THE TRISS TRIAL Holst, L et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. New England Journal of Medicine October 9, (15):1381

CURRENT GUIDELINES ON TRANSFUSION IN SEPSIS Maintain a haematocrit of > 30% in the presence of hypoperfusion in the first 6 hours Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic coronary artery disease, we recommend that red blood cell transfusion occur when the hemoglobin concentration decreases to < 7.0 g/dL to target a hemoglobin concentration of 7.0 to 9.0 g/dL in adults Surviving Sepsis Campaign

PATIENTS 32 ICUs in europe Between 2011 and 2013 Patients with septic shock, 18 years and older With an Hb of 90g/L or less measured by a POC test Excluded for Life threatening bleeding, acute coronary syndrome, had already received blood in ICU

INTERVENTION Randomised to a transfusion threshold ≤ 70g/L or ≤ 90g/L Transfused a single unit of cross matched RBCs Haemoglobin concentrations were reassessed after 3 hours of the completed transfusion This intervention period was the entire ICU stay up to a maximum of 90 days after randomization

C Primary outcome- Death at 90 days post randomisation

O A significant difference in mortality was not found 43% in the lower threshold group 45% in the higher threshold group Mortality 0.94 RR 95% confidence interval, 0.78 to 1.09;

REFERNECES Holst et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. October (15):1381 Surviving Sepsis Campaign Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C. et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013; 368: 11–21