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Critical Care Medicine:
doi: 10.1097/CCM.0b013e318291cce4
Clinical Investigations

Restrictive Versus Liberal Transfusion Strategies for Older Mechanically Ventilated Critically Ill Patients: A Randomized Pilot Trial*

Walsh, Timothy S. MD1; Boyd, Julia A. PhD2; Watson, Douglas MSc3; Hope, David Pg Dip1; Lewis, Steff PhD4; Krishan, Ashma MSc2,4; Forbes, John F. PhD4; Ramsay, Pamela PhD1; Pearse, Rupert MD5; Wallis, Charles FRCA6; Cairns, Christopher FRCA7; Cole, Stephen FRCA8; Wyncoll, Duncan FRCA9

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Abstract

Objectives:

To compare hemoglobin concentration (Hb), RBC use, and patient outcomes when restrictive or liberal blood transfusion strategies are used to treat anemic (Hb ≤ 90 g/L) critically ill patients of age ≥ 55 years requiring ≥ 4 days of mechanical ventilation in ICU.

Design:

Parallel-group randomized multicenter pilot trial.

Setting:

Six ICUs in the United Kingdom participated between August 2009 and December 2010.

Patients:

One hundred patients (51 restrictive and 49 liberal groups).

Interventions:

Patients were randomized to a restrictive (Hb trigger, 70 g/L; target, 71–90 g/L) or liberal (90 g/L; target, 91–110 g/L) transfusion strategy for 14 days or the remainder of ICU stay, whichever was longest.

Measurements and Main Results:

Baseline comorbidity rates and illness severity were high, notably for ischemic heart disease (32%). The Hb difference among groups was 13.8 g/L (95% CI, 11.5–16.0 g/L); p < 0.0001); mean Hb during intervention was 81.9 (sd, 5.1) versus 95.7 (6.3) g/L; 21.6% fewer patients in the restrictive group were transfused postrandomization (p < 0.001) and received a median 1 (95% CI, 1–2; p = 0.002) fewer RBC units. Protocol compliance was high. No major differences in organ dysfunction, duration of ventilation, infections, or cardiovascular complications were observed during intensive care and hospital follow-up. Mortality at 180 days postrandomization trended toward higher rates in the liberal group (55%) than in the restrictive group (37%); relative risk was 0.68 (95% CI, 0.44–1.05; p = 0.073). This trend remained in a survival model adjusted for age, gender, ischemic heart disease, Acute Physiology and Chronic Health Evaluation II score, and total non-neurologic Sequential Organ Failure Assessment score at baseline (hazard ratio, 0.54 [95% CI, 0.28–1.03]; p = 0.061).

Conclusions:

A large trial of transfusion strategies in older mechanically ventilated patients is feasible. This pilot trial found a nonsignificant trend toward lower mortality with restrictive transfusion practice.

Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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