The TRICC trial: Restrictive transfusion in intensive care does not increase mortality [Classics Series]

Classics Series, Landmark Trials in Medicine

1. Using a restrictive transfusion strategy in critically ill patients did not significantly increase 30-day mortality when compared with a liberal transfusion strategy.

2. Subgroup analyses demonstrated that a restrictive transfusion strategy was associated with significantly lower mortality in patients with APACHE II score ≤20 and age <55 years.

Original Date of Publication: February 11, 1999

Study Rundown: The Transfusion Requirements in Critical Care (TRICC) trial sought to explore whether restrictive and liberal red-cell transfusion strategies in critically ill patients resulted in different outcomes. Prior to this study, there were conflicting views regarding the risks of anemia in critical care patients, and whether liberal transfusion was justified. Several observational studies had suggested that anemia was a risk factor for mortality in critically ill patients, particularly those with cardiovascular disease. It was suggested that anemia may cause excessive stress in severely ill patients, resulting in poorer outcomes. On the other hand, other studies suggested that the risks of blood transfusion were elevated in the critically ill.

This randomized, controlled trial was performed to examine the risks and benefits associated with different transfusion strategies in the critically ill. One strategy was deemed restrictive and sought to maintain lower haemoglobin levels (target between 7.0-9.0 g/dL), while the other was deemed liberal and maintained higher haemoglobin levels (target between 10.0-12.0 g/dL). In summary, there was no difference in 30-day mortality when comparing the two groups (ARR 4.7%; 95%CI -0.84-10.2; p=0.11). Moreover, the study demonstrated that survival was significantly better when using the restrictive transfusion strategy in subgroups of patients with APACHE II score ≤20 and age <55 years (p=0.02). This trial supported the use of a restrictive transfusion strategy in critically ill patients, with a transfusion threshold of 7.0 g/dL.

Click to read the study in NEJM

In-Depth [randomized, controlled study]: Published in 1999, this study involved 838 critically ill patients recruited from 22 tertiary-level and 3 community intensive care units across Canada. Patients were included if they were expected to stay in intensive care for >24 hours, had a haemoglobin concentration ≤9.0 g/dL within 72 hours of admission, and were considered to be euvolemic by treating physicians. Exclusion criteria included being <16 years old, inability to receive blood products, active blood loss at the time of enrolment, chronic anemia, pregnancy, brain death, or imminent death. Eligible patients were then randomized to either restrictive (target haemoglobin from 7.0-9.0 g/dL) or liberal transfusion strategies (target haemoglobin 10.0-12.0 g/dL). The primary outcome measure was 30-day mortality. Secondary outcomes included 60-day mortality and mortality in intensive care/during hospitalization.

There was no significant difference between the two groups with regards to 30-day mortality (ARR 4.7%; 95%CI -0.84-10.2; p=0.11). The in-hospital mortality rate, however, was significantly lower for patients in the restrictive arm (ARR 5.8%; 95%CI -0.3-11.7; p=0.05). In the subgroups of patients with APACHE II score ≤20 and age <55 years, survival was significantly higher for patients in the restrictive-transfusion group (p=0.02).

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