"Restrictive Red-Cell Transfusion Strategy in Cardiac Surgery".The New England Journal of Medicine. 2017. 377(22):2133-2144.
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Is a restrictive red-cell transfusion strategy noninferior to a liberal strategy with respect to clinical outcomes in patients undergoing cardiac surgery at moderate-to-high risk for death?
In patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive red-cell transfusion strategy was noninferior to a liberal strategy, resulting in fewer transfusions without increasing the risk of composite outcomes including death, myocardial infarction, stroke, or new-onset renal failure with dialysis.
Cardiac surgery patients have been among the highest recipients of red-cell transfusion. There has been uncertainty regarding the safety of restrictive transfusion strategies in cardiac surgery due to potential anemia-induced tissue hypoxia in already high-risk patients. The Transfusion Requirements in Cardiac Surgery (TRICS) III trial showed that in adults undergoing cardiac surgery with cardiopulmonary bypass, a restrictive transfusion therapy (transfusion if hemoglobin <7.5 g/dL) was noninferior to a liberal strategy (transfusion if hemoglobin <9.5 g/dL in OR/ICU or <8.5 g/dL in a non-ICU ward).
As of the knowledge cut-off date, no specific updated guidelines have been released that reflect the results of this trial.
Multicenter, open-label, randomized, controlled, noninferiority trial.
5,243 adults (age ≥18 years) undergoing cardiac surgery with cardiopulmonary bypass who had a EuroSCORE I of 6 or more.
Inclusion Criteria - Scheduled for cardiac surgery with cardiopulmonary bypass - Predicted preoperative risk of death with EuroSCORE I ≥6
Exclusion Criteria - Unable to receive blood products - Declined blood products - Involved in preoperative autologous donation - Undergoing heart transplantation or ventricular assist device insertion - Pregnant or lactating
Baseline Characteristics - Mean age: 72±10 years - 35.4% females - Mean EuroSCORE I: 7.8±1.9 - Type of surgery: CABG only (26.1%), CABG plus another procedure (27.7%), non-CABG procedure (46.2%)
- Randomized to restrictive (n=2,430) or liberal (n=2,430) red-cell transfusion strategies, from anesthesia induction to hospital discharge or day 28 post-surgery.
Primary Outcomes - Composite of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28 (whichever came first). - Occurred in 11.4% of restrictive group vs. 12.5% of liberal group (odds ratio, 0.90; p<0.001 for noninferiority).
- Red-cell transfusion occurred in 52.3% of restrictive group vs. 72.6% of liberal group (odds ratio, 0.41, p<0.001). - No significant differences in other secondary outcomes between groups.
- Non-blinded design may introduce bias in outcome reporting. - The restrictive group achieved a hemoglobin concentration on average 1 g/dL less than the liberal group during the study, which was less than the difference in transfusion triggers. - Excluded low-risk patients, and did not test efficacy of transfusion or whether lower transfusion thresholds might be safe. - Did not include patients with acute coronary artery disease.
Canadian Institutes of Health Research, Canadian Blood Services–Health Canada, the National Health and Medical Research Council of Australia, and the Health Research Council of New Zealand.
1. Mazer CD, et al.; TRICS Investigators. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med. 2017;377(22):2133-2144. doi:10.1056/NEJMoa1711818