The Pulmonary Center and.
Department of Global Health, Boston University School of Public Health, Boston, Massachusetts.
Ann Am Thorac Soc. 2022 Jul;19(7):1177-1184. doi: 10.1513/AnnalsATS.202109-1078OC.
In critically ill patients, a hemoglobin transfusion threshold of <7.0 g/dl compared with <10.0 g/dl improves organ dysfunction. However, it is unclear if transfusion at a hemoglobin of <7.0 g/dl is superior to no transfusion. To compare degrees of organ dysfunction between transfusion and no transfusion at a hemoglobin threshold of <7.0 g/dl among critically ill patients using quasiexperimental regression discontinuity methods. We performed regression discontinuity analysis using hemoglobin measurements from patients admitted to intensive care units in three cohorts (Medical Information Mart for Intensive Care IV, eICU, and Premier Inc.), estimating the change in organ dysfunction (modified sequential organ failure assessment score) in the 24- to 72-hour window following each hemoglobin measurement. We compared hemoglobin concentrations just above and below 7.0 g/dl using a "fuzzy" discontinuity approach, based on the concept that measurement noise pseudorandomizes similar hemoglobin concentrations on either side of the transfusion threshold. A total of 11,181, 13,664, and 167,142 patients were included in the Medical Information Mart for Intensive Care IV (MIMIC-IV), eICU, and Premier Inc. cohorts, respectively. Patient characteristics below the threshold did not differ from those above the threshold, except that crossing below the threshold resulted in a >20% absolute increase in transfusion rates in all three cohorts. Transfusion was associated with increases in hemoglobin concentration in the subsequent 24-72 hours (MIMIC-IV, 2.4 [95% confidence interval (CI), 1.1 to 3.6] g/dl; eICU, 0.7 [95% CI, 0.3 to 1.2] g/dl; Premier Inc., 1.9 [95% CI, 1.5 to 2.2] g/dl) but not with improvement in organ dysfunction (MIMIC-IV, 4.6 [95% CI, -1.2 to 10] points; eICU, 4.4 [95% CI, 0.9 to 7.8] points; Premier Inc., 1.1 [95% CI, -0.2 to 2.3] points) compared with no transfusion. Transfusion was not associated with improved organ dysfunction compared with no transfusion at a hemoglobin threshold of 7.0 g/dl, suggesting that evaluation of transfusion targets other than a hemoglobin threshold of 7.0 g/dl may be warranted.
在危重病患者中，与血红蛋白 <10.0 g/dl 相比，将输血阈值降至 <7.0 g/dl 可改善器官功能障碍。然而，目前尚不清楚将血红蛋白降至 <7.0 g/dl 时输血是否优于不输血。 本研究采用拟似实验回归不连续性方法，比较将血红蛋白阈值设定为 <7.0 g/dl 时输血与不输血两组患者的器官功能障碍程度。 我们使用三个队列（重症监护医学信息集市第四版（Medical Information Mart for Intensive Care IV，MIMIC-IV）、eICU 和 Premier Inc.）中患者的血红蛋白测量值进行回归不连续性分析，估计在每次血红蛋白测量后的 24-72 小时窗口内器官功能障碍（改良序贯器官衰竭评估评分）的变化。我们使用“模糊”不连续性方法比较了血红蛋白浓度略高于和略低于 7.0 g/dl 的情况，该方法基于测量噪声会使输血阈值两侧相似的血红蛋白浓度随机化的概念。 MIMIC-IV、eICU 和 Premier Inc. 队列分别纳入了 11181、13664 和 167142 例患者。阈值以下的患者特征与阈值以上的患者特征无差异，但在所有三个队列中，阈值以下的患者的输血率绝对增加了>20%。输血后血红蛋白浓度在随后的 24-72 小时内增加（MIMIC-IV，2.4[95%置信区间（CI），1.1-3.6]g/dl；eICU，0.7[95%CI，0.3-1.2]g/dl；Premier Inc.，1.9[95%CI，1.5-2.2]g/dl），但器官功能障碍无改善（MIMIC-IV，4.6[95%CI，-1.2-10]分；eICU，4.4[95%CI，0.9-7.8]分；Premier Inc.，1.1[95%CI，-0.2-2.3]分）与不输血相比。 与不输血相比，将血红蛋白阈值设定为 7.0 g/dl 时输血并未改善器官功能障碍，这表明可能需要评估除血红蛋白阈值 7.0 g/dl 以外的输血目标。
