L. B. Holst

Red blood cell transfusion during septic shock in the ICU

Transfusion of red blood cells (RBCs) remains controversial in patients with septic shock, but current practice is unknown. Our aim was to evaluate RBC transfusion practice in septic shock in the intensive care unit (ICU), and patient characteristics and outcome associated with RBC transfusion.

Higher vs. lower haemoglobin threshold for transfusion in septic shock: subgroup analyses of the TRISS trial

Using a restrictive transfusion strategy appears to be safe in sepsis, but there may be subgroups of patients who benefit from transfusion at a higher haemoglobin level. We explored if subgroups of patients with septic shock and anaemia had better outcome when transfused at a higher vs. a lower haemoglobin threshold.

Association between fluid balance and mortality in patients with septic shock: a post hoc analysis of the TRISS trial

Several studies have shown an association between a positive fluid balance and increased mortality in patients with septic shock. This may have led to a more restrictive use of intravenous fluids. The association between fluid accumulation and mortality in the setting of a more restrictive use of intravenous fluids, however, is uncertain. We therefore aimed to investigate the association between a cumulative fluid balance 3 days after randomization and 90‐day mortality in a recent Nordic multicentre cohort of patients with septic shock.

Hemoglobin threshold for transfusion in septic shock.

To the Editor: Holst et al. (Oct. 9 issue)1 found no significant differences in 90-day mortality and the rate of overt ischemic events between a lower and a higher hemoglobin threshold for transfusion in patients with septic shock. This study did not assess the occurrence of silent ischemic events that may have a substantial effect on long-term outcomes. Previous studies have shown that a low hemoglobin concentration is associated with silent cerebral ischemia in specific populations (e.g., patients with sickle cell anemia, those who require dialysis, and those with β-thalassemia).2 In children with sickle cell anemia, silent cerebral infarction is associated with cognitive impairment and an increased risk of stroke. A recent controlled trial by DeBaun et al. showed that regular blood-transfusion therapy significantly reduced the incidence of recurrence of both silent and overt cerebral infarction in this group.3 To rule out whether patients with septic shock who have a lower hemoglobin concentration are at risk for ischemic events such as silent cerebral ischemia and cognitive impairment, both brain imaging and cognitive-function tests after hospital discharge should be considered. Mariëlle Beerepoot, M.D., Ph.D. Liffert Vogt, M.D., Ph.D.

Development and internal validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU)

Intensive care unit (ICU) mortality prediction scores deteriorate over time, and their complexity decreases clinical applicability and commonly causes problems with missing data. We aimed to develop and internally validate a new and simple score that predicts 90‐day mortality in adults upon acute admission to the ICU: the Simplified Mortality Score for the Intensive Care Unit (SMS‐ICU).

Simplified Mortality Score for the Intensive Care Unit (SMS-ICU): protocol for the development and validation of a bedside clinical prediction rule

Introduction Mortality prediction scores are widely used in intensive care units (ICUs) and in research, but their predictive value deteriorates as scores age. Existing mortality prediction scores are imprecise and complex, which increases the risk of missing data and decreases the applicability bedside in daily clinical practice. We propose the development and validation of a new, simple and updated clinical prediction rule: the Simplified Mortality Score for use in the Intensive Care Unit (SMS-ICU). Methods and analysis During the first phase of the study, we will develop and internally validate a clinical prediction rule that predicts 90-day mortality on ICU admission. The development sample will comprise 4247 adult critically ill patients acutely admitted to the ICU, enrolled in 5 contemporary high-quality ICU studies/trials. The score will be developed using binary logistic regression analysis with backward stepwise elimination of candidate variables, and subsequently be converted into a point-based clinical prediction rule. The general performance, discrimination and calibration of the score will be evaluated, and the score will be internally validated using bootstrapping. During the second phase of the study, the score will be externally validated in a fully independent sample consisting of 3350 patients included in the ongoing Stress Ulcer Prophylaxis in the Intensive Care Unit trial. We will compare the performance of the SMS-ICU to that of existing scores. Ethics and dissemination We will use data from patients enrolled in studies/trials already approved by the relevant ethical committees and this study requires no further permissions. The results will be reported in accordance with the Transparent Reporting of multivariate prediction models for Individual Prognosis Or Diagnosis (TRIPOD) statement, and submitted to a peer-reviewed journal.

Effects of red blood cell storage time on transfused patients in the ICU—protocol for a systematic review

Patients in the intensive care unit (ICU) are often anaemic due to blood loss, impaired red blood cell (RBC) production and increased RBC destruction. In some studies, more than half of the patients were treated with RBC transfusion. During storage, the RBC and the storage medium undergo changes, which lead to impaired transportation and delivery of oxygen and may also promote an inflammatory response. Divergent results on the clinical consequences of storage have been reported in both observational studies and randomised trials. Therefore, we aim to gather and review the present evidence to assess the effects of shorter vs. longer storage time of transfused RBCs for ICU patients.

Variability in targeted arterial oxygenation levels in patients with severe sepsis or septic shock

Supplemental oxygen therapy is used for intensive care (ICU) patients with severe sepsis, but with no general guidelines and few safety data. The aim of this observational study was to describe the variability in oxygen administration as well as the association between partial pressure of arterial oxygen (PaO2) and mortality.

Should red blood cell transfusion be individualized? No.

)Department of Intensive Care, Rigshospitalet, University ofCopenhagen, Copenhagen, Denmarke-mail: anders.perner@regionh.dkL. B. Holste-mail: lars.broksoe.holst@regionh.dkJ. L. CarsonDivision of General Internal Medicine, Department of Medicine,Rutgers Robert Wood Johnson Medical School, New Brunswick,NJ, USAe-mail: jeffrey.carson@rutgers.edu

Testing current practice is no mistake

Dear Editor, In their recent paper entitled ‘Ten big mistakes in intensive care medicine’ [1], Vincent and colleagues wrote ‘We jump to prospective randomized clinical trials, before fully identifying the right patient population, and then struggle to interpret the results’ and cited this as one of the big mistakes, giving the TRISS trial as an example [2]. We obviously disagree. The authors appear to have misunderstood the reasoning for our trial. The TRISS trial was done to test current practice for blood transfusion in patients with septic shock in Scandinavian ICUs [3]. In cohort studies, we have described current blood transfusion practice in septic shock as being frequent and driven mainly by haemoglobin levels independent of disease and shock severity and independent of time from shock debut [4–6]. Therefore, we included a broad group of patients with septic shock in the TRISS trial. Haemoglobin of 7 and 9 g/dl were frequent pre-transfusion levels [5] and therefore chosen as triggers for blood transfusion in the TRISS trial. In this context, the results of the TRISS trial are easily interpreted [2]. Using a transfusion trigger of 7 g/dl instead of 9 g/dl in a broad population of ICU patients with septic shock throughout their ICU stay seems to be safe and to reduce the rate of transfusion and the number of units transfused. As blood is an expensive and limited resource, we find this very useful for clinicians, guideline committee members and policymakers.