Liberal transfusion in cancer patients with septic shock: no gain in lactate, more thrombosis

Design

Multicentre, randomised superiority trial, stopped early for safety

Population

187 adults with cancer, septic shock, lactate >2 mmol/L and Hb <9 g/dL

Primary outcome

Lactate reduction at 12 hours

Effect

52% vs 50%, OR 1.07 (0.60–1.90); thrombosis 13% vs 1%

TRANSPORT was a multicentre randomised trial in 18 French ICUs enrolling adults with haematological or solid cancers, septic shock with lactate above 2 mmol/L, and haemoglobin below 9 g/dL. Patients were transfused to a threshold of 9 g/dL (liberal) or 7 g/dL (restrictive) for the first 48 hours of resuscitation.

The trial was planned for 260 patients but stopped at 187 for safety concerns. Lactate reduction at 12 hours was achieved in 52% (liberal) and 50% (restrictive) (OR 1.07, 95% CI 0.60–1.90). Arterial or venous thrombotic events occurred in 13% with liberal transfusion against 1% with restrictive (p = 0.001). Mortality at 28 days was 46% and 53% (p = 0.34).

Patients with cancer are often thought to need a higher haemoglobin, especially when anaemic from chemotherapy. This trial found no evidence of better resuscitation with liberal transfusion and a clear excess of clots. The authors stop short of declaring the restrictive strategy superior, since the mortality difference was not significant and the trial was truncated, but there is no basis here to depart from a 7 g/dL threshold in these patients. In Indian ICUs, where blood is scarce, that matters doubly.

• Keep a restrictive haemoglobin threshold of about 7 g/dL in septic shock, including in patients with cancer.
• Do not transfuse to correct lactate alone; liberal transfusion did not clear lactate faster.
• Watch for venous and arterial thrombosis in transfused cancer patients.
• Individualise for active bleeding or myocardial ischaemia, which were not the focus of this trial.

Why it matters

It removes the assumption that cancer patients in shock need a higher haemoglobin target.

Don't overread it

The trial stopped early; the 28-day mortality difference was not significant in either direction.

The statistics, in plain English

An odds ratio of 1.07 with a confidence interval from 0.60 to 1.90 means the two strategies cleared lactate about equally. The thrombosis difference (13% vs 1%) is large and statistically clear, although trials stopped early can overstate harms.

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