The edition · Emergency & Critical Care
Cancer and septic shock: transfusing to 9 g/dL brought clots, not better lactate
TRANSPORT was stopped early with more thrombosis in the liberal arm; a Bayesian re-look at AID-ICU suggests haloperidol helps in both hypoactive and hyperactive delirium.
The edition in brief
TRANSPORT randomised 187 patients with cancer, septic shock, raised lactate and haemoglobin below 9 g/dL across 18 French ICUs to transfusion thresholds of 9 or 7 g/dL for the first 48 hours. Lactate clearance at 12 hours was the same (52% vs 50%), thrombotic events were far more frequent with the liberal strategy (13% vs 1%), and 28-day mortality did not differ significantly (46% vs 53%). The trial stopped early for safety, and there is no reason to abandon the restrictive threshold in cancer patients. A post hoc Bayesian analysis of the AID-ICU trial in 987 ICU patients with delirium found haloperidol associated with more days alive out of hospital and lower mortality in both hypoactive and hyperactive subtypes, with a moderate probability of a larger effect in hyperactive delirium and no excess of serious adverse reactions. A target trial emulation in 3810 septic shock patients linked adding vasopressin within 3 hours of norepinephrine reaching 0.25 µg/kg/min with lower 28-day mortality than waiting 3–6 hours (48.1% vs 53.0%). The FDA lists a Class II recall of Baxter's premixed vasopressin infusion bags for manufacturing-practice deviations. The pearl is about finding hypoactive delirium, the subtype most often missed.
Haloperidol in ICU delirium: probable benefit in both hypoactive and hyperactive subtypes
Consider haloperidol for ICU delirium whether it presents as agitation or as withdrawal, after addressing reversible causes.
Adding vasopressin within 3 hours of norepinephrine escalation linked to lower mortality
When norepinephrine reaches about 0.25 µg/kg/min in septic shock, consider adding vasopressin within hours rather than later.
FDA lists Class II recall of Baxter's premixed vasopressin infusion
Check premixed vasopressin stock against the recall and standardise any substitute preparation.
Hypoactive delirium is the one you miss
Screen for delirium with a validated tool, and remember that a quiet patient can be delirious.
Liberal transfusion in cancer patients with septic shock: no gain in lactate, more thrombosis
Use a restrictive transfusion threshold of about 7 g/dL in septic shock, whether or not the patient has cancer.
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