Children with single-ventricle physiology do not benefit from higher hemoglobin levels post cavopulmonary connection: Results of a prospective, randomized, controlled trial of a restrictive versus liberal red-cell transfusion strategy*

Cholette, Jill M.; Rubenstein, Jeffrey S.; Alfieris, George M.; Powers, Karen S.; Eaton, Michael P.; Lerner, Norma B.

doi:10.1097/pcc.0b013e3181e329db

Cited by 109 publications

(98 citation statements)

References 21 publications

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“…Furthermore, RBC transfusion is associated with increased morbidity and mortality in adults with cardiac disease [8][9][10]. Indeed, a restrictive RBC transfusion strategy was not inferior to a liberal strategy in clinical trials of critically ill adults [11], critically ill children [12], and critically ill children after cardiac surgery [13,14]. Whether these studies have changed clinical practice is unknown.…”

Section: Introductionmentioning

confidence: 97%

Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice

et al. 2016

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The optimal red blood cell transfusion threshold for postoperative pediatric cardiac surgery patients is unknown. This study describes the stated red blood cell transfusion practice of physicians who treat postoperative pediatric cardiac surgery patients in intensive care units. A scenario-based survey was sent to physicians involved in postoperative intensive care of pediatric cardiac surgery patients in all Canadian centers that perform such surgery. Respondents reported their red blood cell transfusion practice in four postoperative scenarios: acyanotic or cyanotic cardiac lesion, in a neonate or an infant. In part A of each scenario, the patient was critically ill, but stabilized; in part B, the patient became unstable. Response rate was 58 % (71 of 123), with 45 respondents indicating direct involvement in postoperative intensive care. There was a wide variability in stated transfusion threshold, ranging from <7.0-14.0 g/dL for stabilized cases. There was no significant difference between neonates and infants in stated transfusion threshold. The mean hemoglobin level below which respondents would transfuse a stabilized patient was 9 g/dL for acyanotic and 11.2 g/dL for cyanotic patients, a statistically significant difference (2.2 ± 0.9 g/dL, p < 0.001). All clinical determinants of instability significantly increased transfusion threshold. Hemodynamic instability increased transfusion threshold by 2.3 ± 1.3 g/dL in acyanotic patients and by 1.3 ± 1.1 g/dL in cyanotic patients. Cyanotic lesion and clinical instability, but not patient age, increased stated red blood cell transfusion threshold. Significant variation in reported red blood cell transfusion practice exists among physicians treating pediatric patients in intensive care following cardiac surgery.

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Section: Introductionmentioning

confidence: 97%

Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice

et al. 2016

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“…No outcome improvements were found by a higher Hb concentration. 17,37 However, in older age the compensatory functions are reduced. Several studies have demonstrated the association between chronic anemia and mortality in critical illness.…”

Section: Should Age Influence Transfusion Strategies?mentioning

confidence: 99%

“…In the patients <60 years no such difference was found. 46 In infants and children with elective partial or total cavopulmonary connection, Cholette et al 17 found no benefit from a liberal transfusion strategy with an Hb threshold of 13 g/dL compared to a restrictive of 9 g/ dL within 48 hours after surgery. …”

Section: Cardiopulmonary Surgerymentioning

confidence: 99%

“…Seven of the RCTs are pilot studies [7][8][9][10][11][12][13] and another seven base their results on <200 patients per trial [14][15][16][17][18][19][20] and are probably too underpowered to explore differences in patient outcomes. Accordingly, they should be interpreted with caution.…”

Section: Relevant Clinical Outcomesmentioning

confidence: 99%

“…One RCT used a threshold of 11.3 g/dL, 32 another 12 g/dL, 8 and a third 13 g/dL. 17 A challenge of the trials was protocol adherence. In some studies, eg, FOCUS, TRICC, TRACS, and TRISS, the patients in the restrictive RBC transfusion group were transfused when Hb concentrations were higher than those of the protocol thresholds.…”

Section: Rbc Transfusion Thresholdsmentioning

confidence: 99%

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Comparison of liberal and restrictive blood transfusion: current insights into clinical outcomes

Gregersen¹,

Damsgaard²

2016

IJCTM

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Health Care–Associated Infection After Red Blood Cell Transfusion

Rohde

Dimcheff

Blumberg

et al. 2014

JAMA

557

338

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IMPORTANCE The association between red blood cell (RBC) transfusion strategies and health care–associated infection is not fully understood. OBJECTIVE To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction. DATA SOURCES MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014. STUDY SELECTION Randomized clinical trials with restrictive vs liberal RBC transfusion strategies. DATA EXTRACTION AND SYNTHESIS Twenty randomized trials with 8598 patients met eligibility criteria, of which 17 trials (n = 7456 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method. MAIN OUTCOMES AND MEASURES Incidence of health care–associated infection such as pneumonia, mediastinitis, wound infection, and sepsis. RESULTS The pooled risk of all serious infections was 10.6% (95% CI, 5.6%-15.9%) in the restrictive group and 12.7% (95% CI, 7.0%-18.7%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and infection (serious infections and selected infections, combined) was 0.92 (95% CI, 0.82-1.04) with little heterogeneity (I2 = 6.3%; τ2 = .0041). The RR for the association between transfusion strategies and serious infection was 0.84 (95% CI, 0.73-0.96; I2 = 0%, τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 48 (95% CI, 36-71). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.83 [95% CI, 0.69-0.99]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.86 (95% CI, 0.72-1.02). With stratification by patient type, the RR for serious infection was 0.72 (95% CI, 0.53-0.97) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight. CONCLUSIONS AND RELEVANCE Among hospitalized patients, a restrictive RBC transfusion strategy compared with a liberal transfusion strategy was not associated with a reduced risk of health care–associated infection overall, although it was associated with a reduced risk of serious infection. Implementing restrictive strategies may have the potential to lower the incidence of serious health care–associated infection.

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Children with single-ventricle physiology do not benefit from higher hemoglobin levels post cavopulmonary connection: Results of a prospective, randomized, controlled trial of a restrictive versus liberal red-cell transfusion strategy*

Cited by 109 publications

References 21 publications

Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice

Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice

Comparison of liberal and restrictive blood transfusion: current insights into clinical outcomes

Health Care–Associated Infection After Red Blood Cell Transfusion

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