Landmark papers in critical care: Blood transfusions

Here are the transfusion guidelines for different patients:

  1. stable CAD: 7.0-8.0
  2. CKD: 8.0
  3. anemia with sx: 8.0
  4. asx, stable pts in ICU: 7.0
  5. acute UGIB: 7.0

One of the landmark papers that helped determine the benefits of low-threshold vs high-threshold transfusions was the TRICC trial. This trial randomized over 800 hemodynamically stable ICU patients with Hgb <9 to a goal of Hgb 7-9 or Hgb 10-12. There was no statistically significant difference in 30-day mortality, though it was very close to being significant for the more conservative group (Hgb 7-9) (22.2 vs. 28.1, p=0.05). Subgroup analysis showed lower mortality when using goal Hgb 7-9 among patients with APACHE II <20 (8.7% vs. 16.1%, p=0.03) and in patients younger than 55 (5.7 vs. 13.0 p=0.02). Although there was no noted difference in mortality among patients with cardiac disease, the authors acknowledge a high rate of refusal to participate among patients with cardiac disease, possibly affecting the results. That is one of the reasons there is a slightly higher transfusion goal set for cardiac patients.

NB: CAD is still a gray area, and some attendings may still prefer to transfuse asymptomatic patients with a history of CAD for a Hgb <8.0. However, trials on restrictive transfusion did use 7 as a threshold…




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