Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury.
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.
McIntyre
Lauralyn A
LA
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
Fergusson
Dean A
DA
Hutchison
James S
JS
Pagliarello
Giuseppe
G
Marshall
John C
JC
Yetisir
Elizabeth
E
Hare
Gregory M T
GM
Hébert
Paul C
PC
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
D006454:Hemoglobins