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Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury

Palmieri, Tina L. MD*; Holmes, James H. IV MD; Arnoldo, Brett MD; Peck, Michael MD, ScD§; Potenza, Bruce MD; Cochran, Amalia MD||; King, Booker T. MD, Col**; Dominic, William MD††; Cartotto, Robert MD‡‡; Bhavsar, Dhaval MD§§; Kemalyan, Nathan MD¶¶; Tredget, Edward MD||||; Stapelberg, Francois MD***; Mozingo, David MD†††; Friedman, Bruce MD‡‡‡; Greenhalgh, David G. MD*; Taylor, Sandra L. PhD§§§; Pollock, Brad H. PhD, MPH§§§

doi: 10.1097/SLA.0000000000002408

Objective: Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality.

Background: Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown.

Methods: This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7–8 g/dL) or liberal (hemoglobin 10–11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes.

Results: Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 ± 32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 ± 44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, χ2 test).

Conclusions: A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy ( identifier NCT01079247).

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*Department of Surgery, University of California Davis and Shriners Hospital for Children Northern California, Sacramento, CA

Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC

Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX

§Department of Surgery, The Arizona Burn Center, The Arizona Burn Center and University of Arizona College of Medicine, Phoenix, AZ

Department of Surgery, University of California San Diego, San Diego, CA

||Department of Surgery, University of Utah, Salt Lake City, UT

**Department of Surgery, Institute of Surgical Research, San Antonio, TX

††Department of Surgery, Community Regional Medical Center, Fresno, CA

‡‡Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

§§Department of Surgery, Kansas University Medical Center, Kansas City, KS

¶¶Department of Surgery, Oregon Burn Center, Portland, OR

||||Department of Surgery, University of Alberta, Edmonton, AB, Canada

***Department of Anesthesia, New Zealand National Burn Centre, Middlemore Hospital, Middlemore, New Zealand

†††Department of Surgery, University of Florida Health Science Center, Gainesville, FL

‡‡‡Department of Surgery, JM Still Burn Center, Augusta, GA

§§§Department of Public Health Sciences, University of California Davis, Sacramento, CA.

Reprints: Tina L. Palmieri, MD, Department of Surgery, University of California Davis and Shriners Hospital for Children Northern California, 2425 Stockton Blvd, Suite 718, Sacramento, CA 95817. E-mail:

This study was supported by the American Burn Association and funded by USAMRMC Award W81XWH-08-1-0760 with support from the National Center for Research Resources, National Institutes of Health, through grant UL1 RR024146, the National Center for Advancing Translational Sciences, National Institutes of Health, through grant TR 000002, and the National Center for Advancing Translational Sciences, National Institutes of Health through grant UL1 TR001860.

Presented at the American Surgical Association Meeting, Philadelphia, PA, April 2017.

The views expressed are those of the authors and do not reflect the official policy or position of the Department of Defense or the US Government.

Dr Holmes: Equity positions in Abbott Labs, AbbVie, and Permeaderm Inc. Dr Tredget: Contract research, Scar X, KLOX Therapeutics, and Exciton (ExSALT), collaborative research British Canadian BioSciences Corp (novel antifibrotic agent). The remaining authors reports no conflicts of interest.

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