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Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery

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  • C David Mazer
  • Richard P Whitlock
  • Dean A Fergusson
  • Judith Hall
  • Emilie Belley-Cote
  • Katherine Connolly
  • Boris Khanykin
  • Alexander J Gregory
  • Étienne de Médicis
  • Shay McGuinness
  • Alistair Royse
  • François M Carrier
  • Paul J Young
  • Juan C Villar
  • Hilary P Grocott
  • Manfred D Seeberger
  • Stephen Fremes
  • François Lellouche
  • Summer Syed
  • Kelly Byrne
  • Sean M Bagshaw
  • Nian C Hwang
  • Chirag Mehta
  • Thomas W Painter
  • Colin Royse
  • Subodh Verma
  • Gregory M T Hare
  • Ashley Cohen
  • Kevin E Thorpe
  • Peter Jüni
  • Nadine Shehata
  • TRICS Investigators and Perioperative Anesthesia Clinical Trials Group
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BACKGROUND: The effect of a restrictive versus liberal red-cell transfusion strategy on clinical outcomes in patients undergoing cardiac surgery remains unclear.

METHODS: In this multicenter, open-label, noninferiority trial, we randomly assigned 5243 adults undergoing cardiac surgery who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) I of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery) to a restrictive red-cell transfusion threshold (transfuse if hemoglobin level was <7.5 g per deciliter, starting from induction of anesthesia) or a liberal red-cell transfusion threshold (transfuse if hemoglobin level was <9.5 g per deciliter in the operating room or intensive care unit [ICU] or was <8.5 g per deciliter in the non-ICU ward). The primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28, whichever came first. Secondary outcomes included red-cell transfusion and other clinical outcomes.

RESULTS: The primary outcome occurred in 11.4% of the patients in the restrictive-threshold group, as compared with 12.5% of those in the liberal-threshold group (absolute risk difference, -1.11 percentage points; 95% confidence interval [CI], -2.93 to 0.72; odds ratio, 0.90; 95% CI, 0.76 to 1.07; P<0.001 for noninferiority). Mortality was 3.0% in the restrictive-threshold group and 3.6% in the liberal-threshold group (odds ratio, 0.85; 95% CI, 0.62 to 1.16). Red-cell transfusion occurred in 52.3% of the patients in the restrictive-threshold group, as compared with 72.6% of those in the liberal-threshold group (odds ratio, 0.41; 95% CI, 0.37 to 0.47). There were no significant between-group differences with regard to the other secondary outcomes.

CONCLUSIONS: In patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive strategy regarding 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, with less blood transfused. (Funded by the Canadian Institutes of Health Research and others; TRICS III ClinicalTrials.gov number, NCT02042898 .).

Original languageEnglish
JournalThe New England journal of medicine
Volume377
Issue number22
Pages (from-to)2133-2144
Number of pages12
ISSN0028-4793
DOIs
Publication statusPublished - 30 Nov 2017

    Research areas

  • Adult, Aged, Cardiac Surgical Procedures, Cardiopulmonary Bypass, Erythrocyte Transfusion, Female, Hemoglobins, Hospital Mortality, Humans, Intensive Care Units, Intention to Treat Analysis, Length of Stay, Male, Middle Aged, Myocardial Infarction, Perioperative Care, Postoperative Complications, Renal Insufficiency, Stroke, Equivalence Trial, Journal Article, Multicenter Study, Randomized Controlled Trial

ID: 52781723