Cancer patients in septic shock: keep the 7 g/dL transfusion threshold

Design

Multicentre randomised superiority trial, stopped early for safety

Population

187 adults with cancer, septic shock and haemoglobin below 9 g/dL

Primary outcome

Lactate reduction at 12 hours

Effect

52% vs 50%; OR 1.07 (95% CI 0.60–1.90); thrombosis 13% vs 1%

TRANSPORT was a multicentre randomised trial at 18 French ICUs. It enrolled adults with solid or haematological cancer, septic shock, lactate above 2 mmol/L and haemoglobin below 9 g/dL, and randomised them to transfusion at a threshold of 9 g/dL or 7 g/dL for the first 48 hours. It was designed for 260 patients but stopped at 187 for safety concerns.

Lactate fell adequately at 12 hours in 52% on the liberal strategy and 50% on the restrictive one (OR 1.07, 95% CI 0.60–1.90). Arterial or venous thrombotic events occurred in 13% with liberal transfusion and 1% with restrictive. Mortality at 28 days was 46% and 53%, not a significant difference.

Cancer patients are often transfused more generously in shock because of anaemia and concern about oxygen delivery. This trial gives no support for that. It was small and stopped early, so neither the thrombosis signal nor the mortality numbers are precise, but the restrictive threshold used in general septic shock remains the sensible default.

• Use a haemoglobin threshold of 7 g/dL for transfusion in cancer patients with septic shock.
• Do not transfuse to 9 g/dL to improve lactate; it did not help.
• Watch for venous and arterial thrombosis, especially after multiple transfusions.
• Individualise for active bleeding or myocardial ischaemia, which were not the focus of this trial.

Why it matters

Cancer does not justify a more liberal transfusion target in septic shock.

Don't overread it

The trial stopped early with 187 patients, so it is underpowered for mortality.

The statistics, in plain English

An odds ratio of 1.07 with an interval from 0.60 to 1.90 means no difference in lactate clearance. The 28-day mortality difference was not statistically significant. Trials stopped early can exaggerate harms or benefits, so the 13% vs 1% thrombosis figure should be read as a warning rather than a precise estimate.

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