Liberal vs Restrictive Transfusion in Traumatic Brain Injury

TOPLINE:

A study on patients with traumatic brain injury and anemia has found no significant differences in the risk for unfavorable neurologic outcomes and mortality rates at 6 months between liberal and restrictive red blood cell (RBC) transfusion strategies.

METHODOLOGY:

• Researchers conducted a multicenter randomized trial in Canada, the United Kingdom, France, and Brazil, involving adults with acute moderate or severe traumatic brain injury and anemia who were admitted to the intensive care unit (ICU).
• A total of 742 participants (mean age, 48.7 years; 72.7% men) were randomly assigned in a 1:1 ratio to receive RBC transfusions via either a liberal strategy (transfusion initiated at a hemoglobin level ≤ 10 g/dL) or the standard restrictive strategy (transfusion initiated at a hemoglobin level ≤ 7 g/dL).
• The transfusion strategy was implemented until the patient’s discharge from the ICU, and unfavorable outcomes were primarily assessed at 6 months.
• The secondary outcomes were mortality rate and scores on some measures of functional independence, quality of life, and depression at 6 months.

TAKEAWAY:

• The median hemoglobin level during the ICU stay and the median number of RBC units transfused per patient were 10.8 g/dL and 3, respectively, in the liberal strategy group and 8.8 g/dL and 0, respectively, in the restrictive strategy group.
• The liberal and restrictive transfusion strategies were not associated with a significant difference in the risk for unfavorable outcomes (adjusted absolute difference, 5.4 percentage points; 95% CI, −2.9 to 13.7) or mortality rates (26.8% vs 26.3%) at 6 months.
• Among survivors, the liberal strategy was associated with higher scores on some measures of functional independence and quality of life, but confidence intervals were not adjusted for multiple testing.
• Venous thromboembolic events and acute respiratory distress syndrome were noted in both groups.

IN PRACTICE:

“A lib­eral transfusion strategy did not decrease the risk of an unfavorable neurologic outcome at 6 months as measured with the GOS-E [Glasgow Outcome Scale–Extended] in critically ill pa­tients with traumatic brain injury,” the authors wrote.

SOURCE:

The study was led by Alexis F. Turgeon, MD, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Québec City, Québec, Canada. It was published online on June 13, 2024, in The New England Journal of Medicine.

LIMITATIONS:

The study population was limited to patients with anemia, which may have resulted in a higher baseline risk for unfavorable outcomes. Baseline imbalances between the groups, including prognostic variables, may have influenced the results. The inability to mask treatment assignments from the clinical team could have introduced bias. The study was not designed to assess the noninferiority of a restrictive transfusion strategy, so the potential for harm with such a strategy cannot be excluded.

DISCLOSURES:

The study was supported by funding from the Canadian Institutes of Health Research and the Canadian Accelerating Clinical Trials Consortium. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.