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Transfusion Requirements in Critical CareA Pilot Study
Paul C. Hébert, MD, MHSc, FRCPC;
George Wells, PhD;
John Marshall, MD, FRCSC;
Claudio Martin, MD, MSc, FRCPC;
Martin Tweeddale, MD, PhD, FRCPC;
Giuseppe Pagliarello, MD, FRCSC;
Morris Blajchman, MD, FRCPC;
the Canadian Critical Care Trials Group;
G. Wood, MD;
R. Hill, MD, MSc;
J. Granton, MD;
G. Wood, MD;
J. Calvin, MD;
D. Cook, MD, MSc;
W. Demajo, MD;
P. Dodek, MD;
C. Bradley, MD;
L. Champion, MD;
H. Devitt, MD;
G. Ford, MD;
G. Fox, MD;
M. Girotti, MD;
R. Hall;
P. Hebert;
J. Hewson, MD;
H. Fuller, MD;
B. Guslits, MD;
S. Hamilton, MD;
M. Heule, MD;
D. Heyland, MD;
T. Hillers, MD, MSc;
P. Houston, MD;
J. Kronick, MD;
A. Laupacis, MD, MSc;
D. Leasa, MD;
R. Hodder, MD, MSc;
R. Hill, MD, MSc;
J. LaCroix, MD;
N. Lazar, MD;
S. Magder, MD;
J. Marshall;
S. Moffatt, MD;
L. Oppenheimer, MD;
L. Passerini, MD;
P. Powles, MD;
R. Mclntyre, MD;
T. Noseworthy, MD, MHA;
J. Pagliarello, MD;
S. Peters, MD;
D. Roberts, MD;
T. Rosenal, MD;
J. Russell, MD;
J. D. Sandham, MD;
P. Walker, MD;
P. Roy, MD;
R. Saeschke, MD;
D. W. Shragge, MD;
T. R. Todd, MD ;
J. Watters, MD ;
T. Winton, MD ;
M. Tweeddale;
M. Heule, MD;
A. Slutsky, MD ;
J. Granton, MD;
B. Wilson, MD ;
A. Kirby, MD ;
G. Rocker, MD;
T. Hillers, MD, MSc;
K. Inman, MSc;
P. Boiteau, MD;
P. Kernerman, MD;
G. Doig, DVM;
T. Stewart, MD
JAMA. 1995;273(18):1439-1444.
Abstract
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Objective.
—To evaluate the effects of a restrictive and a liberal red blood cell (RBC) transfusion strategy on mortality and morbidity in critically ill patients.
Study Design.
—Multicenter, prospective, randomized clinical trial.
Patient Population.
—Sixty-nine normovolemic critically ill patients admitted to one of five tertiary level intensive care units with hemoglobin values less than 90 g/L within 72 hours of admission.
Interventions.
—Patients were randomly allocated to one of two RBC transfusion strategies. Hemoglobin values were maintained between 100 and 120 g/L in the liberal transfusion group and between 70 and 90 g/L in the restrictive group.
Results.
—Primary diagnosis and mean±SD age (58.6±15 vs 59.0±21 years) and Acute Physiology and Chronic Health Evaluation II score (20±6.2 vs 21 ±7.2) were similar in the restrictive and liberal groups, respectively. Daily hemoglobin values averaged 90 g/L in the restrictive group vs 109 g/L in the liberal group (P<.001). The restrictive group received 2.5 U per patient compared with 4.8 U per patient in the liberal group. This represents a 48% relative decrease (P<.001) in RBC units transfused per patient. The 30-day mortality rate was 24% in the restrictive group compared with 25% in the liberal group; the 95% confidence interval around the absolute difference was –19% to 21%. Similar observations were noted for intensive care unit mortality (P=.76) and 120-day mortality (P>.99). In addition, survival analysis comparing time until death in both groups did not reveal any significant difference (P=.93) between groups. Organ dysfunction scores were also similar (P=.44).
Conclusion.
—In this small randomized trial, neither mortality nor the development of organ dysfunction was affected by the transfusion strategy, which suggests that a more restrictive approach to the transfusion of RBCs may be safe in critically ill patients. However, the study lacked power to detect small but clinically significant differences. Therefore, further investigations of RBC transfusion strategies are warranted.
(JAMA. 1995;273:1439-1444)
Author Affiliations
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Critical Care Medicine, Richardson House, Kingston, Ontario; Rush-Presbyterian-St Luke's Medical Center, Chicago, III; St Joseph's Hospital, Hamilton, Ontario; The Toronto (Ontario) Hospital; St Paul's Hospital, Vancouver, British Columbia; Hamilton (Ontario) General Hospital; University Hospital, London, Ontario; Sunnybrook Health Science Centre, Toronto, Ontario; Calgary (Alberta) General Hospital; Memorial University of Newfoundland, St John's; Victoria Hospital, London, Ontario; Victoria General Hospital, Halifax, Nova Scotia; Hamilton General Hospital; St Joseph's Hospital, Hamilton, Ontario; Henry Ford Hospital, Detroit, Mich; University Hospital, Edmonton, Alberta; Misericordia Hospital, Edmonton, Alberta; Hamilton General Hospital; Hamilton General Hospital; The Toronto Hospital; Children's Hospital, London, Ontario; Ottawa (Ontario) Civic Hospital; University Hospital, London, Ontario; Ottawa Civic Hospital; Health Science Centre, Calgary, Alberta; Hospital Sainte-Justine, Montreal, Quebec; General Division, Toronto, Ontario; Royal Victoria Hospital, Montreal, Quebec; Kingston (Ontario) General Hospital; Health Science Center, Winnipeg, Manitoba; Hotel Dieu de Montreal (Quebec); St Joseph's Hospital, Hamilton, Ontario; Ottawa Civic Hospital; Royal Alexandra Hospital, Edmonton, Alberta; Ottawa Civic Hospital; Health Science Centre, St John's, Newfoundland; Health Science Centre, Winnipeg, Manitoba; Calgary General Hospital; St Paul's Hospital, Vancouver, British Columbia; Jewish General Hospital, Montreal, Quebec; The Toronto Hospital; R. Wigle, MD, Kingston General Hospital; Victoria General Hospital, Halifax, Nova Scotia; St Joseph's Hospital, Hamilton, Ontario; Hamilton, Ontario; (chair), The Toronto Hospital; Ottawa Civic Hospital; The Toronto Hospital; Misericordia Hospital, Edmonton, Ontario; Mt Sinai Hospital, Toronto, Ontario; Vancouver, British Columbia; St Joseph Hospital, London, Ontario; Victoria General Hospital, Halifax, Nova Scotia; Hamilton General Hospital; Victoria Hospital Research Institute, London, Ontario; Mt Sinai Hospital, Toronto, Ontario; Toronto, Ontario; London, Ontario; Wellesley Hospital, Toronto, Ontario
Health Science Centre, Calgary, Alberta; Vancouver, British Columbia
From the Critical Care Programs at the University of Ottawa (Ontario) (Drs Hébert and Pagliarello); the University of Toronto (Ontario) (Dr Marshall); the University of Western Ontario, London, Ontario (Dr Martin); and the University of British Columbia, Vancouver (Dr Tweeddale); the Clinical Epidemiology Unit, University of Ottawa (Drs Hébert and Wells); and the Department of Pathology, McMaster University, Hamilton, Ontario (Dr Blajchman). Dr Hébert is a Career Scientist with the Ontario Ministry of Health.
Footnotes
A complete list of the study participants from the Canadian Critical Care Trials Group appears at the end of this article.
Presented in abstract form at the 60th Annual International Meeting of the Scientific Assembly of the American College of Chest Physicians, October 30-November 3, 1994, New Orleans, La.
Reprint requests to the Department of Medicine, Division of Respiratory Medicine, Room N14, Ottawa General Hospital, 501 Smyth Rd, Ottawa, Ontario, Canada K1H 8L6 (Dr Hébert).
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