Liberal Transfusion Strategy Research Articles

Restrictive Versus Liberal Transfusion Strategies for Cardiac Surgery

Background: Anaemia is an important complication affecting cardiac surgery patients. Following cardiac surgery, transfusion of red blood cells is often required for haemodynamic support. Traditionally, haemoglobin cutoffs of 9–10 g/dL were used for to trigger transfusion. New randomised trial evidence has recently bolstered support for restrictive protocols with haemoglobin cutoffs of 7–8 g/dL. Methods: A best evidence topic was written addressing the question “does post-operative mortality among adult patients undergoing cardiac surgery differ with restrictive versus liberal transfusion strategies?” Altogether, ten randomised trials representing 11,826 patients were identified searching Medline, Embase, and Pubmed databases from 1980 to February 2019 which represented the best evidence to answer the question. Results: Some older trials have suggested a trend toward long-term mortality benefit with liberal transfusion protocols: Hazard Ratio (HR) 0.7 [95% confidence interval (CI) 0.49–1.02, p = 0.06] from a meta-analysis summarising six trials. However, more recent, larger, high-quality contemporary trials have demonstrated noninferiority with regard to mortality for a restrictive strategy, with the largest of which producing an odds ratio of 0.85 (95% CI 0.62–1.16) for 28-day mortality and 1.02 (95% CI 0.87–1.18, p = 0.006) for 6-month mortality. Conclusions: Among cardiac surgery patients, restrictive and liberal transfusion strategies do not differ with respect to mortality. Adverse outcomes such as stroke, nonfatal myocardial infarction, and renal failure did not differ between the two groups. Restrictive strategies result in fewer transfusions and less health care expenditure.

Red Blood Cell Transfusion Thresholds in Critically Ill Patients.

ABSTRACTAnemia of multifactorial etiology is common among critically ill patients and several arbitrary transfusion thresholds have been proposed. Transfusion of red blood cells has been well established to increase morbidity and even mortality among critically ill patients. Several randomized controlled studies have evaluated the use of a restrictive compared to a more liberal transfusion strategy in the critically ill. A transfusion threshold of 7 g/dL appears to be generally safe, especially in the younger age group without significant comorbidities. Besides, a restrictive transfusion strategy reduces the incidence of transfusion-related complications. However, the decision to transfuse needs to be individualized depending on the clinical situation, balancing putative benefits against possible complications.How to cite this articleChacko J, Brar G. Red Blood Cell Transfusion Thresholds in Critically Ill Patients. Indian J Crit Care Med 2019;23(Suppl 3):S181–S184.

Red blood cell concentrate transfusion strategies utilised at a tertiary-level paediatric intensive care unit: A descriptive study on impact and cost

Background. Optimal haemoglobin threshold for red blood cell (RBC) transfusions in critically ill anaemic children in a paediatric intensive care unit (PICU) is uncertain. Objective. To describe outcomes and costs associated with different RBC transfusion strategies in anaemic patients admitted to a tertiary PICU in Durban, South Africa. Methods. Transfusion data gathered over a 1-year period were analysed retrospectively. RBC transfusion strategies were classified as restrictive, ‘modified liberal’ or mixed. The ‘modified liberal’ group was subdivided into haemodynamically stable or unstable clusters. Transfusion-related effects, comorbidities and mortality were described. Costs associated with RBC transfusions in the various strategy groups were analysed. Results. Over the 118 transfusion records analysed, a restrictive strategy was adopted in 27 cases (22.9%) and a modified liberal strategy was used in 68 cases (57.6%). A mixed strategy was followed in 23 (19.5%) cases. Although mortality was higher in the modified liberal group than in the restrictive group (27.9% v. 11.1%), the difference was not statistically different ( p =0.09). There were no differences in the duration of intermittent positive pressure ventilation, length of PICU stay or post-transfusion effects between the restrictive and modified liberal transfusion strategies. A saving of R155 280.15 could have been realised if a restrictive transfusion strategy had been used for haemodynamically stable patients assigned to the modified liberal group. A further R28 988.67 was spent on avoidable after-hours transfusions levies. Conclusion. Adopting a restrictive daytime strategy for RBC transfusions at a PICU could introduce considerable cost savings without affecting outcomes.

The Effects of Storage Age of Blood in Massively Transfused Burn Patients: A Secondary Analysis of the Randomized Transfusion Requirement in Burn Care Evaluation Study.

Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused. A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation study which compared restrictive and liberal transfusion strategies. Eighteen tertiary-care burn centers. Transfusion Requirement in Burn Care Evaluation evaluated 345 adults with burns greater than or equal to 20% of the body surface area. We included only the 303 patients that received blood transfusions. The storage ages of all transfused red cell units were collected during Transfusion Requirement in Burn Care Evaluation. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 d). The primary outcome was the severity of multiple organ dysfunction. Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality. There were 6,786 red cell transfusions with a mean (± SD) storage age of 25.6 ± 10.2 days. Participants received a mean of 23.4 ± 31.2 blood transfusions (range, 1-219) and a mean of 5.3 ± 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on multiple organ dysfunction severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood, but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r ≤ 0.01). Despite massive blood transfusion, including very old blood, the duration of red cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion.

Red cell transfusion thresholds in haematopoietic stem cell transplantation

Red cell transfusions are part of the routine supportive care following haematopoietic stem cell transplantation. There is increasing evidence from randomized controlled trials demonstrating that restrictive transfusion thresholds are equivalent to liberal thresholds in other patient populations. However, given the lack of patient‐centred outcomes and the longer transfusion support required for patients with haematologic malignancies, the results of these trials may not be generalizable to haematology–oncology patients. In the recently completed multicentre TRIST trial, we randomized 300 patients requiring an autologous or allogeneic haematopoietic stem cell transplantation to either a restrictive (haemoglobin threshold <70 g/l) or liberal (haemoglobin threshold <90 g/l) red cell transfusion strategy. Our primary outcome was health‐related quality of life measured by FACT‐BMT through day 100 post‐transplant. The median number of red cell units transfused was lower in the restrictive strategy group (2 vs. 4). The FACT‐BMT total score was higher at all time points for patients in the restrictive transfusion group including at baseline (109 vs. 103) and at 100 days (116·3 vs. 109·2). After adjustment for baseline, the FACT‐BMT score at day 100 in the restrictive group was statistically non‐inferior to the liberal group (P < 0·0001). There were no significant differences between the two groups for any other clinical outcomes. Based on the results of the TRIST trial, a restrictive haemoglobin threshold of 70 g/l should become standard practice in haematopoietic stem cell transplant patients, and, given the lack of other clinical studies, all other haematology–oncology inpatients.

Surveying the Literature

Surveying the Literature

To transfuse or not transfuse: an intensive appraisal of red blood cell transfusions in the ICU.

This review is a critical appraisal of the current data comparing restrictive vs. liberal transfusion strategies for patients who are critically ill in ICUs. We focus on four subsets of critically ill patients: pediatric patients, patients with gastrointestinal bleeds, septic patients and patients undergoing cardiac surgery. Almost a decade after the TRICC trial, a randomized trial showing the safety of a restrictive transfusion threshold in critically ill patients, four large randomized controlled trials have shown that a restrictive transfusion strategy is safe in pediatric critically ill patients, patients with acute upper gastrointestinal bleeds, patients with septic shock and patients undergoing cardiac surgery. A large multicenter randomized trial is underway to determine the safety of a restrictive strategy in myocardial infarction. A restrictive transfusion threshold is recommended in nearly all critically ill patients. This is at least noninferior to more liberal transfusion practice; in addition, a restrictive threshold has shown improved outcomes in some patients and decreased chances of adverse events in patients. Judicious use of red cells improves patient outcome and protects the blood supply, a limited resource. More data are needed to determine appropriate transfusion threshold recommendations for patients with traumatic brain injury and acute coronary syndrome.

Six-Month Outcomes after Restrictive or Liberal Transfusion for Cardiac Surgery

BackgroundWe reported previously that, in patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive transfusion strategy was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or 28 days after surgery, whichever came first. We now report the clinical outcomes at 6 months after surgery.MethodsWe randomly assigned 5243 adults undergoing cardiac surgery to a restrictive red-cell transfusion strategy (transfusion if the hemoglobin concentration was <7.5 g per deciliter intraoperatively or postoperatively) or a liberal red-cell transfusion strategy (transfusion if the hemoglobin concentration was <9.5 g per deciliter intraoperatively or postoperatively when the patient was in the intensive care unit [ICU] or was <8.5 g per deciliter when the patient was in the non-ICU ward). The primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis occurring within 6 months after the initial surgery. An expanded secondary composite outcome included all the components of the primary outcome as well as emergency department visit, hospital readmission, or coronary revascularization occurring within 6 months after the index surgery. The secondary outcomes included the individual components of the two composite outcomes.ResultsAt 6 months after surgery, the primary composite outcome had occurred in 402 of 2317 patients (17.4%) in the restrictive-threshold group and in 402 of 2347 patients (17.1%) in the liberal-threshold group (absolute risk difference before rounding, 0.22 percentage points; 95% confidence interval [CI], −1.95 to 2.39; odds ratio, 1.02; 95% CI, 0.87 to 1.18; P=0.006 for noninferiority). Mortality was 6.2% in the restrictive-threshold group and 6.4% in the liberal-threshold group (odds ratio, 0.95; 95% CI, 0.75 to 1.21). There were no significant between-group differences in the secondary outcomes.ConclusionsIn patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive strategy for red-cell transfusion was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis at 6 months after surgery. (Funded by the Canadian Institutes of Health Research and others; TRICS III ClinicalTrials.gov number, NCT02042898.)

Questioning the benefit of restrictive transfusion practice in older adults

Restrictive transfusion practice is widely promoted, with many international guidelines recommending haemoglobin thresholds of 70 to 80 g/l for adult patients who are asymptomatic. Randomized controlled trials comparing outcomes associated with liberal and restrictive transfusion strategies underpin this approach. Meta‐analyses including trials of adult patients &gt;18 years of age have concluded that restrictive practice is noninferior to liberal transfusion approaches. A restrictive approach to transfusion reduces resource consumption and cost, as well as the hazards associated with unnecessary exposure to blood products. Although adults aged ≥65 years consume over half of the blood supply, there are few randomized controlled transfusion trials exclusive to this cohort. Our 2017 meta‐analysis of a small number of trials focussed on older adults found that higher transfusion haemoglobin thresholds were associated with lower mortality and fewer cardiac complications in this age group. Other studies have also shown that higher transfusion haemoglobin thresholds are beneficial in older adults. This paper presents recent evidence regarding transfusion outcomes in older adults and discusses aspects of the pathophysiology of ageing that impact on the reduced resilience of older patients to anaemic states. This evidence challenges the use of Hb thresholds that apply across the adult lifespan, regardless of age. It proposes that older age be considered as a risk factor in assessing transfusion requirements, and that transfusion practice in older adults may require higher haemoglobin thresholds than for younger adults.

Liberal Versus Restrictive Red Cell Transfusion Thresholds in Hematopoietic Stem Cell Transplantation (TRIST): A Randomized, Open Label, Phase 3, Non-Inferiority Trial

Background Evidence regarding red blood cell (RBC) transfusion practices in Hematopoietic Cell Transplantation (HCT) is lacking. As a result, the impact of RBC transfusions on outcomes following HSCT is not well understood. Methods We performed a multicenter (n=4) non-inferiority randomized controlled trial evaluating patients with a a hematologic malignancy requiring HCT. Patients were randomized to either a restrictive (Hemoglobin (Hb) threshold <70g/L) or liberal (Hb threshold <90g/L) RBC transfusion strategies between Day-0 and Day-100). Permutated randomization blocks of 2 and 4 were used. The non-inferiority margin corresponds to a 12% absolute difference between groups in FACT-BMT score relative to baseline. The Primary Outcome was health related quality of life (HRQOL) measured by FACT-BMT at Day 100. The following endpoints were collected: 1) HRQOL by FACT-BMT at Baseline, Day 7, 14, 28, 60 and 100), transplant related mortality, length of hospital stay, ICU admissions, incidence and grade of acute graft-versus-host disease, Bearman toxicity score, sinusoidal obstruction syndrome, serious infections, transfusion requirements, bleeding as per WHO Bleeding Scale and adverse transfusion reactions. Clinicaltrials.gov: NCT01237639 Findings A total of 300 patients underwent randomisation between 2011 and 2016. Post-HCT, mean pre-transfusion hemoglobin levels were 70.9g/L and 84.6g/L in the restrictive and liberal strategies (p < 0.0001). The number of RBC units transfused was lower in the restrictive-strategy than in the liberal-strategy [mean of 2.73(4.81) vs. 5.02(6.13), p=0.0004]. The restrictive-strategy had a marginally higher FACT-BMT score at day 100 [RR=1.02; 95%CI(0.96-1.07)] which was statistically non-inferior (p<0.0001) compared to the liberal-strategy. There were no significant differences in any clinical outcomes between the two groups. Interpretation In patients undergoing HCT, the use of a restrictive RBC transfusion strategy of 70g/L as compared to a threshold of 90g/L results in similar HRQOL and HCT outcomes with fewer transfusions. Trial Registration Number: Clinicaltrials.gov: NCT01237639 Funding: Canadian Institute of Health Research & Canadian Blood Services Declaration of Interest: The listed authors have no relevant conflict of interest to declare. Ethical Approval: Following approval from each participating center’s local ethics committee, four Canadian adult HSCT centers underwent screening and randomization of participants between 28 Mar 2011 and 3 Feb 2016. Written consent was obtained from all participants.

Joint recommendations on management of anaemia in patients with gastrointestinal bleeding in Hong Kong.

The demand for blood products continues to grow in an unsustainable manner in Hong Kong. While anaemia associated with gastrointestinal bleeding (GIB) is the leading indication for transfusion, there is no local recommendation regarding best practices for transfusion. We aimed to provide evidence-based recommendations regarding management of anaemia in patients with acute and chronic GIB. We reviewed all original papers, meta-analyses, systematic reviews, or guidelines that were available in PubMed. For acute GIB, a restrictive transfusion strategy, targeting a haemoglobin threshold of 7 to 8 g/dL, should be adopted because overtransfusion is associated with significantly higher all-cause mortality and re-bleeding. A liberal transfusion strategy should only be considered in patients with co-existing symptomatic coronary artery disease, targeting a haemoglobin threshold of 9 to 10 g/dL. When acute GIB settles, patients should be prescribed iron supplements if iron deficiency is present. For chronic GIB, iron stores should be replenished aggressively via iron supplementation before consideration of blood transfusion, except in patients with symptoms of severe anaemia. Oral iron replacement is the preferred first-line therapy, while intravenous iron is indicated for patients with inflammatory bowel disease, poor response or poor tolerability to oral iron, and in whom a rapid correction of iron deficit is preferred. Intravenous iron is underutilised and the risk of anaphylactic reaction to current preparations is extremely low. These recommendations are provided to local clinicians to facilitate judicious and appropriate use of red cell products and iron replacement therapy in patients with GIB.

Red blood cell transfusion to treat or prevent complications in sickle cell disease: an overview of Cochrane reviews.

This is the protocol for a review and there is no abstract. The objectives are as follows: To summarize the evidence in Cochrane reviews of the effectiveness and safety of red cell transfusions versus no transfusion, or restrictive (to increase the total haemoglobin) versus liberal (to decrease the haemoglobin S level below a specified percentage) transfusion, for treatment or prevention of complications experienced by people with SCD.

Transfusion for Patients With Sepsis in 2018

Red blood cell transfusion (RBCT) threshold in patients with sepsis remains a matter of controversy. In this review, we report a summary of the benefits and risks of RBCT. We then focus on the latest studies addressing this controversy, including the randomized controlled trials dealing with the early goal-directed therapy, the randomized controlled trials comparing liberal versus restrictive transfusion strategies, and finally the cohort studies assessing the impact of RBCT. The conclusions of these studies no longer argue for a 10 g/dL (30% hematocrit) transfusion threshold during the early phase of septic shock. Similarly, following the initial stabilization, most septic patients can be managed with a restrictive transfusion strategy using a 7 g/dL hemoglobin threshold. A more liberal transfusion strategy should be adopted if patients are not stabilized or for patients at risk of bleeding, with myocardial ischemia, or oncohematologic patients with potential hemostasis disorders. Triggers of RBCT other than hemoglobin level, more related to macrocirculation or microcirculation failures, should be developed to decide RBCT in septic patients.

Transfusion of Fresh Frozen Plasma in Critically Ill Patients: Effective or Useless?

BACKGROUND:Fresh frozen plasma (FFP) is widely used in critically ill patients to correct the deficiency of coagulation factors or increased INR.AIM:In the present study we aimed to evaluate the outcome of the freshly frozen plasma use as prophylaxis in ICU patients before an invasive procedure.METHODS:The study was conducted at Central Anaesthesiology and Intensive Care Service UHCT “Mother Theresa”, Tirana. 136 patients were enrolled with coagulopathy with no bleeding before the invasive procedure, from June 2016 to December 2016. A group of 75 patients underwent a median volume of 12.5 ml/kg FFP given, and 61 had no transfusion. Data were collected on demographics, the severity of illness measured by APACHE III scores, INR, medication use, hemodynamic data.RESULTS:From 136 patients with coagulopathy with no bleeding who underwent planned invasive interventions, 75 [55%] received FFP, vs 61 [45%] p = 0.04 who did not receive. Overall, the median FFP dose was 12.5 ml kg-1. Median INR level in FFP and non-FFP groups was respectively 3.1 (1.9-4.8) and 3.5 (1.8-5.2). INR was corrected in 24 of 75 (32%) of those who received a transfusion. The frequency of minor bleeding episodes was 9.3% in transfused patients vs 4.9% in the non-transfused group. Patients who developed an onset of acute lung injury were more frequent in the FFP group. No allergic transfusion complications were observed. Also, the median length of hospital stay [LOS] was 3.05 days vs 2.91 days and mortality rate 8.2% vs 6.5% with no significant difference between two groups.CONCLUSIONS:Freshly frozen plasma transfusions are often unnecessarily administered during an inadequate correction of the deficiencies of coagulation factors. When comparing a liberal FFP transfusion strategy vs restrictive other clinical trials are required to asses which one is the best to adopt in intensive care settings.

Intracranial hemorrhage in adults on ECMO.

Extracorporeal membrane oxygenation (ECMO) use has exploded over the last decade. However, it remains invasive and associated with significant complications, including tamponade, infection, thrombosis, gas embolism and bleeding. The most dreaded complication is intracranial hemorrhage (ICH). In this article, we review the literature on the incidence, diagnosis, risk factors, pathophysiology, prognosis, prevention and management of ICH in adults on ECMO. We found a high incidence of ICH in the literature with a poor prognosis. Important risk factors included pre-ECMO cardiac arrest, sepsis, influenza, renal failure, renal replacement therapy, hemolysis and thrombocytopenia. The optimal anticoagulation strategy is still uncertain. As platelet dysfunction and depletion appear to play an important role in the pathogenesis of ICH in patients on ECMO, a liberal platelet transfusion strategy may be advised. Prompt computed tomography (CT) diagnosis is of great importance as interventions to limit hematoma expansion and secondary neurological injury are most effective if instituted early. Transporting patients to the radiology department can be performed safely while on ECMO. A strategy combining screening CT on admission with a heparin-free period of extracorporeal support was demonstrated to be safe in VV-ECMO patients and resulted in a better prognosis compared to similar cohorts in the literature. Despite major technological improvements and all the experience gained in adults, ECMO remains associated with a high incidence of ICH. There are still wide gaps in our understanding of the disease. Optimal management strategies that minimize the risk of ICH and improve prognosis need to be further studied.

Retrospective Evaluation of a Restrictive Transfusion Strategy in Older Adults with Hip Fracture.

To compare the association between a restrictive transfusion strategy and cardiovascular complications during hospitalization for hip fracture with the association between a liberal transfusion strategy and cardiovascular complications, accounting for all transfusions from the emergency department to postacute rehabilitation settings. Retrospective study. Perioperative geriatric care unit. All individuals aged 70 and older admitted to the emergency department for hip fracture and hospitalized in our perioperative geriatric care unit (N=667; n=193 in the liberal transfusion group, n=474 in the restrictive transfusion group) from July 2009 to April 2016. A restrictive transfusion strategy (hemoglobin level threshold ≥8 g/dL or symptoms) used from January 2012 to April 2016 was compared with the liberal transfusion strategy (hemoglobin level threshold ≥10 g/dL) used from July 2009 to December 2011. Primary endpoint was in-hospital acute cardiovascular complications (heart failure, myocardial infarction, atrial fibrillation or stroke). The change to a restrictive transfusion strategy was associated with fewer acute cardiovascular complications (odds ratio=0.45, 95% confidence interval (CI)=0.31-0.67, p<.001), without any noticeable difference in in-hospital or 6-month mortality. The change also led to a reduction in packed red blood cell units used per participant (median 1, interquartile range (IQR) 0-2 in restrictive vs median 2, IQR 0-3 in liberal transfusion strategy, P<.001). In rehabilitation settings, the frequency of transfusion was greater with the restrictive transfusion strategy than the liberal transfusion strategy (18% vs 9%, P<.001). A restrictive transfusion strategy in older adults with hip fracture was found to be safe and was associated with fewer cardiovascular complications but more transfusions in rehabilitation settings. Prospective studies are needed to confirm these findings.

Risks of restrictive red blood cell transfusion strategies in patients with cardiovascular disease (CVD): a meta-analysis.

To evaluate the risks of restrictive red blood cell transfusion strategies (haemoglobin 7-8g dL-1 ) in patients with and without known cardiovascular disease (CVD). Recent guidelines recommend restrictive strategies for CVD patients hospitalised for non-CVD indications, patients without known CVD and patients hospitalised for CVD corrective procedures. Database searches were conducted through December 2017 for randomised clinical trials that enrolled patients with and without known CVD, hospitalised either for CVD-corrective procedures or non-cardiac indications, comparing effects of liberal with restrictive strategies on major adverse coronary events (MACE) and death. In CVD patients not undergoing cardiac interventions, a liberal strategy decreased (P = 0·01) the relative risk (95% CI) (RR) of MACE [0·50 (0·29-0·86)] (I2 = 0%). Among patients without known CVD, the incidence of MACE was lower (1·7 vs 3·9%), and the effect of a liberal strategy on MACE [0·79, (0·39-1·58)] was smaller and non-significant but not different from CVD patients (P = 0·30). Combining all CVD and non-CVD patients, a liberal strategy decreased MACE [0·59, (0·39-0·91); P = 0·02]. Conversely, among studies reporting mortality, a liberal strategy decreased mortality in CVD patients (11·7% vs·13·3%) but increased mortality (19·2% vs 18·0%) in patients without known CVD [interaction P = 0·05; ratio of RR 0·73, (0·53-1·00)]. A liberal strategy also did not benefit patients undergoing cardiac surgery; data were insufficient for percutaneous cardiac procedures. In patients hospitalised for non-cardiac indications, liberal transfusion strategies are associated with a decreased risk of MACE in both those with and without known CVD. However, this only provides a survival benefit to CVD patients not admitted for CVD-corrective procedures.

Clinical trials evaluating red blood cell transfusion thresholds: An updated systematic review and with additional focus on patients with cardiovascular disease

BackgroundSeveral new trials evaluating transfusion strategies in patients with cardiovascular disease have recently been published, increasing the number of enrolled patients by over 30%. The objective was to evaluate transfusion thresholds in patients with cardiovascular disease. MethodsWe conducted an updated systematic review of randomized trials that compared patients assigned to maintain a lower (restrictive transfusion strategy) or higher (liberal transfusion strategy) hemoglobin concentration. We focused on new trial data in patients with cardiovascular disease. The primary outcome was 30-day mortality. Specific subgroups were patients undergoing cardiac surgery and with acute myocardial infarction. ResultsA total of 37 trials that enrolled 19,049 patients were appraised. In cardiac surgery, mortality at 30days was comparable between groups (risk ratio 0.99; 95% confidence interval 0.74-1.33). In 2 small trials (n=154) in patients with myocardial infarction, the point estimate for the mortality risk ratio was 3.88 (95% CI, 0.83-18.13) favoring the liberal strategy. Overall, from 26 trials enrolling 15,681 patients, 30-day mortality was not different between restrictive and liberal transfusion strategies (risk ratio 1.0, 95% CI, 0.86-1.16). Overall and in the cardiovascular disease subgroup, there were no significant differences observed across a range of secondary outcomes. ConclusionsNew trials in patients undergoing cardiac surgery establish that a restrictive transfusion strategy of 7 to 8g/dL is safe and decreased red cell use by 24%. Further research is needed to define the optimal transfusion threshold in patients with acute myocardial infarction.

Outcome of Restrictive versus Liberal Blood Transfusion Strategies in Intensive Care Unit Admitted Patients

Background: Anemia is a very common disease in critically ill patients. Approximately 29% of patients have lower than normal hemoglobin levels when admitted to an ICU, and about 95% develop anemia within 3 days of admission. Aim of the Work: The purpose of this study was to evaluate the effects of restrictive and liberal red blood cell transfusion strategies on mortality and morbidity in critically ill patients. And as a result, recommend the more beneficial and the less deleterious strategy for critically ill patients. Patients and Methods: This clinical interventional study was carried out at Intensive Care Unit, Benha Teaching Hospital, Egypt, during a period from July 2017 to November 2017. This study was approved by Ethical Committee of Faculty of Medicine, Ain Shams University, including the informed consents which were obtained from either the patient or the closest family member. Results: Mortality rates in ICU were 16 % and 20% in group A and B respectively, 24% and 28% within 60 days respectively. There were lower mortality rates with group A but with no statistically significant difference between groups according to mortality during ICU Stay and mortality within 60 days. Conclusion: Comparison between the effect of restrictive and liberal strategies of blood transfusion on mortality and morbidity in critically ill patients showed no significant differences. Restrictive strategy is at least as effective to liberal strategy in critically ill patients. Blood transfusion may be hazardous and cost-effective. Recommendations: Anemia is associated with adverse clinical outcomes. However, randomized clinical trials are required to establish if transfusion is beneficial or harmful in anemic patients. A restrictive transfusion strategy should be recommended within the well-studied patient populations and clinical conditions, and the clinicians must continue to use their experience and bedside clinical judgment to advocate the best management for their patients.

Fluids and Organ Dysfunction: A Narrative Review of the Literature and Discussion of 5 Controversial Topics

Evidence-based clinical decision making is at the forefront of modern cardiothoracic anesthesia practice. Therefore, as a field, cardiac anesthesiologist should strive to ensure that the available evidence is of the highest possible quality. In this narrative review, 5 important topics that the authors believe require additional investigation in cardiothoracic anesthesia and critical care related to fluid therapy and organ dysfunction are outlined briefly. In particular, the authors believe that the areas of pulmonary artery catheter use, restrictive versus liberal transfusion strategies, cardiopulmonary bypass prime composition, colloid use in resuscitation and its effects on acute kidney injury, and management of acute kidney injury after cardiac surgery hold many unanswered questions and opportunities for continued improvement in the specialty of cardiac anesthesia. This article accompanies a presentation at the 46th Association of Cardiac Anesthesiologists Annual Meeting on October 22, 2017.