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• W2901528441 abstract "Central MessageWith the recent publication of the TRICS II and III trial, have we laid to rest the appropriate trigger for a PRBC transfusion? The following editorial by Drs Levy and Steiner suggest that the question is still up in the air.See Article page 1038. With the recent publication of the TRICS II and III trial, have we laid to rest the appropriate trigger for a PRBC transfusion? The following editorial by Drs Levy and Steiner suggest that the question is still up in the air. See Article page 1038. Ever since the Transfusion Requirements in Critical Care trial in 1999,1Hebert P.C. Wells G. Blajchman M.A. Marshall J. Martin C. Pagliarello G. et al.A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian critical care trials group.N Engl J Med. 1999; 340: 409-417Crossref PubMed Scopus (4058) Google Scholar there has been an effort to adjust downward the hemoglobin level trigger for a transfusion. This gained traction in the field of cardiac surgery when JAMA published in their October 2010 issue the results of the Transfusion Requirements After Cardiac Surgery trial,2Hajjar L.A. Vincent J.L. Galas F.R. Nakamura R.E. Silva C.M. Santos M.H. et al.Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.JAMA. 2010; 304: 1559-1567Crossref PubMed Scopus (791) Google Scholar a randomized controlled trial (RCT) comparing a hemoglobin transfusion trigger of 8 g/dL to a trigger of 10 g/dL in patients undergoing cardiac surgery. No difference was found. In that same issue was an impressive article by Bennett-Guerrero and colleagues3Bennett-Guerrero E. Zhao Y. O'Brien S.M. Ferguson Jr., T.B. Peterson E.D. Gammie J.S. et al.Variation in use of blood transfusion in coronary artery bypass graft surgery.JAMA. 2010; 304: 1568-1575Crossref PubMed Scopus (365) Google Scholar showing the wide range of patients (8% to 93%) receiving packed red blood cell transfusions in coronary bypass surgery in the close to 800 Society of Thoracic Surgeons reporting institutions in the country at that time. An accompanying editorial4Shander A.S. Goodnough L.T. Blood transfusion as a quality indicator in cardiac surgery.JAMA. 2010; 304: 1610-1611Crossref PubMed Scopus (32) Google Scholar suggested that this discrepancy in behavior represented an opportunity for our specialty, intimating that the Transfusion Requirements After Cardiac Surgery trial, which provided evidence that a hemoglobin level of 8 g/dL was as good as 10 g/dL, should help standardize cardiac surgeons' transfusion behavior. In fact, it called for transfusion behavior to become a publically reported quality metric. Recognizing our drain on hospital blood supplies, the cost of transfusions, and their potential for harm, many of us jumped on the bandwagon, adopting 8 g/dL as the new 10 g/dL hemoglobin transfusion trigger. The problem was the Transfusion Indication Threshold Reduction 2 (TITRe2) trial of 2015,5Murphy G.J. Pike K. Rogers C.A. Wordsworth S. Stokes A. Angelini G.D. et al.Liberal or restrictive transfusion after cardiac surgery.N Engl J Med. 2015; 372: 997-1008Crossref PubMed Scopus (536) Google Scholar an RCT that compared a transfusion trigger of 7.5 g/dL hemoglobin versus 9.0 g/dL hemoglobin in 2000 elective cardiac procedures. The authors found a higher 30- and 90-day mortality in the restrictive-threshold group, as well as a trend toward more infection/ischemic events. That stunning result caused many of us to forego our prior zealotry, acknowledging that despite the favorable results of a restrictive transfusion policy in critical care,1Hebert P.C. Wells G. Blajchman M.A. Marshall J. Martin C. Pagliarello G. et al.A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian critical care trials group.N Engl J Med. 1999; 340: 409-417Crossref PubMed Scopus (4058) Google Scholar hip surgery,6Carson J.L. Terrin M.L. Noveck H. Sanders D.W. Chaitman B.R. Rhoads G.G. et al.Liberal or restrictive transfusion in high-risk patients after hip surgery.N Engl J Med. 2011; 365: 2453-2462Crossref PubMed Scopus (976) Google Scholar and gastrointestinal bleeding,7Villanueva C. Colomo A. Bosch A. Concepción M. Hernandez-Gea V. Aracil C. et al.Transfusion strategies for acute upper gastrointestinal bleeding.N Engl J Med. 2013; 368: 11-21Crossref PubMed Scopus (910) Google Scholar patients undergoing cardiac surgery might not be generalizable. Then, during the past year, publication of results of the Transfusion Requirements in Cardiac Surgery II and III trials8Mazer C.D. Whitlock R.P. Fergusson D.A. Hall J. Belley-Cote E. Connolly K. et al.Restrictive or liberal red-cell transfusion for cardiac surgery.N Engl J Med. 2017; 377: 2133-2144Crossref PubMed Scopus (399) Google Scholar, 9Mazer C.D. Whitlock R.P. Fergusson D.A. Belley-Cote E. Connolly K. Khanykin B. et al.Six-month outcomes after restrictive or liberal transfusion for cardiac surgery.N Engl J Med. 2018; 379: 1224-1233Crossref PubMed Scopus (134) Google Scholar rejuvenated the zealotry of our restrictive brethren. These most recent RCTs involved more than 5000 patients undergoing cardiac surgery, sicker as a group than seen in TITRe2, with a protocol involving intraoperative as well as postoperative care (unlike TITRe2), comparing 7.5 g/dL hemoglobin with 9.5 g/dL hemoglobin in the operating room/intensive care unit and 8.5 g/dL hemoglobin on the floor. The study failed to find any difference between groups regarding mortality or combined myocardial infarction, stroke, and renal failure. Furthermore, the Transfusion Requirements in Cardiac Surgery III trial addressed what many believe to be an association of lower discharge hemoglobin levels with postdischarge complications requiring readmissions10Koch C.G. Li L. Sun Z. Hixson E.D. Tang A. Chagin K. et al.Magnitude of anemia at discharge increases 30-day hospital readmissions.J Patient Saf. 2017; 13: 202-206Crossref PubMed Scopus (23) Google Scholar; they found no such association. Not knowing what to do with this new-found data, we asked 2 experts outside our field to help us shed what light there might be on this conundrum. How to interpret recent restrictive transfusion trials in cardiac surgery: More new data or new more data?The Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 3PreviewPatient blood management strategies have increasingly become an area of focus for clinicians to reduce allogeneic blood exposure.1 There are multiple reasons to reduce blood exposures to decrease costs, risks, and antigenic exposure. Algorithms for blood product administration are the basis for most strategies and routinely specifically state indications and thresholds for blood product admnistration.2 Of all the hospitalized patients, cardiac surgical patients are at significant risk for bleeding and transfusion because of the complexities of the surgery, activation of the multiple coagulation and inflammatory pathways, dilutional changes, hypothermia, and extracorporeal activation. Full-Text PDF Open Archive" @default.
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• W2901528441 title "Transfusion triggers in cardiac surgery: Does the Transfusion Requirements in Cardiac Surgery III trial answer the question?" @default.
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