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Type: Journal article
Title: Restrictive or liberal red-cell transfusion for cardiac surgery
Author: Mazer, C.
Whitlock, R.
Fergusson, D.
Hall, J.
Belley-Cote, E.
Connolly, K.
Khanykin, B.
Gregory, A.
De Medicis, E.
McGuinness, S.
Royse, A.
Carrier, F.
Young, P.
Villar, J.
Grocott, H.
Seeberger, M.
Fremes, S.
Lellouche, F.
Syed, S.
Byrne, K.
et al.
Citation: New England Journal of Medicine, 2017; 377(22):2133-2144
Publisher: Massachusetts Medical Society
Issue Date: 2017
ISSN: 0028-4793
Statement of
C. David Mazer, M.D., Richard P. Whitlock, M.D., Ph.D., Dean A. Fergusson, Ph.D., M.H.A., Judith Hall, M.Sc., Emilie Belley-Cote, M.D., Katherine Connolly, M.D., Boris Khanykin, M.D., Alexander J. Gregory, M.D., Étienne de Médicis, M.D., Shay McGuinness, M.B., Ch.B., Alistair Royse, M.B., B.S., M.D., François M. Carrier, M.D., Paul J. Young, F.C.I.C.M., Ph.D., Juan C. Villar, M.D., Ph.D., Hilary P. Grocott, M.D., Manfred D. Seeberger, M.D., Stephen Fremes, M.D., François Lellouche, M.D., Ph.D., Summer Syed, M.D., Kelly Byrne, M.B., Ch.B., Sean M. Bagshaw, M.D., Nian C. Hwang, M.B., B.S., G.D.Acu., Chirag Mehta, M.D., Thomas W. Painter, M.B., Ch.B., Colin Royse, M.B., B.S., M.D., Subodh Verma, M.D., Ph.D., Gregory M.T. Hare, M.D., Ph.D., Ashley Cohen, M.Sc., Kevin E. Thorpe, M.Math., Peter Jüni, M.D. and Nadine Shehata, M.D. for the TRICS Investigators and Perioperative Anesthesia Clinical Trials Group
Abstract: Background: The effect of a restrictive versus liberal red-cell transfusion strategy on clinical outcomes in patients undergoing cardiac surgery remains unclear. Methods: In this multicenter, open-label, noninferiority trial, we randomly assigned 5243 adults undergoing cardiac surgery who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) I of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery) to a restrictive red-cell transfusion threshold (transfuse if hemoglobin level was <7.5 g per deciliter, starting from induction of anesthesia) or a liberal red-cell transfusion threshold (transfuse if hemoglobin level was <9.5 g per deciliter in the operating room or intensive care unit [ICU] or was <8.5 g per deciliter in the non-ICU ward). The primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28, whichever came first. Secondary outcomes included red-cell transfusion and other clinical outcomes. Results: The primary outcome occurred in 11.4% of the patients in the restrictive-threshold group, as compared with 12.5% of those in the liberal-threshold group (absolute risk difference, −1.11 percentage points; 95% confidence interval [CI], −2.93 to 0.72; odds ratio, 0.90; 95% CI, 0.76 to 1.07; P<0.001 for noninferiority). Mortality was 3.0% in the restrictive-threshold group and 3.6% in the liberal-threshold group (odds ratio, 0.85; 95% CI, 0.62 to 1.16). Red-cell transfusion occurred in 52.3% of the patients in the restrictive-threshold group, as compared with 72.6% of those in the liberal-threshold group (odds ratio, 0.41; 95% CI, 0.37 to 0.47). There were no significant between-group differences with regard to the other secondary outcomes. Conclusions: In patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive strategy regarding red-cell transfusion was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis, with less blood transfused. (Funded by the Canadian Institutes of Health Research and others; TRICS III number, NCT02042898.)
Keywords: Hospital Mortality
Rights: © 2017 Massachusetts Medical Society.
DOI: 10.1056/NEJMoa1711818
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