title: Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury.
abstract: OBJECTIVE
  To compare a restrictive versus a liberal transfusion strategy in patients with moderate to severe closed head injury following multiple trauma in 13 Canadian intensive care units (ICUs).
  
  
  METHODS
  This is a subgroup analysis of a multicenter randomized controlled clinical trial involving sixty-seven critically ill patients from the Transfusion Requirements in the Critical Care trial who sustained a closed head injury. Patients had a hemoglobin concentration less than 9.0 g/dL within 72 hours of admission to the ICU. Patients were randomized to a restrictive allogeneic red blood cell transfusion strategy (hemoglobin 7.0 g/dL and maintained between 7.0 and 9.0 g/dL) or a liberal strategy (hemoglobin 10.0 g/dL and maintained between 10.0 and 12.0 g/dL).
  
  
  RESULTS
  Baseline characteristics in the restrictive ( n = 29) and the liberal ( n = 38) transfusion groups were comparable. Average hemoglobin concentrations and red blood cell units transfused per patient were significantly lower in the restrictive compared to the liberal group. The 30-day all-cause mortality rates in the restrictive group were 17% as compared to 13% in the liberal group (risk difference 4.1 with 95% confidence interval [CI], 13.4 to 21.5, p = 0.64). Presence of multiple organ dysfunction (12.1 +/- 6.4 versus 10.6 +/- 6.3, p = 0.35) and changes in multiple organ dysfunction from baseline scores adjusted for death (4.5 +/- 6.2 versus 3.4 +/- 6.2, p = 0.49) were similar between the restrictive and liberal transfusion groups, respectively. Median length of stay in ICU (10 days, interquartile range 5 to 21 days versus 8 days, interquartile range 5 to 11 days, p = 0.26) and hospital (27 days, interquartile range 14 to 39 days versus 30.5 days, interquartile range 17 to 47 days, p = 0.72) were similar between the restrictive and liberal transfusion groups.
  
  
  CONCLUSIONS
  We were unable to detect significant improvements in mortality with a liberal as compared to restrictive transfusion strategy in critically ill trauma victims with moderate to severe head injury.
authors.affiliation: Centre for Transfusion and Critical Care Research, Clinical Epidemiology Unit, Critical Care Program, University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario. lmcintyre@ottawahospital.on.ca
authors.forename: Lauralyn A
authors.initials: LA
authors.lastname: McIntyre
authors.forename: Dean A
authors.initials: DA
authors.lastname: Fergusson
authors.forename: James S
authors.initials: JS
authors.lastname: Hutchison
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Pagliarello
authors.forename: John C
authors.initials: JC
authors.lastname: Marshall
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Yetisir
authors.forename: Gregory M T
authors.initials: GM
authors.lastname: Hare
authors.forename: Paul C
authors.initials: PC
authors.lastname: Hébert
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000401:mortality / Q000473:pathology / Q000628:therapy; D016638:Critical Illness; D017707:Erythrocyte Transfusion / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D016489:Head Injuries, Closed / Q000401:mortality / Q000473:pathology / Q000628:therapy; D006454:Hemoglobins / Q000378:metabolism; D006760:Hospitalization; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D015995:Prevalence; D015996:Survival Rate; D013997:Time Factors
chemical_list: D006454:Hemoglobins