transfusion trial etc

1. TRANSFUSION TRIALS
(TRICC, TRISS, REALITY, FOCUS)
PRESENTER: MURTI A/L GANESAN
MODERATOR: DR UMUL( CONSULTANT)

2. TRICC TRIAL
( TRANSFUSION REQUIREMENT IN CRITICASL CARE) 1999

3. • Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3
percent, P= 0.11)
• , the rates were significantly lower with the restrictive transfusion strategy among
patients who were less acutely ill
• The mortality rate during hospitalization was significantly lower in the restrictive-
strategy group (22.3 percent vs. 28.1 percent, P=0.05).

4. • recommend that critically ill patients receive red-cell transfusions when their
hemoglobin concentrations fall below 7.0 g/dL and that hemoglobin
concentrations should be maintained between 7.0 and 9.0 g per deciliter.
• The diversity of the patients enrolled in this trial and the consistency of the results
suggest that our conclusions may be generalized to most critically ill patients
• the possible exception of patients with active coronary ischemic syndromes
• Patients who were admitted after cardiac surgery were excluded from this
study, Euvolaemic patients .

5. FOCUS TRIAL
( FUNCTIONAL OUTCOMES IN CARDIOVASCULAR PATIENTS UNDERGOING SURGICAL HIP)
2011
• Clinical questions?
-Among high-risk patients undergoing hip surgery, does a
liberal transfusion strategy (target hemoglobin >10 g/dL)
improve survival or functional outcomes at 60 days
compared to a restrictive strategy (target hemoglobin >8
g/dL)?

8. • INPUT:
findings suggest that it is reasonable to withhold transfusion in patients who have
undergone surgery in the absence of symptoms of anemia or a decline in the hemoglobin
level below 8 g per deciliter, even in elderly patients with underlying cardiovascular
disease or risk factors.
Among high-risk patients undergoing hip surgery, a liberal transfusion strategy targeting
a hemoglobin >10 g/dL does not improve survival or functional outcomes compared
to a restrictive strategy targeting a hemoglobin of >8 g/dL.

9. TRISS TRIAL
(TRANSFUSION REQUIREMENT IN SEPTIC SHOCK) 2014

11. • Conclusion:
---In patients with septic shock, mortality and rates of ischaemic events were similar in those assigned to a
blood transfusion at a higher vs. lower threshold
• This paper supports current practice.
--- Avoiding unnecessary blood transfusion removes the risk of infectious, immune and non-immune related
complications as well as conserving this limited resource.
--- 10% of patients, in the low threshold group, received transfusions despite being above the treatment
threshold, therefore there may be times when the threshold needs to be modified.
Patients with acute coronary syndromes were excluded from this trial. Further research is needed to assess
assess the safety of lower haemoglobin thresholds for transfusion in these patients
Surviving Sepsis Campaign severe sepsis and septic shock (2016, adapted)
•RBC transfusion only when Hgb is <7 g/dL unless extenuating circumstances (e.g., MI, severe hypoxemia,
hemorrhage; strong recommendation, moderate quality of evidence

12. TRICS 3 TRIAL
(TRANSFUSION REQUIREMENT IN CARDIAC SURGERY ) 2017
• Background: The effect of a restrictive versus liberal red-cell transfusion strategy on
clinical outcomes in patients undergoing cardiac surgery remains unclear.

14. • The restrictive transfusion strategy is non-inferior to the liberal transfusion
strategy in cardiac surgery patients with a moderate-to-high risk of death with
regards to a composite outcome of death and major disability
• This study demonstrates that post-cardiac surgery patients can safely be
managed with haemoglobins as low as 7.5g/dL

15. REALITY TRIAL
( RESTRICTIVE AND LIBERAL TRANSFUSION STRATEGIES WITH AMI AND ANEMIA) 2021
• Clinical questions:
- Is a restrictive strategy of blood transfusion non-inferior to a
liberal strategy among patients with acute myocardial infarction
and anemia?
From March 2016 to September 2019, a total of 668 patients with AMI and anemia
were consecutively enrolled in the trial (in 26 centers in France and 9 centers in
Spain)

18. • CONCLUSION:
In patients with AMI and anaemia, a restrictive transfusion strategy compared with a liberal
transfusion strategy was non-inferior in regards to 30 day MACE outcomes
The bottom line:
--- Although not definitive this trial suggests that a restrictive transfusion strategy in patients with
AMI and anaemia is safe with a non-statistically significant trend towards
superiority
--- A larger trial would be needed to definitely guide management of anaemia in this patient
population

19. • Unfortunately, this trial does not answer the question of a restrictive vs liberal
transfusion strategy in patients with anemia and AMI.
• It appears the theoretical benefits of a restrictive transfusion strategy make
pragmatic sense, however there could still be some potential harms using this
strategy.
• Which strategy is used will most likely be dependent on clinician judgment and
we will just have to wait for further trials to clarify this question.

21. MINT TRIAL
( MYOCARDIAL INFARCTION AND ANEMIA AND TRANSFUSION) 2024
• Clinical question:
In patients with acute myocardial infarction and anemia, does a restrictive or liberal transfusion
strategy affect the risk of death or recurrent myocardial infarction at 30 days?
• Multicenter, open-label, randomized trial
• 144 sites in the United States, Canada, France, Brazil, New Zealand, and Australia
• Enrollment from April 2017 to April 2023
• Patients with acute myocardial infarction and anemia randomized 1:1

24. CONCLUSION:
• “In patients with acute myocardial infarction
and anemia, a liberal transfusion strategy did
not significantly reduce the risk of recurrent
myocardial infarction or death at 30 days.
However, potential harms of a restrictive
transfusion strategy cannot be excluded.”

25. THE BOTTOM LINE:
• In the largest randomized trial to date for patients presenting with myocardial
infarction and anemia:
- there was no significant difference in the incidence of myocardial infarction or
death at 30 days in patients randomized to a liberal versus a restrictive
transfusion strategy.
- The data suggesting a potential favorable trend from the liberal strategy is not
robust enough in the face of the study limitations to recommend a change from
current practice

26. THANK YOU