Restrictive versus Liberal Transfusion in Patients with Diabetes Undergoing Cardiac Surgery: An Open-Label Randomized, Blinded Outcome Evaluation Trial

Department of Anesthesia, St. Michael's Hospital, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada. Division of Hematology, Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada. Department of Anesthesia and Critical Care, Hospital Universitari and Politecnic La Fe, Valencia, Spain. Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland. Department of Anesthesia, Austin Hospital, Melbourne, Victoria, Australia. Department of Anesthesiology & Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada. Carrefour de l'innovation et santé des populations, Centre de recherche du CHUM, Montreal, QC, Canada. Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa. Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California, USA. Department of Surgery, The University of Melbourne and The Royal Melbourne Hospital, Royal Melbourne Hospital, Parkville, Victoria, Australia. Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia. Outcomes Research Consortium, The Cleveland Clinic, Cleveland, Ohio, USA. Department of Cardiac Anaesthesia and Intensive Care Medicine, Emergency Institute for Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. Department of Cardiac Anaesthesia, Epic Hospital, Ahmedabad, Gujarat, India. Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Kingston, Ontario, Canada. Fundación Cardioinfantil-Instituto de Cardiología, Bogota; Universidad Autónoma de Bucaramanga, Bucaramanga, Columbia. Department of Anesthesiology, Perioperative and Pain Medicine, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. Department of Anesthesia, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada. Department of Anesthesia, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Department of Physiology, University of Toronto, Toronto, Ontario, Canada. Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Institute of Health Policy, Management and Evaluation University of Toronto; ICES, Toronto, Ontario, Canada. Division of Cardiac Surgery, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Department of Surgery, Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada. Department of Anesthesia, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Institute of Medical Sciences, Department of Physiology, University of Toronto, Toronto, Ontario, Canada.

Diabetes, obesity & metabolism. 2021
PICO Summary

Population

Patients with diabetes undergoing cardiac surgery enrolled in the multinational TRICS-III trial (n= 1,396).

Intervention

Restrictive transfusion threshold strategy (n= 679).

Comparison

Liberal transfusion threshold strategy (n= 717).

Outcome

Of the 5,092 patients analysed, 1396 (27.4%) had diabetes. Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes nor the restrictive strategy increased the risk for the primary composite outcome vs. no diabetes. In patients with vs. without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion.
Abstract
AIM: To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. MATERIALS AND METHODS The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (hemoglobin [Hb] transfusion threshold <75 g/L) compared to a liberal strategy (Hb <95 g/L for operating room or ICU; or < 85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all-cause death, stroke, myocardial infarction, and new-onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days. RESULTS Of the 5092 patients analyzed, 1396 (27.4%) had diabetes (Restrictive: n = 679, Liberal n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95%CI]1.10[0.93-1.31]) or the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95%CI]1.04[0.68-1.59] vs. no diabetes OR 1.02[0.85-1.22],p(interaction) = 0.92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95%CI] 0.28[0.21-0.36]; no diabetes OR [95%CI] 0.40[0.35-0.47];p(interaction) = 0.04). CONCLUSIONS The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery. This article is protected by copyright. All rights reserved.
Study details
Language : eng
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