Transfusion Thresholds for Septic Cancer Patients

May 18, 2017

Transfusion Thresholds for Septic Cancer Patients

  1. Patricia Kritek, MD

A single-center study demonstrated somewhat lower 90-day mortality with a transfusion threshold <9 g/dL than with <7 g/dL.

  1. Patricia Kritek, MD

Convincing evidence supports a restrictive transfusion threshold — hemoglobin, <7 g/dL — for most critically ill patients (NEJM JW Gen Med Mar 1 1999 and N Engl J Med 1999; 340:409; NEJM JW Gen Med Nov 1 2014 and N Engl J Med 2014; 371:1381). However, oncology patients have been poorly represented in previous trials. In this single-center study from Brazil, investigators randomized 300 adults with solid-organ malignancies and septic shock to either a restrictive (hemoglobin, <7 g/dL) or a liberal (hemoglobin, <9 g/dL) transfusion strategy. In 60% of patients, the source of sepsis was pneumonia. Transfusions were performed in 61% of patients in the liberal group and in 41% of patients in the restrictive group.

At 28 days, mortality was 45% in the liberal group and 56% in the restrictive group (P=0.08). At 90 days, mortality was 59% in the liberal group and 70% in the restrictive group (P=0.03). Thus, an 11-percentage-point difference was noted at both 1 and 3 months, with P values straddling the conventional 0.05 level of statistical significance. Mechanical ventilation, renal replacement therapy, and organ ischemia were similar in the two groups.

Comment

These findings, coupled with similar results in patients admitted to the intensive care unit after surgery for abdominal cancer (NEJM JW Gen Med Feb 1 2015 and Anesthesiology 2015; 122:29), support consideration of earlier transfusion in sick cancer patients. Without a clear pathophysiologic mechanism, I remain unconvinced that a “correct” transfusion threshold exists for these patients; nevertheless, it seems reasonable to loosen our usual intensive care unit threshold for cancer patients with septic shock and consider transfusing patients whose hemoglobin falls to between 7 g/dL and 9 g/dL.

Editor Disclosures at Time of Publication

  • Disclosures for Patricia Kritek, MD at time of publication Speaker’s Bureau American College of Chest Physicians (Critical Care Board Review Course) Editorial boards American Journal of Respiratory and Critical Care Medicine Leadership positions in professional societies American Thoracic Society (Chair of the Nominating Committee, Section on Medical Education)

Citation(s):

Reader Comments (1)

Jon Schwartz Physician, Oncology, Usa

Unfortunately this is being used to deny all cancer patients of transfusions unless they're below. A 7 Hgb. Less box clicking in the EMR. This illustrates the insanity of modern day so called studies And how they are used to deny care and justify letting people suffer. What a crazed society we have become.

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