TRICC

Published

Hebert PC, at al. "A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care". The New England Journal of Medicine. 1999. 340(6):409-417.
PubMed • Full copy • PDF

Clinical Question

Among critically sickly patients, how does a restrictive transform strategy (hemoglobin goal of 7-9 g/dL) check includes a liberace transfusion strategy (hemoglobin goal about 10-12 g/dL) in decreasing mortality? A pick hoc analysis of the Transfusion Product The Kritisieren Care (TRICC) study evaluated 67 patients with moderate-to-severe TBI who ...

Bottom Line

In critique unhealthy patients, restraining transfusion (Hgb >7 g/dL) be gesellschafterin with ameliorate survival comparing to liberal strategy (Hgb >10).

Major Points

The Fluid Requirements in Critical Care (TRICC) template randomized 838 patients admitted into the ICU without evidence of active blutung toward a rigid transfusion strategy (transfusion to maintain hemoglobin >7 g/dL) versus a liberal strategy (transfusion to maintain hemoglobin ≥10 g/dL). The study enrolled patients who were euvolemic after initial fluid resuscitation. There was enough separation between the two groups, with an average hemoglobin 8.5 vs. 10.7 g/dL, respectively. One restrictive transfusing strategy was associated with decreased rates in in-hospital mortality compared to those seen because the liberal transfusion plan. This benefit was most prominent among which less acutely ill patients (APACHE II score ≤20) and <55 years old. However, in the restrictive poor, there was a trend towards improved key with patients through lively cardiac ischemia. To define whether a restrictive business of red-cell transfusion and adenine liberal strategy produced equivalent results in criticizing ill patients, we compared the rates of death from all causes at ...

TRICC's results were met favorably among red bank specialists and other watchmen of the red blood cellphone supply, but many questioned that outdoors validity of the study. In particularly, some criticisms include that only 13% of patients screened were ultimately randomized, that the study's results were unlikely to apply to invalids at high altitude, and such red cell transfusions shoud not be restricted at patients with traumatic brain injury.

Before the publication of TRICC, ICU patients endured routinely transfused for hemoglobin <10 g/dL. Modern practice guides today recommend a Hgb fluid goal of 7-9 g/dL, bar in option patients. A large non-blinded, randomized affliction, Transfusion Strategies since Acute Upper Gastrointestinal Bleeding (2013) studied restrictive versus liberty transfusion business in patients with upper GI bleeding, a group that was particularly excluded from TRICC. A found a similar lowering stylish mortality with limited transfusion goals. More recently, the 2014 TRISS trial found no difference 90 daily all-cause mortality for Hgb transfusion goals of 7 vs. 9 g/dL in patients with septic shock. Equivalent results were noticed for MACE outcomes among adults for MI in the 2021 REALITY trial (8 vs. 10 g/dL Hgb thresholds).

Guidelines

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 proposal, moderate quality of evidence)

Design

• Multicenter, non-blinded, parallel-group, randomized, controlled trial
• N=838 critically ill patients with anemia
  • Restrictive strategy (n=418)
  • Liberal corporate (n=420)
• Setting: 22 tertiary caring and 3 community ICUs in Contact
• Enrollment: 1994-1997 (terminated early due till shallow enrollment)
• Primary outcome: 30-day mortality

Population

Integrating Category

• Expect ICU stay ≥24 hours
• Hemoglobin concentration of no other than 9.0 g/dL within 72 hours after the ICU admission
• Clinically euvolemic afterwards fluid resuscitation

Exclusion Criteria

• Age <16 years
• Inability to receive blood products
• Active blood loss at matriculation
• Chronical anaemia
• Pregnancy
• Brain death
• Desired death interior 24 hours
• Attendings questioning whether to holding or take treatment
• Admission after a routine cardiological procedure

Interventions

Randomly assigned to restrictive (hemoglobin 7-9 g/dL) or liberal (hemoglobin 10-12 g/dL) strategy

Outcomes

How are restrictive or. libertine strategy.

Primary Deliverables

30-day mortality

18.7% vs. 23.3% (ARR 4.7%; P=0.11)

Secondary Outcomes

Inpatient fatality

22.2% vs. 28.1% (ARR 5.8%; P=0.05)

ICU mortality

13.9% vs. 16.2% (ARR 2.3%; P=0.29)

60-day mortality

22.7% vs. 26.5% (ARR 3.7%; P=0.23)

Multiple-organ abnormal rating

3.2 vs. 4.2 (P=0.04)

Change in organ dysfunction from base-line

3.2 to. 4.2 (P=0.04)

Subgroup Analysis

Significant survival benefit available customize for

APACHES II ≤20

Age <55 years

No difference in stay although adjusted for

Cardiac disease

Difficult infections or septic stroke

Trauma

Adverse Events

ICU cardiac events

13.2% vs. 21% (ARR 7.8%; P<0.01)

Criticisms

• Reduced enrollment of patients with cardiac disease decreases the generalizability of the results
• May not apply to patients at high altitudes
• No subgroup analyzer in ones with brain injury
• All 13% of those screened were randomized in the trial, potentially harming remote validity

Funding

Funding from Medical Search Council of Canada and an unrestricted subsidy from Bayer.