Red blood cell transfusion in the resuscitation of septic patients with hematological malignancies

Mirouse et al. Ann. Intensive Care Red blood cell transfusion in the resuscitation of septic patients with hematological malignancies Adrien Mirouse Matthieu Resche‑Rigon Virginie Lemiale Djamel Mokart Achille Kouatchet Julien Mayaux François Vincent Martine Nyunga Fabrice Bruneel Antoine Rabbat Christine Lebert Pierre Perez Anne Renault Anne‑Pascale Meert Dominique Benoit Rebecca Hamidfar Mercé Jourdain Michaël Darmon Elie Azoulay Frédéric Pène on behalf of the Groupe de Recherche sur la Réanimation Respiratoire en Onco‑ Hématologie (Grrr‑ OH) Background: Indications for red blood cell (RBC) transfusion in septic acute circulatory failure remain unclear. We addressed the practices and the prognostic impact of RBC transfusion in the early resuscitation of severe sepsis and septic shock in patients with hematological malignancies. Methods: We performed a retrospective analysis of a prospectively collected database of patients with hematological malignancies who required intensive care unit (ICU) admission in 2010-2011. Patients with a main admission diagnosis of severe sepsis or septic shock were included in the present study. We assessed RBC transfusion during the first two days as part of initial resuscitation. Results: Among the 1011 patients of the primary cohort, 631 (62.4%) were admitted to the ICU for severe sepsis (55%) or septic shock (45%). Among them, 210 (33.3%) patients received a median of 2 [interquartile 1-3] packed red cells during the first 48 h. Hemoglobin levels were lower in transfused patients at days 1 and 2 and became similar to those of non‑ transfused patients at day 3. Early RBC transfusion was more likely in patients with myeloid neoplasms and neutropenia. Transfused patients displayed more severe presentations as assessed by higher admission SOFA scores and blood lactate levels and the further requirements for organ failure supports. RBC transfusion within the first two days was associated with higher day 7 (20.5 vs. 13.3%, p = 0.02), in‑ ICU (39 vs. 25.2%, p < 0.001) and in‑ hospital (51 vs. 36.6%, p < 0.001) mortality rates. RBC transfusion remained independently associated with increased in‑ hospital mortality in multivariate logistic regression (OR 1.52 [1.03-2.26], p = 0.03) and propensity score‑ adjusted (OR 1.64 [1.05-2.57], p = 0.03) analysis. Conclusions: RBC transfusion is commonly used in the early resuscitation of septic patients with hematological malignancies. Although it was preferentially provided to the most severe patients, we found it possibly associated with an increased risk of death. Hematological malignancy; Severe sepsis; Septic shock; Anemia; Red blood cell transfusion - Background Septic shock is a frequent and dreaded complication in patients with malignancies. Following the overall improvement in the management of the disease, the last two decades have witnessed dramatic improvements in the prognosis of cancer patients presenting with severe sepsis and septic shock [1–4]. A major advance in the general management of sepsis was the implementation of aggressive resuscitation strategies, primarily inspired from the pivotal study by Rivers and colleagues, which promoted a protocol-guided hemodynamic resuscitation based on circulatory and tissue oxygenation objectives, the so-called early goal-directed therapy (EGDT) [5]. The genuine EGDT algorithm included a hematocrit target of 30% in case of persistent tissue hypoxia. Two-thirds of EGDT-treated patients therefore received red blood cell (RBC) transfusion within the early 72 h of resuscitation. However, the own prognostic value of RBC transfusion was not specifically assessed. Moreover, the study was performed in the late 1990s at the time when liberal fluid filling accounted for a high incidence of dilution anemia. All three recent replication studies of early goal-directed therapy retrieved lower requirements in RBC transfusion along with a more restrictive fluid filling policy [6–8]. Indications of RBC transfusion in the resuscitation of severe sepsis remain unclear [9], and it is noteworthy that the 2012 Surviving Sepsis Campaign guidelines were not able to provide any firm recommendation about the optimal transfusion threshold during hemodynamic instability [10]. Owing to the remaining controversy about optimal hemoglobin thresholds for transfusion in sepsis resuscitation, additional data are needed to optimize practices at the bedside. Cancer patients with septic shock are at high risk of untractable multiple organ failure within the first days of ICU admission [11]. Early and aggressive resuscitation through restoration of both hemodynamics and tissue oxygenation is a major therapeutic goal in this setting. The optimal threshold for RBC transfusion and the eventual benefit in septic acute circulatory failure are debated. This issue appears particularly relevant to patients with hematological malignancies since the high prevalence of anemia imposed by malignant bone marrow infiltration or (...truncated)