title: Lower versus higher hemoglobin threshold for transfusion in septic shock.
abstract: BACKGROUND
  Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established.
  
  
  METHODS
  In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization.
  
  
  RESULTS
  We analyzed data from 998 of 1005 patients (99.3%) who underwent randomization. The two intervention groups had similar baseline characteristics. In the ICU, the lower-threshold group received a median of 1 unit of blood (interquartile range, 0 to 3) and the higher-threshold group received a median of 4 units (interquartile range, 2 to 7). At 90 days after randomization, 216 of 502 patients (43.0%) assigned to the lower-threshold group, as compared with 223 of 496 (45.0%) assigned to the higher-threshold group, had died (relative risk, 0.94; 95% confidence interval, 0.78 to 1.09; P=0.44). The results were similar in analyses adjusted for risk factors at baseline and in analyses of the per-protocol populations. The numbers of patients who had ischemic events, who had severe adverse reactions, and who required life support were similar in the two intervention groups.
  
  
  CONCLUSIONS
  Among patients with septic shock, mortality at 90 days and rates of ischemic events and use of life support were similar among those assigned to blood transfusion at a higher hemoglobin threshold and those assigned to blood transfusion at a lower threshold; the latter group received fewer transfusions. (Funded by the Danish Strategic Research Council and others; TRISS ClinicalTrials.gov number, NCT01485315.).
authors.affiliation: From the Department of Intensive Care (L.B.H., N.H., L.H.A., U.G.P., N.R., J. Wiis, J.O.W., L.R., K.J.T., P.B.H., R.G.M., M.H.M., M.S., A.P.), Copenhagen Trial Unit, Center for Clinical Intervention Research (J. Wetterslev, P.W.), and Section for Transfusion Medicine (P.I.J.), Rigshospitalet and University of Copenhagen, Copenhagen, Randers Hospital, Randers (M.L.V., H.B., M.A.T.), Herning Hospital, Herning (R.W., D.L., R.M.), Hvidovre Hospital, Hvidovre (L.N., C.A.), Aarhus University Hospital, Aarhus (H.L.N., D.I.), Aalborg University Hospital, Aalborg (B.S.R.), Holbæk Hospital, Holbæk (J.R.M.L.), Kolding Hospital, Kolding (J.S.N.), and Hjørring Hospital, Hjørring (M.K.) - all in Denmark; Karolinska University Hospital, Huddinge, Stockholm (J. Wernerman, I.T., K.K., S.O.-W.), Karolinska University Hospital, Solna (A.O.), and Södersjukhuset, Stockholm (M.B.C.) - all in Sweden; Haukeland University Hospital and University of Bergen, Bergen, Norway (A.B.G., B.S.); Tampere University Hospital, Tampere (S.K.), and Helsinki University Hospital and University of Helsinki, Helsinki (V.P.) - all in Finland; and Liverpool Hospital, Sydney (A.Å.).
authors.forename: Lars B
authors.initials: LB
authors.lastname: Holst
authors.forename: Nicolai
authors.initials: N
authors.lastname: Haase
authors.forename: Jørn
authors.initials: J
authors.lastname: Wetterslev
authors.forename: Jan
authors.initials: J
authors.lastname: Wernerman
authors.forename: Anne B
authors.initials: AB
authors.lastname: Guttormsen
authors.forename: Sari
authors.initials: S
authors.lastname: Karlsson
authors.forename: Pär I
authors.initials: PI
authors.lastname: Johansson
authors.forename: Anders
authors.initials: A
authors.lastname: Aneman
authors.forename: Marianne L
authors.initials: ML
authors.lastname: Vang
authors.forename: Robert
authors.initials: R
authors.lastname: Winding
authors.forename: Lars
authors.initials: L
authors.lastname: Nebrich
authors.forename: Helle L
authors.initials: HL
authors.lastname: Nibro
authors.forename: Bodil S
authors.initials: BS
authors.lastname: Rasmussen
authors.forename: Johnny R M
authors.initials: JR
authors.lastname: Lauridsen
authors.forename: Jane S
authors.initials: JS
authors.lastname: Nielsen
authors.forename: Anders
authors.initials: A
authors.lastname: Oldner
authors.forename: Ville
authors.initials: V
authors.lastname: Pettilä
authors.forename: Maria B
authors.initials: MB
authors.lastname: Cronhjort
authors.forename: Lasse H
authors.initials: LH
authors.lastname: Andersen
authors.forename: Ulf G
authors.initials: UG
authors.lastname: Pedersen
authors.forename: Nanna
authors.initials: N
authors.lastname: Reiter
authors.forename: Jørgen
authors.initials: J
authors.lastname: Wiis
authors.forename: Jonathan O
authors.initials: JO
authors.lastname: White
authors.forename: Lene
authors.initials: L
authors.lastname: Russell
authors.forename: Klaus J
authors.initials: KJ
authors.lastname: Thornberg
authors.forename: Peter B
authors.initials: PB
authors.lastname: Hjortrup
authors.forename: Rasmus G
authors.initials: RG
authors.lastname: Müller
authors.forename: Morten H
authors.initials: MH
authors.lastname: Møller
authors.forename: Morten
authors.initials: M
authors.lastname: Steensen
authors.forename: Inga
authors.initials: I
authors.lastname: Tjäder
authors.forename: Kristina
authors.initials: K
authors.lastname: Kilsand
authors.forename: Suzanne
authors.initials: S
authors.lastname: Odeberg-Wernerman
authors.forename: Brit
authors.initials: B
authors.lastname: Sjøbø
authors.forename: Helle
authors.initials: H
authors.lastname: Bundgaard
authors.forename: Maria A
authors.initials: MA
authors.lastname: Thyø
authors.forename: David
authors.initials: D
authors.lastname: Lodahl
authors.forename: Rikke
authors.initials: R
authors.lastname: Mærkedahl
authors.forename: Carsten
authors.initials: C
authors.lastname: Albeck
authors.forename: Dorte
authors.initials: D
authors.lastname: Illum
authors.forename: Mary
authors.initials: M
authors.lastname: Kruse
authors.forename: Per
authors.initials: P
authors.lastname: Winkel
authors.forename: Anders
authors.initials: A
authors.lastname: Perner
mesh_terms: D000368:Aged; D017707:Erythrocyte Transfusion / Q000009:adverse effects; D005260:Female; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D007362:Intensive Care Units; D007511:Ischemia / Q000209:etiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000209:etiology; D012306:Risk; D012772:Shock, Septic / Q000097:blood / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016037:Single-Blind Method
chemical_list: D006454:Hemoglobins