Anders Perner - When to Pull the Transfusion Trigger?
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Transcript of Anders Perner - When to Pull the Transfusion Trigger?
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When to pull the Tx-trigger?
University ofCopenhagen
Anders Perner
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University ofCopenhagen
COIsResearch funds from Fresenius Kabi, CSL Behring
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Royal North Shore Hospital - Sydney
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TRISS TRIAL
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After fluid resuscitation, MAP is 75, HR 100 on 0.1mcg/kg/min of NA
Hb is 8.5 g/dl and ScvO2 50%
What would you do next?
Early sepsis case
Emerg Med J 2010;27:110-15
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0
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US EM
ANZ ICU
ANZ EM
UK EM
UK ICU
US ICU
Transfuse until Hb > 10 g/dl
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0
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US EM
ANZ ICU
ANZ EM
UK EM
UK ICU
US ICU
Transfuse until Hb > 10 g/dl
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Transfuse until Hb > 10 g/dl
0
10
20
30
40
50
60
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80
90
100
US EM
ANZ ICU
ANZ EM
UK EM
UK ICU
US ICU
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Transfuse until Hb > 10 g/dl
0
10
20
30
40
50
60
70
80
90
100
US EM
ANZ ICU
ANZ EM
UK EM
UK ICU
US ICU
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SSC
First 6 hours:Hematocrit above 30 percent if ScvO2 < 70%
EGDT protocol
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More patients Tx‘ed in EGDT vs usual care groups in
ProCESS 14 vs 8%
ARISE 14 vs 7%
ProMise 9 vs 4%
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More patients Tx‘ed in EGDT vs usual care groups in
ProCESS 14 vs 8%
ARISE 14 vs 7%
ProMise 9 vs 4%
Rivers 64 vs 19%
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• Benefit vs. harm• Triggers• Blind spots• Expensive and limited resource
Blood Tx
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Odds for Tx given in ICU• Sweden 5.0
• Denmark 4.0
• USA 3.8
• China 3.3
• Canada 1.0
• UK 0.9
• France 0.9
• NZ 0.5SAFE TRIPS 2007
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Risks of transfusion Infectious
Non-infectious
Storage-lession
Immuno-modulation
Benefits vs harms
Risks of anemiaLow DO2
Ischemia
Organ dysfunction
Multiple organ dysfunction
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TRISS TRIAL
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32 Scandinavian ICUs TRISS TRIAL
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1000 adult ICU patients with septic shock
1 unit leuko-reduced RBCs
at
Hb < 7 g/dl
1 unit leuko-reduced RBCs
at
Hb < 9 g/dl
Hb < 9 g/dl
TRISS TRIAL
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HbTx-triggers
Chest pain
Hypotension
Tachycardia
Heart failure
Fatigue
SvO2 / ScvO2
Lactate
ECG-dynamics
SAP x heart rate
Severity
Cardiac output
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ScreenedTRISS TRIAL
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ExcludedTRISS TRIAL
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AnalysedTRISS TRIAL
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Median no. of units Tx’ed
Lower Threshold : 1 (IQR 0-3)
Higher Threshold : 4 (IQR 2-7)
(P <0.001)
TRISS TRIAL
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Lowest median HbTRISS TRIAL
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Many more red cellsvs.
Sustained severe anemia
TRISS TRIAL
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Deaths within 90 daysTRISS TRIAL
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Primary analysis supported by subgroup analyses
Age > 70 years
Chronic cardiovascular disease
Severely ill - SAPS II > 53
TRISS TRIAL
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and…post-hoc subgroup analyses
Inclusion < 6 h of ICU admission
TRISS TRIAL
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and…post-hoc subgroup analyses
Inclusion < 6 h of ICU admission
Lactate > 4 mM at randomisation
TRISS TRIAL
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Lars B Holst et al. BMJ 2015;350:bmj.h1354
©2015 by British Medical Journal Publishing Group
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RE-update
8000 patients randomised in lower risk of bias trials of Tx-triggers
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RR 0.97 (0.79-1.19)
for mortality
Unpublished
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3000 critically ill patients randomised in lower risk of bias trials of Tx-triggers
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RR 0.92 (0.80-1.06)
for mortality
Holst et al. BMJ 2015
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• No effect on mortality• Fewer patients Tx’ed and fewer Tx’s
7 g/dl as the new normal
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• Myocardial infarction• Bleeding• Severe brain damage
Blind spots
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200,000 MI patients can’t be wrong?
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Or 20,000 trauma patients?
Perel et al. PLoS Med 2014
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Or 20,000 trauma patients?
Perel et al. PLoS Med 2014
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• Tx in MI - association with increased
mortality• Tx in trauma – association with
increased mortality in low risk patients• Severe brain damage – very little data
Blind Tx-spots
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‘7 g/dl - the new normal’
?MI, bleeding, brain damage?
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University ofCopenhagen