Restricitve Transfusion Threshold is OK in Sepsis – The TRISS Trial

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Several studies in the past have looked into the topic of red blood cell (RBC) transfusions in the ICU and each one of them supports a rather restrictive approach in the ICU. Still though various guidelines around the world vary due to the lack of evidence (see below).

This october the New England Journal of Medicine (unnoticeably and slowly transforming into a critical care journal 😉 published a large multi-centered, partially blinded trial that randomised septic patients in intensive care units to receive RBC at a threshold of 70g/L or 90g/L. The primary outcome was mortality after 90 days. A total of 998 patients finally underwent randomisation and as a result there was no significant difference in mortality after 90 days. Also there were no statistically significant differences in all secondary endpoints like use of life supporting measures, ischemic events, and severe adverse reactions.

This trial adds up to a list of studies showing that a liberal transfusion strategy is not beneficial for patients in critical care. This seems to be especially true for patients with sepsis. And not to forget: a considerable amount of packed RBC can be saved this way.

A higher transfusion threshold of 90g/L in patients with sepsis is non-superior to a lower threshold of 70g/L.
Get an insight into this topic yourself, here’s the ‘must read’s about transfusions:

The TRICC trial

The CRIT study

Sherwood M et al. JAMA. 2014 Feb 26;Vol 311, No.8

The FOCUS trial

A short educational overview can be found here: http://lifeinthefastlane.com/education/ccc/blood-transfusion-in-icu/

Clinical Practice Guidelines from the AABB 2012: Ann Inten Med. 2012;157:49-58

Clinical Practice Guidelines 2009: Red blood cell transfusion in adult trauma and critical care, Crit Care Med 2009

Simvastatin Does Not Improve Clinical Outcome in ARDS… Unfortunately

Beeing involved in this multicenter, double-blind trial myself I am honoured to announce the Harp-2’s publication in the New England Journal of Medicine. Congratulations not only to John Laffey but also to Michael Scully who kept Galway going in the recruitment of patients for this trial.

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In the past several publications have shown a beneficial effect of statins in the process of lung inflammation and injury. So far though none of these studies was designed or powered to show the effect of statins on clinical outcomes. The aim of this trial was therefore to see whether 80mg of daily simvastatin would improve clinical outcomes in patients with ARDS.

For this study 40 intensive care units in Ireland and the United Kingdom (the ICU at the Galway University Hospital being one of them) randomised a total of 540 patients to receive either simvastatin 80mg OD or placebo. Primary outcome was defined as the number of ventilator-free days to day 28. Secondary outcomes included: change in the oxygenation index and the SOFA score up to day 28, the number of days free of non pulmonary organ failure to day 28, death from any cause within 28 days, death before discharge from ICU or the hospital, and safety.

As a result there were no differences in any of the outcomes mentioned. As the authors mention in the discussion themselves:

The use of simvastatin in the management of ARDS cannot be supported.
McAuley et al. September 30, 2014DOI: 10.1056/NEJMoa1403285