1.
Red blood cell transfusion in patients with traumatic brain injury: a systematic review protocol
Boutin A, Chasse M, Shemilt M, Lauzier F, Moore L, Zarychanski R, Lacroix J, Fergusson DA, Desjardins P, Turgeon AF
Systems Review. 2014;3((1):):66.
Abstract
BACKGROUND Anemia is a prevalent condition in critically ill patients and red blood cell transfusions are frequent. Although transfusions at low hemoglobin levels have been shown to be associated with equivalent or better outcomes than higher hemoglobin thresholds, clinical equipoise persists in patients with traumatic brain injury considering their susceptibility to secondary cerebral insults such as those from hypoxemia. METHODS Our objectives are to estimate the frequency of red blood cell transfusion in patients with traumatic brain injury and to evaluate transfusion thresholds, determinants and outcomes associated with transfusion strategies.We will conduct a systematic review of cohort studies and randomized controlled trials of patients with traumatic brain injury. We will search MEDLINE, Embase, BIOSIS and the Cochrane Library for eligible studies. Two independent reviewers will screen all identified references. Studies including adult patients with traumatic brain injury reporting data on red blood cell transfusions will be eligible. We will collect data on baseline demographics, trauma characteristics, hemoglobin thresholds, blood transfusions and clinical outcomes (mortality, length of stay, complications, and so on). Two independent reviewers will extract data using a standardized form. We will pool cumulative incidences using DerSimonian and Lair random-effect models after a Freeman-Tukey transformation to stabilize variances. We will pool risk ratios or mean differences with random-effect models and Mantel-Haenszel or inverse variance methods in order to evaluate the association between red blood cell transfusion and potential determinants or outcomes. Sensitivity and subgroup analysis according to timing of red blood cell transfusion, traumatic brain injury severity, year of conduction of the study, risk of bias, notably, are planned. DISCUSSION We expect to observe high heterogeneity in the proportion of transfused patients across studies and that the global proportion will be similar to the frequency observed in the general medical critically ill population. Our systematic review will allow us to better describe and understand current transfusion practices in patients with traumatic brain injury, a clinical population in which liberal transfusions are still advocated in the absence of evidence-based data. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014007402.
2.
Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury
McIntyre LA, Fergusson DA, Hutchison JS, Pagliarello G, Marshall JC, Yetisir E, Hare GM, Hébert PC
Neurocritical Care. 2006;5((1):):4-9.
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.