Low vs high hemoglobin trigger for transfusion in vascular surgery: a randomized clinical feasibility trial
Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the majority of evidence is based on postoperatively stable patients. We assessed the effects of a protocol aiming to restrict RBC transfusion th...
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Published in | Blood Vol. 133; no. 25; pp. 2639 - 2650 |
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Main Authors | , , , , , , , , , , |
Format | Journal Article |
Language | English |
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Elsevier Inc
20.06.2019
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Abstract | Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the majority of evidence is based on postoperatively stable patients. We assessed the effects of a protocol aiming to restrict RBC transfusion throughout hospitalization for vascular surgery. Fifty-eight patients scheduled for lower limb bypass or open abdominal aortic aneurysm repair were randomly assigned, on hemoglobin drop below 9.7 g/dL, to either a low-trigger (hemoglobin < 8.0 g/dL) or a high-trigger (hemoglobin < 9.7 g/dL) group for RBC transfusion. Near-infrared spectroscopy assessed intraoperative oxygen desaturation in brain and muscle. Explorative outcomes included nationwide registry data on death and major vascular complications. The primary outcome, mean hemoglobin within 15 days of surgery, was significantly lower in the low-trigger group, at 9.46 vs 10.33 g/dL in the high-trigger group (mean difference, −0.87 g/dL; P = .022), as were units of RBCs transfused (median [interquartile range (IQR)], 1 [0-2] vs 3 [2-6]; P = .0015). Although the duration and magnitude of cerebral oxygen desaturation increased in the low-trigger group (median [IQR], 421 [42-888] vs 127 [11-331] minutes × %; P = .0036), muscle oxygenation was unaffected. The low-trigger group associated to a higher rate of death or major vascular complications (19/29 vs 8/29; hazard ratio, 3.20; P = .006) and fewer days alive outside the hospital within 90 days (median [IQR], 76 [67-82] vs 82 [76-84] days; P = .049). In conclusion, a perioperative protocol restricting RBC transfusion successfully separated hemoglobin levels and RBC units transfused. Exploratory outcomes suggested potential harm with the low-trigger group and warrant further trials before such a strategy is universally adopted. This trial was registered at www.clinicaltrials.gov as #NCT02465125.
•Perioperative restriction of red cells significantly lowered hemoglobin levels, red cell units transfused, and cerebral tissue oxygenation.•Explorative outcomes indicated harm with the low transfusion trigger and warrants further trials to establish whether such strategy is safe.
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AbstractList | Abstract
Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the majority of evidence is based on postoperatively stable patients. We assessed the effects of a protocol aiming to restrict RBC transfusion throughout hospitalization for vascular surgery. Fifty-eight patients scheduled for lower limb bypass or open abdominal aortic aneurysm repair were randomly assigned, on hemoglobin drop below 9.7 g/dL, to either a low-trigger (hemoglobin < 8.0 g/dL) or a high-trigger (hemoglobin < 9.7 g/dL) group for RBC transfusion. Near-infrared spectroscopy assessed intraoperative oxygen desaturation in brain and muscle. Explorative outcomes included nationwide registry data on death and major vascular complications. The primary outcome, mean hemoglobin within 15 days of surgery, was significantly lower in the low-trigger group, at 9.46 vs 10.33 g/dL in the high-trigger group (mean difference, −0.87 g/dL; P = .022), as were units of RBCs transfused (median [interquartile range (IQR)], 1 [0-2] vs 3 [2-6]; P = .0015). Although the duration and magnitude of cerebral oxygen desaturation increased in the low-trigger group (median [IQR], 421 [42-888] vs 127 [11-331] minutes × %; P = .0036), muscle oxygenation was unaffected. The low-trigger group associated to a higher rate of death or major vascular complications (19/29 vs 8/29; hazard ratio, 3.20; P = .006) and fewer days alive outside the hospital within 90 days (median [IQR], 76 [67-82] vs 82 [76-84] days; P = .049). In conclusion, a perioperative protocol restricting RBC transfusion successfully separated hemoglobin levels and RBC units transfused. Exploratory outcomes suggested potential harm with the low-trigger group and warrant further trials before such a strategy is universally adopted. This trial was registered at www.clinicaltrials.gov as #NCT02465125. Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the majority of evidence is based on postoperatively stable patients. We assessed the effects of a protocol aiming to restrict RBC transfusion throughout hospitalization for vascular surgery. Fifty-eight patients scheduled for lower limb bypass or open abdominal aortic aneurysm repair were randomly assigned, on hemoglobin drop below 9.7 g/dL, to either a low-trigger (hemoglobin < 8.0 g/dL) or a high-trigger (hemoglobin < 9.7 g/dL) group for RBC transfusion. Near-infrared spectroscopy assessed intraoperative oxygen desaturation in brain and muscle. Explorative outcomes included nationwide registry data on death and major vascular complications. The primary outcome, mean hemoglobin within 15 days of surgery, was significantly lower in the low-trigger group, at 9.46 vs 10.33 g/dL in the high-trigger group (mean difference, −0.87 g/dL; P = .022), as were units of RBCs transfused (median [interquartile range (IQR)], 1 [0-2] vs 3 [2-6]; P = .0015). Although the duration and magnitude of cerebral oxygen desaturation increased in the low-trigger group (median [IQR], 421 [42-888] vs 127 [11-331] minutes × %; P = .0036), muscle oxygenation was unaffected. The low-trigger group associated to a higher rate of death or major vascular complications (19/29 vs 8/29; hazard ratio, 3.20; P = .006) and fewer days alive outside the hospital within 90 days (median [IQR], 76 [67-82] vs 82 [76-84] days; P = .049). In conclusion, a perioperative protocol restricting RBC transfusion successfully separated hemoglobin levels and RBC units transfused. Exploratory outcomes suggested potential harm with the low-trigger group and warrant further trials before such a strategy is universally adopted. This trial was registered at www.clinicaltrials.gov as #NCT02465125. •Perioperative restriction of red cells significantly lowered hemoglobin levels, red cell units transfused, and cerebral tissue oxygenation.•Explorative outcomes indicated harm with the low transfusion trigger and warrants further trials to establish whether such strategy is safe. [Display omitted] Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the majority of evidence is based on postoperatively stable patients. We assessed the effects of a protocol aiming to restrict RBC transfusion throughout hospitalization for vascular surgery. Fifty-eight patients scheduled for lower limb bypass or open abdominal aortic aneurysm repair were randomly assigned, on hemoglobin drop below 9.7 g/dL, to either a low-trigger (hemoglobin < 8.0 g/dL) or a high-trigger (hemoglobin < 9.7 g/dL) group for RBC transfusion. Near-infrared spectroscopy assessed intraoperative oxygen desaturation in brain and muscle. Explorative outcomes included nationwide registry data on death and major vascular complications. The primary outcome, mean hemoglobin within 15 days of surgery, was significantly lower in the low-trigger group, at 9.46 vs 10.33 g/dL in the high-trigger group (mean difference, -0.87 g/dL; = .022), as were units of RBCs transfused (median [interquartile range (IQR)], 1 [0-2] vs 3 [2-6]; = .0015). Although the duration and magnitude of cerebral oxygen desaturation increased in the low-trigger group (median [IQR], 421 [42-888] vs 127 [11-331] minutes × %; = .0036), muscle oxygenation was unaffected. The low-trigger group associated to a higher rate of death or major vascular complications (19/29 vs 8/29; hazard ratio, 3.20; = .006) and fewer days alive outside the hospital within 90 days (median [IQR], 76 [67-82] vs 82 [76-84] days; = .049). In conclusion, a perioperative protocol restricting RBC transfusion successfully separated hemoglobin levels and RBC units transfused. Exploratory outcomes suggested potential harm with the low-trigger group and warrant further trials before such a strategy is universally adopted. This trial was registered at www.clinicaltrials.gov as #NCT02465125. |
Author | Shahidi, Saeid Marcussen, Klaus V. Mortensen, Anette Jakobsen, Janus C. Hellemann, Dorthe Pedersen, Ole B. Winkel, Per Møller, Anders Wetterslev, Jørn Ramsing, Benedicte G.U. Nielsen, Henning B. |
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BackLink | https://www.ncbi.nlm.nih.gov/pubmed/30858230$$D View this record in MEDLINE/PubMed |
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CitedBy_id | crossref_primary_10_1111_trf_15848 crossref_primary_10_1111_trf_15708 crossref_primary_10_1182_blood_2019_04_901140 crossref_primary_10_2147_VHRM_S427211 crossref_primary_10_1111_vox_13274 crossref_primary_10_1590_1806_9282_66_4_466 crossref_primary_10_1016_j_cvsm_2020_07_001 crossref_primary_10_1016_j_jclinane_2024_111439 crossref_primary_10_1001_jama_2023_12914 crossref_primary_10_1002_14651858_CD002042_pub5 crossref_primary_10_1016_j_bja_2019_08_028 crossref_primary_10_1097_SLA_0000000000005620 crossref_primary_10_1097_SLA_0000000000004931 crossref_primary_10_1111_anae_14973 crossref_primary_10_1111_aas_13733 crossref_primary_10_1007_s00134_021_06531_x crossref_primary_10_3390_biomedicines11071873 crossref_primary_10_1111_vox_13068 crossref_primary_10_1111_trf_16429 crossref_primary_10_1182_blood_2022018521 crossref_primary_10_1016_j_avsg_2019_11_043 crossref_primary_10_2147_CLEP_S427348 crossref_primary_10_1111_anae_15019 crossref_primary_10_1053_j_jvca_2020_11_020 crossref_primary_10_1016_j_jclinane_2024_111472 crossref_primary_10_1186_s12872_023_03647_4 crossref_primary_10_1186_s13054_020_2827_5 |
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5 Goel (2020021108413292500_B12) 2018; 153 Hahn (2020021108413292500_B48) 2018; 62 Sørensen (2020021108413292500_B27) 2016; 30 Cahan (2020021108413292500_B54) 1999; 178 Prinssen (2020021108413292500_B5) 2004; 351 Villanueva (2020021108413292500_B46) 2013; 368 Wikkelsø (2020021108413292500_B24) 2017; 72 Møller (2020021108413292500_B21) 2017; 61 Kuper (2020021108413292500_B23) 2011; 342 Holmgaard (2020021108413292500_B56) 2020021108413292500_B50 Kei (2020021108413292500_B52) 2017; 5 Myles (2020021108413292500_B42) 2018; 378 |
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Snippet | Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the... Abstract Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain... |
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SubjectTerms | Adult Clinical Protocols Erythrocyte Transfusion - methods Feasibility Studies Female Hemoglobins - analysis Humans Male Middle Aged Vascular Surgical Procedures - methods |
Title | Low vs high hemoglobin trigger for transfusion in vascular surgery: a randomized clinical feasibility trial |
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