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Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery.

C David Mazer1, Richard P Whitlock1, Dean A Fergusson1

  • 1From the Department of Anesthesia (C.D.M., G.M.T.H.) and the Department of Surgery, Division of Cardiac Surgery (S.V.), Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital (J.H., A.C.), Sunnybrook Health Sciences Center (S.F.), AHRC, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Dalla Lana School of Public Health (K.E.T.), and AHRC, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation (P.J.), University of Toronto, and the Departments of Medicine, Laboratory Medicine, and Pathobiology, Institute of Health Policy, Management, and Evaluation, University of Toronto, and the Division of Hematology, Mount Sinai Hospital, Canadian Blood Services (N.S.), Toronto, Population Health Research Institute (R.P.W., E.B.-C.), Hamilton Health Sciences Centre (R.P.W., E.B.-C., K.C.), and McMaster University (R.P.W., E.B.-C., S.S.), Hamilton, ON, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.A.F.), the Department of Anesthesia, Foothills Medical Centre, University of Calgary, Calgary, AB (A.J.G.), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (É.M.), the Departments of Anesthesia and Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal (F.M.C.), the Departments of Anesthesia and Surgery, University of Manitoba, St. Boniface Hospital, Winnipeg (H.P.G.), the Department of Anesthesiology and Critical Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Laval, QC (F.L.), and the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (S.M.B.) - all in Canada; the Department of Cardiothoracic Anesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen (B.K.); Medical Research Institute of New Zealand, Wellington (S.M., P.J.Y.), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Department of Surgery, University of Melbourne (A.R., C.R.), and the Department of Anaesthesia and Pain Management, Royal Melbourne Hospital (C.R.), Melbourne, VIC, and the Department of Anaesthesia, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA (T.W.P.) - all in Australia; Fundación Cardioinfantil-Instituto de Cardiología, Bogota, and Universidad Autónoma de Bucaramanga, Bucaramanga - both in Colombia (J.C.V.); the University of Basel, Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, and Klinik Hirslanden, Zurich - both in Switzerland (M.D.S.); the Department of Cardiothoracic Anesthesia, National Heart Center, and the Department of Anesthesiology, Singapore General Hospital, Singapore (N.C.H.); and Heart Care Associates, Ahmedabad, India (C.M.).

The New England Journal of Medicine
|November 14, 2017
PubMed
Summary

A restrictive red-cell transfusion strategy was as effective as a liberal strategy for patients undergoing cardiac surgery. This approach resulted in fewer blood transfusions without compromising patient outcomes.

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Area of Science:

  • Cardiology
  • Transfusion Medicine
  • Critical Care Medicine

Background:

  • The optimal red-cell transfusion strategy for cardiac surgery patients is not well-defined.
  • This study addresses the uncertainty surrounding restrictive versus liberal transfusion thresholds.

Purpose of the Study:

  • To compare the clinical outcomes of restrictive versus liberal red-cell transfusion strategies in high-risk cardiac surgery patients.
  • To determine noninferiority of a restrictive strategy.

Main Methods:

  • A multicenter, open-label, noninferiority trial involving 5243 adults undergoing cardiac surgery with EuroSCORE I ≥ 6.
  • Patients were randomized to a restrictive (hemoglobin <7.5 g/dL) or liberal (hemoglobin <9.5 g/dL in OR/ICU, <8.5 g/dL on ward) transfusion strategy.
  • Primary composite outcome: all-cause death, myocardial infarction, stroke, or new-onset renal failure with dialysis by day 28 or hospital discharge.

Main Results:

  • The primary composite outcome occurred in 11.4% (restrictive) vs. 12.5% (liberal), demonstrating noninferiority (P<0.001).
  • Mortality rates were 3.0% (restrictive) and 3.6% (liberal).
  • Red-cell transfusion rates were significantly lower in the restrictive group (52.3%) compared to the liberal group (72.6%).

Conclusions:

  • A restrictive red-cell transfusion strategy is noninferior to a liberal strategy for moderate-to-high-risk cardiac surgery patients.
  • The restrictive strategy led to significantly fewer red-cell transfusions.
  • No significant differences were observed in other secondary clinical outcomes between the groups.