in the first 6 hours of ICU admission. Mortality rate at 28 days (the primary endpoint of the study) was potentially lower in the liberal group with 45% versus 56% (hazard ratio, 0.74; 95% CI, 0.53-1.04; P = 0.08), mortality was similar at 60 days but significantly lower at 90 days (59% vs. 70% (hazard ratio, 0.72; 95% CI, 0.53-0.97; P = 0.03).

It is noteworthy that 153 out of 300 patients received RBC transfusions and the median difference between groups was 1 RBC unit. Can this cause an effect responsible for 18 deaths at 90 days, or is this just once again a potential chance finding, as in previous trials supporting a liberal transfusion strategy in surgical oncology patients, cardiac surgery patients and frail elderly patients with hip fractures?

We should collaborate internationally in performing adequately powered high-quality randomised trials like the TRISS trial (Holst LB et al. N Engl J Med 2014;371:1381-91) and well-performed systematic reviews (Docherty AB et al. BMJ 2016;352:i1351) to further develop clinical practice.

– Jakob Stensballe