"Transfusion Requirements in Septic Shock (TRISS) Trial". The New England Journal of Medicine. 2014. PubMed
Links to original sources: Wiki Journal Post Full Journal Article
Does a lower hemoglobin threshold for red cell transfusion in patients with septic shock affect 90-day mortality compared to a higher hemoglobin threshold?
In patients with septic shock, using a lower hemoglobin threshold (≤7 g per deciliter) for red cell transfusion compared with a higher threshold (≤9 g per deciliter) resulted in fewer transfusions without a significant difference in 90-day mortality, ischemic events, use of life support, or days alive out of the hospital.
The TRISS trial was a multicenter, randomized study evaluating the impact of different hemoglobin thresholds for transfusion in patients with septic shock on 90-day mortality. One group received blood transfusions at a hemoglobin level ≤7 g/dL (the lower threshold), while the other group received them at ≤9 g/dL (the higher threshold). The study found no significant difference in mortality at 90 days, ischemic events, severe adverse reactions, or life support use between the two groups, with the lower-threshold group receiving 50% fewer transfusions.
The current guidelines for transfusion in septic shock patients recommend maintaining a hemoglobin concentration above 7 g/dL unless the patient exhibits symptoms such as myocardial ischemia, severe hypoxemia, or ongoing hemorrhage.
Multicenter, stratified, parallel-group, randomized, partially blinded clinical trial N=998 adult patients with septic shock Interventions: - Lower-threshold group (≤7 g per deciliter) for transfusion (n=502) - Higher-threshold group (≤9 g per deciliter) for transfusion (n=496) Primary outcome: Death at 90 days post-randomization Secondary outcomes: Ischemic events, life support use, adverse reactions to transfusion, percentage of days alive without life support, and days alive out of the hospital within 90 days Enrollment: December 2011 to December 2013
Inclusion Criteria: - Adult patients (≥18 years) in the ICU - Septic shock diagnosis according to criteria - Hemoglobin concentration ≤9 g/dL Exclusion Criteria: - Significant bleeding - Requirement for ECMO - Not specified acute myocardial infarction Baseline Characteristics: - Similar between both groups
- Red cell transfusions at hemoglobin ≤7 g/dL for the lower-threshold group - Transfusions at hemoglobin ≤9 g/dL for the higher-threshold group
Primary Outcomes: - At 90 days, mortality was 43.0% in the lower-threshold group versus 45.0% in the higher-threshold group (relative risk, 0.94; P=0.44) Secondary Outcomes: - Similar use of life support at days 5, 14, and 28 - Comparable numbers of ischemic events and severe adverse reactions - No significant difference in the percentages of days alive without life support or out of the hospital
- Lack of blinding for investigators, clinicians, and patients regarding transfusion thresholds could introduce bias. - Limited power to detect significant differences in secondary outcomes and certain subgroup analyses. - The choice to use leukoreduced blood, potentially limiting the applicability concerning nonleukoreduced blood. - Trial did not specify surveillance for myocardial ischemia, possibly missing some events and resulting in detection bias.
Supported by the Danish Strategic Research Council, Copenhagen University Hospital, Rigshospitalet, the Scandinavian Society of Anaesthesiology and Intensive Care Medicine, ACTA Foundation, and others.
For further details, please refer to the Transfusion Requirements in Septic Shock (TRISS) research articles and guidelines.