TRISS Trial

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seinfeld

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This week in the NEJM yet another article was published showing that a conservative goal (7) for Hgb has no impact on outcome versus Hgb of 9. The article is added to a pool of trials dating all the way back to the TRICC trial, all of which have failed to find that a lower threshold for transfusion is injurious. Also noted that 2 new sepsis trials, the ProCESS and the ARISE, failed to show that blood transfusion goal of HCT of 30 as per the original Rivers trial were helpful. Lastly the Study by Villanueva (NEJM 2013, 368:11-21) showed that higher transfusion goals in Upper GI bleeds worsened mortality.

Working both in the ICU and the OR I am always in conflict. In the ICU no one bats a eye with a HCT of 22 but in the OR I get calls to hang blood when the HCT is 25, 26,27, 28, 29. Obviously if the patient is showing hypotension with increasing base deficit or there is more anticipated blood loss I would transfuse earlier than later but what are other peoples practices? To note it doesn't seem to matter whether its a doc or crna in the case. Actually i find docs to be less in tune with new transfusion guidelines.

Another common issue is the hip fracture patient. When they sit on the medical floor the medicine guys, don't transfuse based on the above data but inevitably if they come down to the OR with a HCT <27 they will most likely need blood during the operation simply as a matter of ongoing loss during the case. I have read studies showing worse outcomes for the hip fx patient with OR transfusions but how do you all balance that? What are you protocols and/or personal decision making?

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I don't generally give blood in the OR unless I have good reason, and a drop in Hct below 30 is not a good reason to me (to my surgeons on the other hand...). If I am concerned about blood loss ahead of time, I will obtain a baseline ABG, and trend BE and istat Hct, knowing that the Hct on the istat will invariably be lower than that on a formal CBC. Most commonly, when I hear the surgeon say "I'm ok if you give blood" I respond that the patient is doing well, what I'm tracking, and that I'll transfuse if an indication arises. This is usually met by grumbles, and when the patient arrives on the ward or ICU with a Hct of 27, BE 1, with good UOP, and hemodynamically stable, they end up being transfused 2 units PRBCs by the surgeons.
 
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I just do what the surgeons tell me.
 
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Really Consigliere? Is there a hint of sarcasm there or are you serious?

I don't transfuse that much, but in residency, I did what the surgeons told me.
 
I have not read the article yet. Will check it out next week at work. The abstract left me wondering why would I, or anyone, transfuse a septic patient? The have a high cardiac output and are extremely dilated. I'm not sure they need more oxygen carrying capacity. It's like giving five bucks to a millionaire. It's not going to make much difference.

What draws my attention is that they didn't show a harm from transfusing, being that all the transfusion literature is pretty much about that.

In a sense I think the blood transfusion group was the winner.
 
This week in the NEJM yet another article was published showing that a conservative goal (7) for Hgb has no impact on outcome versus Hgb of 9. The article is added to a pool of trials dating all the way back to the TRICC trial, all of which have failed to find that a lower threshold for transfusion is injurious. Also noted that 2 new sepsis trials, the ProCESS and the ARISE, failed to show that blood transfusion goal of HCT of 30 as per the original Rivers trial were helpful. Lastly the Study by Villanueva (NEJM 2013, 368:11-21) showed that higher transfusion goals in Upper GI bleeds worsened mortality.

Working both in the ICU and the OR I am always in conflict. In the ICU no one bats a eye with a HCT of 22 but in the OR I get calls to hang blood when the HCT is 25, 26,27, 28, 29. Obviously if the patient is showing hypotension with increasing base deficit or there is more anticipated blood loss I would transfuse earlier than later but what are other peoples practices? To note it doesn't seem to matter whether its a doc or crna in the case. Actually i find docs to be less in tune with new transfusion guidelines.

Another common issue is the hip fracture patient. When they sit on the medical floor the medicine guys, don't transfuse based on the above data but inevitably if they come down to the OR with a HCT <27 they will most likely need blood during the operation simply as a matter of ongoing loss during the case. I have read studies showing worse outcomes for the hip fx patient with OR transfusions but how do you all balance that? What are you protocols and/or personal decision making?

Every situation is different... depends on the patient, surgery, and surgeon.

Any healthy person with GIB/blood loss during ortho case (anemia as only significant problem) for colo/endo or during ortho case HCT >20 is OK
Any person with ischemia risks (hx of CVA, MI) HCT >28 would be my goal in almost any situation
No ischemic history with baseline HCT 22 (chronic disease), depends on surgery, if reasonable chance for >200-300ml EBL, get blood up prior to going into OR, if simple case, Type and Cross only
Any seriously acute bleeder (uterine, vaginal, intraabdominal/thoracic whatever) with unknown HCT or dropping HCT near 30 who is symptomatic or unconscious - immediate transfusion titrated to vital signs
Based on absolutely nothing, with a septic guy I would keep HCT >25. Make sure oxygentation is covered, add a little colloid to the mix by giving RBCs.
 
Ischemia risk... These studies are showing that your fear of ischemia risk is unfounded when a goal of 21 is used versus 27, so why the 28? Whats the evidence to show that your transfusion trigger is appropriate. Having a hx of CAD, CVA was shown in the subset of TRICC to not warrant a higher goal of HCT. Only place where it is still controversial is in acute coronary syndromes, essentially becuase no one will test the theory.

Urge you have pointed out one significant take away. Transfusins are not causing an increase in mortality they merely dont help. Can, increased use of ABX from false SIRS, TRALI and fluid overload complicate things? for sure.

the recent GI bleed trial did show an increase in mortality with more transfusing though.
 
I'm not sure what to make of all the transfusion literature. I would not like to be transfused, hence I tend not to transfuse much. However, I have never regretted transfusing people on death's door. I see more often than I would like, pts maxed out on epi, norepi, vaso, milrinone.... with no urine output, no leg perfusion, looking grey...... who are not being transfused because the htc is 27. I think it is insane to go by the htc. I give those patients 4 units and bring the htc to mid 30 or 40. Somehow my pts don't look like Skeletor.

My personal experience is mostly with hypovolemic and myocardial dysfunction pts, different from sepsis, but I still believe that blood is not as harmful as the literature makes me believe.
 
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