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Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury

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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.

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References

  1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors, 6th ed. Chicago, 1997.

  2. Chesnut RM. Secondary brain insults after head injury: clinical perspectives. New Horizons 1995;3(3):366–375.

    PubMed  CAS  Google Scholar 

  3. Jones PA, Andrews PJ, Midgley S, et al. Measuring the burden of secondary insults in head-injured patients during intensive care. J Neurosurg Anesthesiol 1994;6:4–14.

    PubMed  CAS  Google Scholar 

  4. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216–222.

    PubMed  CAS  Google Scholar 

  5. Chesnut RM, Gautille T, Blunt BA, Klauber MR, Marshall LF. Neurogenic hypotension in patients with severe head injuries. J Trauma 1998;44:958–963.

    PubMed  CAS  Google Scholar 

  6. Winchell RJ, Simons RK, Hoyt DB. Transient systolic hypotension. A serious problem in the management of head injury. Arch Surg 1996;131:533–539.

    PubMed  CAS  Google Scholar 

  7. Chesnut RM, Marshall SB, Piek J, Blunt BA, Klauber MR, Marshall LF. Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank. Acta Neurochir Suppl 1993;59:121–125.

    CAS  Google Scholar 

  8. Wald SL, Shackford SR, Fenwick J. The effect of secondary insults on mortality and long-term disability after severe head injury in a rural region without a trauma system. J Trauma 1993;34:377–381.

    Article  PubMed  CAS  Google Scholar 

  9. Pigula FA, Wald SL, Shackford SR, Vane DW. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg 1993;28:310–314.

    Article  PubMed  CAS  Google Scholar 

  10. Marmarou A, Anderson RL, Ward JD, et al. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 1991;75:S59-S66.

    Google Scholar 

  11. Miller JD, Butterworth JF, Gudeman SK, et al. Further experience in the management of severe head injury. J Neurosurg 1981;54: 289–299.

    PubMed  CAS  Google Scholar 

  12. Price DJ, Murray A. The influence of hypoxia and hypotension on recovery from head injury. Injury 1972;3:218–224.

    Article  PubMed  CAS  Google Scholar 

  13. Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in head injury. J Trauma 1996;40:764–767.

    PubMed  CAS  Google Scholar 

  14. Kokoska ER, Smith GS, Pittman T, Weber TR. Early hypotension worsens neurological outcome in pediatric patients with moderately severe head trauma. J Pediatr Surg 1998;33:333–338.

    Article  PubMed  CAS  Google Scholar 

  15. Fearnside MR, Cook RJ, McDougall P, McNeil RJ. The Westmead Head injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables. Br J Neurosurg 1993;7:267–279.

    PubMed  CAS  Google Scholar 

  16. Hare GMT, Mazer CD, Rassouli AP, et al. Hemodilutional aneumia accentuates cerebral hypoxia following traumatic brain injury. J Neurotrauma 2003;20:1134.

    Google Scholar 

  17. Gibson JB, Maxwell RA, Schweitzer JB, Fabian TC, Proctor KG. Resuscitation from severe hemorrhagic shock after traumatic brain injury using saline, shed blood, or a blood substitute. Shock 2002;17:234–244.

    Article  PubMed  Google Scholar 

  18. Blajchman MA. Transfusion-associated immunomodulation and universal white cell reduction: are we putting the cart before the horse? Transfusion 1999;39:665–670.

    Article  PubMed  CAS  Google Scholar 

  19. Tinmouth A, Chin-Yee I. The clinical consequences of the red cell storage lesion. Transfus Med Rey 2001;15:91–107.

    Article  CAS  Google Scholar 

  20. Moore FA, Moore EE, Sauaia A. Blood transfusion—an independent risk factor for postinjury multiple organ failure. Arch Surg 1997;132:620–625.

    PubMed  CAS  Google Scholar 

  21. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators. Canadian Critical Care Trials Group [comment][erratum appears in N Engl J Med 1999 Apr 1;340(13):1056]. N Engl J Med 1999;340:409–417.

    Article  PubMed  CAS  Google Scholar 

  22. McIntyre L, Hebert PC, Wells G, et al. Is a restrictive transfusion strategy safe for resuscitated and critically ill trauma patients? J Trauma 2004;57:563–568.

    PubMed  Google Scholar 

  23. Audet A-M, Goodenough LT. Practice strategies for electrive red blood cell transfusion. American College of Physicians [comment]. Ann Intern Med 1992;116:403–406.

    Google Scholar 

  24. Romano PS, Roos LL, Jollis JG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. J Clin Epidemiol 1993;46:1075–1079.

    Article  PubMed  CAS  Google Scholar 

  25. Baker SP, O'Neill B, Haddon W jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14: 187–196.

    PubMed  CAS  Google Scholar 

  26. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbard WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995;23: 1638–1652.

    Article  PubMed  CAS  Google Scholar 

  27. Hebert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? [comment]. Crit Care Med 2001;29:227–234.

    Article  PubMed  CAS  Google Scholar 

  28. Wu WC, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction. [comment]. N Engl J Med 2001;345:1230–1236.

    Article  PubMed  CAS  Google Scholar 

  29. Carson JL, Hill S, Carless P, Hebert PC, Henry D. Transfusion triggers: a systematic review of the literature [Review] [61 refs]. Transfus Med Red 2002;16:187–199.

    Article  Google Scholar 

  30. Fortune JB, Feustel PJ, Saifi J, Stratton HH, Newell JC, Shah DM. Influence of hematocrit on cardiopulmonary function after acute hemorrhage. J Trauma 1987;27:243–249.

    PubMed  CAS  Google Scholar 

  31. Topley E, Fisher MR. The illness of trauma. Br J Clin Pract 1956; 10:770–776.

    PubMed  Google Scholar 

  32. Smith MJ, Stiefel MF, Magge S, et al. Packed red blood cell transfusion increases local cerebral oxygenation. Crit Care Med 2005;33:1104–1108.

    Article  PubMed  Google Scholar 

  33. DeWitt DS, Prough DS, Taylor CL, Whitley JM, Deal DD, Vines SM. Regional cerebrovascular responses to progressive hypotension after traumatic brain injury in cats. Am J Physiol 1992; 263:H1276-H1284.

    PubMed  CAS  Google Scholar 

  34. Glass TF, Fabian MJ, Schweitzer JB, Weinberg JA, Proctor KG. Secondary neurologic injury resulting from nonhypotensive hemorrhage combined with mild traumatic brain injury. J Neurotrauma 1999;16:771–782.

    Article  PubMed  CAS  Google Scholar 

  35. Oxman AD, Guyatt GH. A consumer's guide to subgroup analyses [see comments.]. Ann Intern Med 1992;116:78–84.

    PubMed  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Centre for Transfusion Research and Clinical Epidemiology Program, Ottawa Health Research Institute, General Campus, 501 Smyth Road, Box 201, K1H 8L6, Ottawa, Ontario

    Lauralyn A. McIntyre, Dean A. Fergusson & Paul C. Hébert

  2. Departments of Critical Care and Pediatrics, Hospital for Sick Children, University of Toronto, Ottawa, Canada

    James S. Hutchison

  3. Critical Care Program, The Ottawa Hospital, Ottawa, Canada

    Giuseppe Pagliarello

  4. Department of Surgery, Critical Care Program, University of Toronto, Ottawa, Canada

    John C. Marshall

  5. University of Ottawa Heart Insitute, Ottawa, Canada

    Elizabeth Yetisir

  6. Department of Anesthesia and Physiology, University of Toronto, St. Michael's Hospital, Toronto, Canada

    Gregory M. T. Hare

Authors
  1. Lauralyn A. McIntyre
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  2. Dean A. Fergusson
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  3. James S. Hutchison
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  4. Giuseppe Pagliarello
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  5. John C. Marshall
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  6. Elizabeth Yetisir
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  7. Gregory M. T. Hare
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  8. Paul C. Hébert
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Canadian Critical Care Trials Group

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Correspondence to Lauralyn A. McIntyre.

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McIntyre, L.A., Fergusson, D.A., Hutchison, J.S. et al. Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care 5, 4–9 (2006). https://doi.org/10.1385/NCC:5:1:4

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