Are the old really young at heart?

2450 www.ccmjournal. org October 2013 • Volume 41 • Number 10 Fourteen years after the publication of the landmark Transfusion Requirements in Critical Care (TRICC) trial (1), numerous studies have shown poor adherence to a restrictive transfusion strategy in critically ill patients (2–4). Furthermore, questions remain regarding the role and safety of such a restrictive strategy in various subpopulations of critically ill patients with asymptomatic anemia. Elderly persons constitute the largest group of patients in the ICU. Although the TRICC trial enrolled patients with coronary artery disease (CAD) and only excluded patients with unstable angina or evolving myocardial infarction and found a significantly increased risk of cardiac complications in the liberal transfusion arm, many physicians (both intensivists and nonintensivists) are loathe to withhold transfusion, particularly in elderly patients with presumed CAD. Comments, such as “he/she is old, give him/her 2 units,” remain ubiquitous when the hemoglobin is less than 9–10 g/dL despite any evidence of end-organ ischemia or well-designed studies suggesting benefit from transfusion. Indeed, the studies and guidelines published to date mostly suggest either no benefit or actual detriment from liberal transfusion, even in those with evolving coronary ischemia (5–9). The retrospective design of these studies most likely is the underlying reason why a transfusion hemoglobin trigger of 10 g/dL remains the standard in most centers for the treatment of anemic patients with known or suspected CAD. Despite the evidence showing that a restrictive transfusion strategy is safe in the elderly patients and those with CAD, the ongoing uncertainty and great variability in transfusion practice in these groups necessitates an adequately designed and implemented randomized control trial (RCT) to define the role of transfusion in critically ill elderly patients. In this issue of Critical Care Medicine, the RELIEVE investigators (10) have taken the first step in designing such a study by demonstrating that it is feasible. By design, patient-centered endpoints of clinical interest, such as mortality, infection, and length of stay, were secondary outcomes. Of note, clinician refusal to participate in REFERENCES 1. Hébert PC, Wells G, Blajchman MA, et al: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340:409–417; Erratum, N Engl J Med 1999; 340:1056 2. Lacroix J, Hébert PC, Hutchison JS, et al; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network: Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356:1609–1619 3. 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