The edition · Emergency & Critical Care
Septic shock with cancer: hold transfusion at 7 g/dL
A French trial of liberal against restrictive transfusion in cancer patients with septic shock was stopped early, with no lactate or survival benefit and far more clots in the liberal arm. Plus automated oxygen titration, earlier vasopressin, and haloperidol by delirium subtype.
The edition in brief
Transfusion in septic shock with cancer: TRANSPORT randomised 187 adults with cancer, septic shock, lactate above 2 mmol/L and haemoglobin below 9 g/dL to transfusion thresholds of 9 or 7 g/dL for 48 hours. It was stopped early for safety. Twelve-hour lactate clearance was 52% against 50% (OR 1.07, 0.60–1.90), 28-day mortality 46% against 53% (not significant), and thrombotic events 13% against 1%. Closed-loop oxygen: seven randomised trials and 635 hospitalised adults on non-invasive oxygen found automated titration kept saturation within target about 21% more of the time than manual adjustment, more with low-flow than high-flow oxygen. Vasopressin timing: a target trial emulation in 3,810 adults whose noradrenaline reached 0.25 µg/kg/min found starting vasopressin within 3 hours was associated with lower 28-day mortality (48.1% against 53.0%) and less renal replacement therapy than starting at 3–6 hours. Haloperidol: a post hoc Bayesian analysis of the AID-ICU trial found haloperidol associated with benefit in both hypoactive and hyperactive delirium, with a moderate probability of a larger effect in hyperactive delirium.
Automated oxygen titration kept saturation on target about a fifth more of the time
Prescribe a target saturation range for every patient on oxygen; automated titration holds it better where available.
Starting vasopressin within three hours of high-dose noradrenaline was associated with lower mortality
Consider adding vasopressin promptly when noradrenaline reaches moderate doses in septic shock.
Haloperidol in ICU delirium: probable benefit in both subtypes, possibly more in hyperactive
Do not withhold haloperidol in ICU delirium only because it is hypoactive, but treat causes and use non-drug measures first.
Look for retention and pain before sedating an agitated older patient
Check glucose, oxygen, bladder, pain and drugs before sedating an agitated older patient.
Liberal transfusion in cancer patients with septic shock: no gain, more clots, trial stopped
Keep a 7 g/dL transfusion threshold in septic shock for patients with cancer, as for other patients, unless bleeding or ischaemia argues otherwise.
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