Liberal Transfusion Group Research Articles

Restrictive Transfusion in Geriatric Trauma Patients

To determine whether a restrictive strategy of red cell transfusion was safe in elderly trauma patients, we compared those treated with a restrictive transfusion strategy versus those who were liberally transfused. We performed a retrospective study of elderly (age ≥ 70 years) trauma patients admitted to our Level I trauma center from 2005 to 2013. Patients with a hemoglobin (Hg) < 10 g/dL after 48 hours were included. We excluded patients with an Injury Severity Score > 25 or active cardiac ischemia. Patients who were transfused for an Hg < 10 g/dL (liberal group) were compared to those who were transfused for an Hg< 7 g/dL (restrictive group). There were 382 patients included, 229 and 153 in the liberal and restrictive transfusion groups, respectively. All patients in the liberal group and 20 per cent of patients in the restrictive group received a transfusion (P < 0.0001). Patients in the liberal group had more overall complications (52 vs 32%, P = 0.0001). On multivariate analysis, receiving a transfusion was an independent risk factor to develop a complication [odds ratio = 2.3 (1.5-3.6), P < 0.0001]. For survivors, patients in the liberal group spent more days in the hospital (nine versus seven days, P = 0.007) and intensive care unit (two versus one day, P = 0.01). There was no difference in mortality (3 vs 4%, P = 0.82). In conclusion, restrictive transfusion appears to be safe in elderly trauma patients and may be associated with decreased complications and shortened length of stay.

Red Cell Transfusion Triggers and Postoperative Outcomes After Major Surgery

BackgroundThe effect of packed red blood cell (PRBC) transfusion on postoperative outcomes of patients undergoing major surgery remains unclear. We sought to determine the impact of blood utilization, as well as transfusion practices, on perioperative outcomes of patients undergoing cardiothoracic-vascular (CT-V) and gastrointestinal (GI) procedures. MethodsPatients who underwent major surgical procedures at Johns Hopkins Hospital between 2009 and 2014 were identified. Data on perioperative hemoglobin (Hb) and blood utilization were obtained; transfusion strategy was categorized as liberal (Hb trigger ≥7 g/dL) vs. restrictive (Hb trigger <7 g/dL). Risk-adjusted logistic regression models and propensity score matching were used to assess the association between transfusion triggers and perioperative morbidity. ResultsAmong 10,163 patients undergoing either CT-V (50.9 %) or GI (49.1 %) surgery, 4401 (43.3 %) patients received PRBCs. Of the 4401 patients transfused, 71.2 % were transfused using a liberal trigger (≥7 g/dL hemoglobin), while 28.8 % had a restrictive trigger (<7 g/dL). The median number of PRBCs transfused was 3 (restrictive 5 vs. liberal 2 units). While ischemic adverse events were more common among patients undergoing CT-V surgery (17.3 %), infection was the more common complication among patients undergoing GI surgery (11.9 %). American Society of Anesthesiologist (ASA) class 3–4, Charlson score ≥3, and total units of transfused PRBCs were independently associated with overall complications (all P < 0.05). Patients in the restrictive transfusion group did not have increased risk of complications compared with the liberal transfusion group on multivariable analysis (odds ratio (OR) 1.16, 95 % confidence interval (CI) 0.98–1.38; P = 0.08) or after propensity score matching (OR 1.04, 95 % CI 0.88–1.22; P = 0.65). ConclusionsLiberal transfusion triggers after major surgery were more common than restrictive practice. Patients with restrictive transfusion trigger did not have increased risk for complications compared with patients transfused with a liberal trigger.

A liberal strategy of red blood cell transfusion reduces cardiogenic shock in elderly patients undergoing cardiac surgery

ObjectiveThe aim of this study was to compare outcomes in patients undergoing cardiac surgery who are aged 60 years or more or less than 60 years after implementation of a restrictive or a liberal transfusion strategy. MethodsThis is a substudy of the Transfusion Requirements After Cardiac Surgery (TRACS) randomized controlled trial. In this subgroup analysis, we separated patients into those aged 60 years or more (elderly) and those aged less than 60 years randomized to a restrictive or a liberal strategy of red blood cell transfusion. The primary outcome was a composite defined as a combination of 30-day all-cause mortality and severe morbidity. ResultsOf the 502 patients included in the Transfusion Requirements After Cardiac Surgery study, 260 (51.8%) were aged 60 years or more and 242 (48.2%) were aged less than 60 years and were included in this study. The primary end point occurred in 11.9% of patients in the liberal strategy group and 16.8% of patients in the restrictive strategy group (P = .254) for those aged 60 years or more and in 6.8% of patients in the liberal strategy group and 5.6% of patients in the restrictive strategy group for those aged less than 60 years (P = .714). However, in the older patients, cardiogenic shock was more frequent in patients in the restrictive transfusion group (12.8% vs 5.2%, P = .031). Thirty-day mortality, acute respiratory distress syndrome, and acute renal injury were similar in the restrictive and liberal transfusion groups in both age groups. ConclusionsAlthough there was no difference between groups regarding the primary outcome, a restrictive transfusion strategy may result in an increased rate of cardiogenic shock in elderly patients undergoing cardiac surgery compared with a more liberal strategy. Cardiovascular risk of anemia may be more harmful than the risk of blood transfusion in older patients.

A Randomized Clinical Trial of Liberal Versus Restrictive Transfusion Strategy Evaluating Long Term Survival and Cause of Death: Results from the FOCUS Trial

▪IntroductionThere are a large number of randomized clinical trials comparing short-term mortality between liberal and restrictive transfusion strategies. However, transfusion is thought to have long-term consequences related to alteration of immune function. These effects have been hypothesized to increase the risk of subsequent infections and recurrence of cancer. Thus, it is possible that transfusion will increase the risk of long-term mortality by increasing the deaths due to infections and recurrent cancer. Alternatively, more liberal transfusion might reduce cardiac complications by increasing oxygen to vulnerable myocardium and reduce deaths from cardiovascular disease. We hypothesized that liberal transfusion would affect cause specific mortality and might affect all-cause mortality, depending on the predominant impact of transfusion.MethodsWe performed a secondary analysis of the FOCUS trial that randomly allocated patients undergoing hip fracture repair with postoperative hemoglobin concentrations below 10 g/dL within 3 days of surgery. Patients were eligible for the trial if they had underlying cardiovascular disease (coronary artery disease, congestive heart failure, stroke, peripheral vascular disease) or cardiovascular risk factors (diabetes mellitus, hypertension, hyperlipidemia, tobacco use, or renal insufficiency). We randomly allocated patients to liberal transfusion where patients received blood transfusion to maintain hemoglobin 10 g/dL or greater, or restrictive transfusion where patients received blood transfusion when hemoglobin level was less than 8 g/dL or for symptoms. Long-term mortality was determined by linking the study subjects to national death registries in US and Canada. We compared survival time between the two transfusion treatment strategies using the unadjusted log-rank test and Cox proportional hazard models. The underlying cause of death was identified by the national death registries and grouped into seven categories: cardiovascular disease, cancer, infection, stroke, dementia, pulmonary, and other.ResultsThere were 1007 subjects randomly allocated to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The baseline clinical status was similar between the two groups; mean age of the study population was 81.6 years (range, 51 to 103). The liberal transfusion group were transfused a total of 1866 units and restrictive transfusion group 652 units. We established long-term survival for 2002 (99.3%) of the study population. The median follow-up was 3.1 years (interquartile range, 2.4 to 4.1 years) and there were 841 (42.0%) deaths. There was no difference in the long-term mortality between the liberal transfusion strategy (N=432 deaths) and restrictive transfusion strategy (N= 409 deaths); hazard ratio =1.09; 95% confidence interval 0.95 to 1.25 (Figure). The results were consistent across all subgroups including demographics and multiple co-morbidities. There was also no difference in the underlying cause of death between the transfusion strategies (p=0.99) (Table); Cardiovascular disease (liberal-32.6%, restrictive-33.5%), Cancer (liberal-12.5%, restrictive-12.0%), Infection (liberal-9.5%, restrictive 9.0%).ConclusionsLiberal transfusion of 10 g/dL did not reduce or increase long-term mortality compared to restrictive transfusion strategy using an 8 g/dL threshold or symptoms in a high risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death were similar in both arms of the trial and liberal transfusion did not appear to increase risk of death from infection or cancer or reduce the risk of death from cardiovascular disease. These results do not support the hypotheses that transfusion leads to long-term immunosuppression that is severe enough to influence mortality or cause of death. Our findings suggest that clinicians should primarily consider short-term effects of transfusion when deciding whom to transfuse.TableTotal N (%)LiberalN (%)Restrictive N (%)Cardiovascular Disease278 (33.1)141 (32.6)137 (33.5)Cancer103 (12.2)54 (12.5)49 (12.0)Infection78 (9.3)41 (9.5)37 (9.0)Stroke57 (6.8)27 (6.3)30 (7.3)Dementia108 (12.8)56 (13.0)52 (12.7)Pulmonary58 (6.9)29 (6.7)29 (7.1)Other147 (17.5)79 (18.3)68 (16.6)Unknown12 (1.4)5 (1.2)7 (1.7)Totals841432 409 [Display omitted] DisclosuresMagaziner:Ammonett : Consultancy; Sanofi: Consultancy; Regeneron: Consultancy; Novartis: Consultancy; Eli Lilly: Consultancy; American Orthopedic Association: Consultancy.

To transfuse or not to transfuse in upper gastrointestinal hemorrhage? That is the question

To transfuse or not to transfuse in upper gastrointestinal hemorrhage? That is the question

Transfusion practices in a neonatal intensive care unit in a city in Brazil

ObjectiveNewborn infants are the most heavily transfused population inside intensive care units. The hemoglobin level used to indicate the need of transfusions is not well established. The aim of this study was to evaluate transfusional practices in newborns in the neonatal intensive care units of one specific city.MethodsRed blood cell transfusion practices of all transfused newborns in all five of the neonatal intensive care units of the city were analyzed. Data are reported as descriptive statistics, including numbers and percentages and means and standard deviation. Univariate analysis, followed by stepwise logistic regression was performed in respect to transfusional data and outcomes.ResultsA total of 949 patients were admitted to the intensive care units during the 12-month study period with 20.9% receiving at least one transfusion, most (62.4%) of whom received more than one transfusion. The mean number of transfusions per infant was 2.7 ± 2.16; in the liberal transfusion group the mean number was 1.59 ± 1.63 and in the restrictive group it was 1.08 ± 1.51. The mean hemoglobin and hematocrit levels were 9.0 g/dL (±1.4 g/dL) and 27.4% (±4.3%), respectively. The most common indications for blood transfusions were sepsis and prematurity.ConclusionThis study shows that the characteristics and the transfusion practices for newborns admitted in the neonatal intensive care units of Juiz de Fora are similar to recent pubications. There was no significant reduction in the number of transfusions per child in the restrictive group compared to the liberal group. Restrictive transfusions are an independent risk factor for peri-intraventricular hemorrhages and death.

Blood Transfusion and Risk of Infection

In this issue of JAMA, Rohde and colleagues report results of a meta-analysis evaluating the association between a liberal transfusion strategy vs a restrictive strategy and risk of hospital-acquired infections.1 In the meta-analysis, which included 17 randomized trials that compared these strategies among 7456 patients, the absolute rates of serious hospital-associated infection were 12.7% in the liberal transfusion group and 10.6% in the restrictive transfusion group. The number needed to treat with a restrictive transfusion strategy to prevent serious infection was about 48 patients. Results were consistent when analyses were repeated in trials with concealed randomization and infrequent protocol violations but not for overall infections. A prior meta-analysis of liberal vs restrictive transfusion strategies and infection outcomes reported a nonstatistically significant reduction in infections.2 The current meta-analyses by Rohde et al includes several newly published trials, although these significant differences in serious infection rates may not hold up when the results of other large transfusion trials are reported. Most trials define a restrictive transfusion strategy as the administration of red blood cells (RBCs) once hemoglobin falls below either 7 or 8 g/dL, and most trials define a liberal strategy as the administration of RBCs once hemoglobin level falls below 10 g/dL.

Comparison of restrictive and liberal transfusion strategy on postoperative delirium in aged patients following total hip replacement: A preliminary study

Few studies have examined the association between perioperative blood transfusion and postoperative delirium (POD) in aged patients undergoing total hip replacement surgery. In this prospective study, 186 patients older than 65 years undergoing elective unilateral total hip replacement surgery were enrolled. Of those, 94 patients were randomly assigned to the restrictive strategy transfusion strategy group, in which red blood cells were transfused in order to maintain 10.0g/dL>hemoglobin≧8.0g/dL. Ninety-two patients were randomly assigned to the liberal transfusion strategy group, in which red blood cells were transfused in order to maintain hemoglobin≧10.0g/dL. POD was diagnosed by confusion assessment method. The baseline characteristics of patients, the length of hospital stay, the incidence of POD, myocardial infarction, stroke, wound infection, pulmonary embolism, and the transfusion volume were recorded. No difference was observed in the baseline characteristics, the length of hospital stay, and the incidence of POD, myocardial infarction, stroke, wound infection, and pulmonary embolism between the two groups (P>0.05). The proportion of patients transfused with red blood cell and frozen plasma was decreased in the restrictive transfusion group compared with the liberal transfusion group (P<0.05). In conclusion, restrictive transfusion does not influence the incidence of POD but reduces blood transfusion. Thus, restrictive transfusion may serve as an effective and safe strategy for aged patients following total hip replacement.

The Impact of Two Different Transfusion Strategies on Patient Immune Response during Major Abdominal Surgery: A Preliminary Report

Blood transfusion is associated with well-known risks. We investigated the difference between a restrictive versus a liberal transfusion strategy on the immune response, as expressed by the production of inflammatory mediators, in patients subjected to major abdominal surgery procedures. Fifty-eight patients undergoing major abdominal surgery were randomized preoperatively to either a restrictive transfusion protocol or a liberal transfusion protocol (with transfusion if hemoglobin dropped below 7.7 g dL−1 or 9.9 g dL−1, respectively). In a subgroup of 20 patients randomly selected from the original allocation groups, blood was sampled for measurement of IL-6, IL-10, and TNFα. Postoperative levels of IL-10 were higher in the liberal transfusion group on the first postoperative day (49.82 ± 29.07 vs. 15.83 ± 13.22 pg mL−1, P < 0.05). Peak postoperative IL-10 levels correlated with the units of blood transfused as well as the mean duration of storage and the storage time of the oldest unit transfused (r 2 = 0.38, P = 0.032, r 2 = 0.52, P = 0.007, and r 2 = 0.68, P<0.001, respectively). IL-10 levels were elevated in patients with a more liberal red blood cell transfusion strategy. The strength of the association between anti-inflammatory IL-10 and transfusion variables indicates that IL-10 may be an important factor in transfusion-associated immunomodulation. This trial is registered under ClinicalTrials.gov Identifier: NCT02020525.

Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial

To investigate the safety and effects of a restrictive red blood cell (RBC) transfusion strategy in pediatric cardiac surgery patients. Randomized controlled trial. Pediatric ICU in an academic tertiary care center, Leiden University Medical Center, Leiden, The Netherlands. One hundred seven patients with non-cyanotic congenital heart defects between 6 weeks and 6 years of age. One hundred three patients underwent corrective surgery on cardiopulmonary bypass. Prior to surgery patients were randomly assigned to one of two groups with specific RBC transfusion thresholds: Hb 10.8 g/dl (6.8 mmol/l) and Hb 8.0 g/dl (5.0 mmol/l). Length of stay in hospital (primary outcome), length of stay in PICU, duration of ventilation (secondary outcome), incidence of adverse events and complications related to randomization (intention to treat analysis). In the restrictive transfusion group, mean volume of transfused RBC was 186 (±70) ml per patient and in the liberal transfusion group 258 (±87) ml per patient, (95% CI 40.6-104.6), p < 0.001. Length of hospital stay was shorter in patients with a restrictive RBC transfusion strategy: median 8 (IQR 7-11) vs. 9 (IQR 7-14) days, p = 0.047. All other outcome measures and incidence of adverse effects were equal in both RBC transfusion groups. Cost of blood products for the liberal transfusion group was 438.35 (±203.39) vs. 316.27 (±189.96) euros (95% CI 46.61-197.51) per patient in the restrictive transfusion group, p = 0.002. For patients with a non-cyanotic congenital heart defect undergoing elective cardiac surgery, a restrictive RBC transfusion policy (threshold of Hb 8.0 g/dl) during the entire perioperative period is safe, leads to a shorter hospital stay and is less expensive.

Anesthesia Literature Review

J. Lance Lichtor, M.D., Editor In this randomized study, transfusion was set at less than 8 g hemoglobin (restrictive) or less than 10 g hemoglobin (liberal); an opportunity for transfusion based on symptoms of anemia was included. Death or inability to walk without human assistance 60 days after surgery was not different between the liberal and restrictive transfusion groups (see fig. 1). Other complications were similar between groups. If the findings of the study were followed more broadly, the risk of exposure to blood and the cost of transfusion could be greatly reduced.This study examined intraoperative blood transfusion and surgical morbidity and mortality. These data were retrospectively generated from one million patients who underwent noncardiac surgery. Transfusion with even one unit of packed erythrocytes was associated with significantly increased mortality, pulmonary complications, renal dysfunction, wound problems, sepsis, and longer hospitalizations (see fig. 2). These findings are similar to other studies suggesting adverse events in patients who underwent transfusion.In this study, 16 patients were determined to be in a vegetative state using clinical criteria. It was noted that for three patients, distinct commands could generate reproducible electroencephalography responses; yet, behaviorally the patients were not responsive. The authors propose that this test could be used to confirm that patients are in a vegetative state and identify those who may have residual cognitive function and awareness.In this study of 298 women (most of whom were white) with a mean age of 82 yr, sleep-disordered breathing was shown to be associated with an increased risk of cognitive impairment 5 yr later (see fig. 3). Furthermore, hypoxia was found to further associate with cognitive impairment, suggesting that prolonged exposure to intermittent hypoxia may contribute to cognitive decline. This study has implications for perioperative cognitive impairment.Jean Mantz, M.D., Ph.D., Editor This prospective cohort study challenges the common view that age is not a criterion per se to admit critically injured patients into the intensive care unit (ICU). Requests for admissions were evaluated for 11 ICUs over a 2-yr period. Surprisingly, a greater survival benefit was present in older patients but not in younger patients admitted to the ICU (see fig. 4). Although these findings cannot be extrapolated as a general rule, these data suggest that intensivists should revise their triage practices for elderly patients, particularly accepting those appearing “well.”This study highlights a sensitive, somewhat hidden, but very frequent situation occurring with caregivers working in intensive care units (ICUs); that is, determining appropriateness of care. The feeling of providing disproportionately excessive care was the most frequent report. Perceptions of inappropriate care were inversely associated with factors indicating good teamwork, which calls for urgent consideration of good teamwork in ICUs in these countries. Inappropriateness of care was associated with increased likelihood to leave a job.This study provides new insight into the outcome of patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). One hundred twenty-two patients requiring bronchoalveolar lavage were enrolled. Cell counts were compared between patients with ALI/ARDS who survived or did not survive (see fig. 5). A fibrocyte percentage more than 6% was independently associated with mortality. The use of this new biomarker could help stratify ALI/ARDS patients at high risk of poor outcome and to increase our understanding of the mechanisms of fibrocyte proliferation during injury and repair in ALI/ARDS.Timothy J. Brennan, Ph.D., M.D., Editor The mechanisms by which opioids produce itch, especially spinal opioids, are not well understood. These authors previously identified an itch-specific pathway in the dorsal horn of the spinal cord in mice. These itch-transmitting dorsal horn neurons express a gastrin-releasing peptide receptor. In this report, the authors demonstrate that a μ-opioid receptor (MOR) isoform, MOR1D, is required for spinal morphine induced scratching; yet, the MOR1D is not required for analgesia by spinal morphine. Surprisingly, the MOR1D receptor combines with the gastrin- releasing peptide receptor to signal itch by opioids. This study suggests a mechanism whereby itch can be reduced without affecting analgesia.Preoperative predictors of acute postoperative pain vary among different surgeries. In this study, younger age, presence of presurgical pain, presence of nonpelvic pain, pain catastrophizing, and presurgical anxiety together strongly predict moderate to severe postoperative pain (see fig. 6). Anxiety appeared to contribute to pain catastrophizing. The authors propose that for patients undergoing hysterectomy, brief preoperative psychologic interventions be used to reduce the effect of anxiety and catastrophizing, which are modifiable risk factors, on moderate to severe acute postoperative pain.

Targeting Perioperative Hemoglobin in Major Abdominal Surgery

Background: Perioperative transfusion optimization may result in blood saving and minimization of complications associated with blood transfusions. The study aimed to compare units transfused, cytokines and patient outcome in a restrictive versus a liberal transfusion strategy. Materials and methods: We conducted a randomized-controlled study, in a single center, from December 2004 to May 2007. Of the 75 patients scheduled for major abdominal surgery and assessed for eligibility, 58 were randomized and 52 completed the study. Preoperatively, patients were randomly assigned to the Hb 7.7 g dL-1 (restrictive) or to the Hb 9.9 g dL-1 (liberal) group to receive blood transfusion intraoperatively and postoperatively if hemoglobin was below 7.7 g dL-1 or Hb 9.9 g dL-1 respectively. The follow-up for hemoglobin and intervention lasted five days, for cytokine measurements three days and for complications till discharge from the hospital. Units of red blood cells (RBC) per patient and the incidence of transfused patients in each group were the main outcome measure. Results: Median RBC transfused (units/patient) was 0 [interquartile range 0,2] in the restrictive versus 1 [0,3] in the liberal group (p=0.013), and the percentage of patients transfused 36% versus 70% respectively (p=0.027). Postoperative IL-10 levels were higher in the liberal transfusion group 24 h postoperatively (p<0.05). Pooled peak postoperative IL-10 levels correlated with the overall number of units of blood transfused (r2 = 0.38, p = 0.032) as well as with the overall mean duration of storage of blood transfused (in days) (r2 = 0.52, p = 0.007). Complications or time to discharge from hospital did not differ between the groups. Conclusion: In major abdominal surgery, restrictive transfusion decreases RBC requirements and IL-10 levels. The association between IL-10 and transfusion variables indicates that IL-10 may play a role in transfusionassociated immunomodulation.

Neurocognitive profiles of preterm infants randomly assigned to lower or higher hematocrit thresholds for transfusion

Objective: Preterm infants are frequently transfused with red blood cells based on standardized guidelines or clinical concerns that anemia taxes infants' physiological compensatory mechanisms and thereby threatens their health and well-being. The impact of various transfusion guidelines on long-term neurocognitive outcome is not known. The purpose of this study is to evaluate long-term neurocognitive outcome on children born prematurely and treated at birth with different transfusion guidelines. Methods: Neurocognitive outcomes were examined at school age for 56 preterm infants randomly assigned to a liberal (n = 33) or restrictive (n = 23) transfusion strategy. Tests of intelligence, achievement, language, visual-spatial/motor, and memory skills were administered. Between-group differences were assessed. Results: Those in the liberal transfusion group performed more poorly than those in the restrictive group on measures of associative verbal fluency, visual memory, and reading. Conclusions: Findings highlight possible long-term neurodevelopmental consequences of maintaining higher hematocrit levels.

The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery

Perioperative anemia leads to increased morbidity and mortality and potentially inhibits rehabilitation after hip fracture surgery. As such, the optimum transfusion threshold after hip fracture surgery is unknown. A total of 120 elderly, cognitively intact hip fracture patients admitted from their own home were randomly assigned to receive transfusion at a hemoglobin threshold of 10.0 g per dL (liberal) versus 8.0 g per dL (restrictive) in the entire perioperative period. Patients were treated according to a well-defined multimodal rehabilitation program. Primary outcome was postoperative functional mobility measured with the cumulated ambulation score (CAS). Patients in the liberal group received transfusions more frequently than those in the restrictive group (44 patients vs. 22 patients; p < 0.01) and received more transfusions during hospitalization (median, 2 units [interquartile range, 1-2] vs. 1 [1-2]; p < 0.0001). There were no significant differences in postoperative rehabilitation scores (CAS: median, 9 [9-15] vs. 9 [9-13.5]; p = 0.46) or in length of stay (median, 18 days vs. 16 days, respectively; p = 0.46). There were fewer patients in the liberal transfusion group with cardiovascular complications (2% vs. 10%; p = 0.05) and a lower mortality (0% vs. 8%; p = 0.02). Although a liberal transfusion trigger did not result in increased ambulation scores, restrictive transfusion thresholds should be treated with caution in elderly high-risk hip fracture patients, until their safety has been proved in larger randomized studies.

Effect of a Liberal Versus Restrictive Transfusion Strategy on Mortality in Patients With Moderate to Severe Head Injury

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). 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). 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. 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.

Transfusion Requirements in Critical Care

To evaluate the effects of a restrictive and a liberal red blood cell (RBC) transfusion strategy on mortality and morbidity in critically ill patients.Multicenter, prospective, randomized clinical trial.Sixty-nine normovolemic critically ill patients admitted to one of five tertiary level intensive care units with hemoglobin values less than 90 g/L within 72 hours of admission.Patients were randomly allocated to one of two RBC transfusion strategies. Hemoglobin values were maintained between 100 and 120 g/L in the liberal transfusion group and between 70 and 90 g/L in the restrictive group.Primary diagnosis and mean +/- SD age (58.6 +/- 15 vs 59.0 +/- 21 years and Acute Physiology and Chronic Health Evaluation II score (20 +/- 6.2 vs 21 +/- 7.2) were similar in the restrictive and liberal groups, respectively. Daily hemoglobin values averaged 90 g/L in the restrictive group vs 109 g/L in the liberal group (P < .001). The restrictive group received 2.5 U per patient compared with 4.8 U per patient in the liberal group. This represents a 48% relative decrease (P < .001) in RBC units transfused per patient. The 30-day mortality rate was 24% in the restrictive group compared with 25% in the liberal group; the 95% confidence interval around the absolute difference was -19% to 21%. Similar observations were noted for intensive care unit mortality (P = .76) and 120-day mortality (P > .99). In addition, survival analysis comparing time until death in both groups did not reveal any significant difference (P = .93) between groups. Organ dysfunction scores were also similar (P = .44).In this small randomized trial, neither mortality nor the development of organ dysfunction was affected by the transfusion strategy, which suggests that a more restrictive approach to the transfusion of RBCs may be safe in critically ill patients. However, the study lacked power to detect small but clinically significant differences. Therefore, further investigations of RBC transfusion strategies are warranted.