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Lower Transfusion Threshold for Sepsis Equals Fewer Transfusions, No Effect on Mortality


Clinical question

Does a lower transfusion threshold for critically ill patients with septic shock affect outcomes?

Bottom line

Using a lower threshold for transfusion for patients with septic shock in the intensive care unit (ICU) decreases the number of transfusions received without affecting mortality.


Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014;371(15):1381-1391.

Study design

Randomized controlled trial (nonblinded); (LOE: 1b)


Inpatient (ICU only)


Using partial blinding and concealed allocation, these investigators randomized ICU patients with septic shock and a hemoglobin level of less than 9 g/dL to receive red blood cell transfusions at either a higher threshold (< 9 g/dL) or a lower threshold (< 7 g/dL). The intervention continued for the entire ICU stay, to a maximum of 90 days. The 2 groups were similar at baseline with an average age of 67 years and a median Sepsis-Related Organ Failure Assessment (SOFA) score of 10 out of 24. Analysis was by intention to treat. Not suprisingly, patients in the higher threshold group received twice as many transfusions as those in the lower threshold group (3088 transfusions vs 1545; P < .001). Notably, one third of the patients in the lower-threshold group required no transfusions at all compared with only 1% in the higher-threshold group (P < .001). For the primary outcome of death at 90 days, there was no significant difference detected between the 2 groups. The per-protocol analysis, which excluded patients with major protocol violations, also showed the same result. Secondary outcomes, including the use of life support and the number of ischemic events in the ICU (eg, acute myocardial or cerebral ischemia), were also similar in the 2 groups.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

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