Does Liberal Transfusion Benefit Patients with TBI?

August 7, 2024

Written by Andy Hogan

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In ICU patients with traumatic brain injury (TBI) and anemia, transfusing blood to a liberal hemoglobin threshold (10 g/dL) compared to a restrictive threshold (7 g/dL) did not lead to better neurological outcomes at 6 months.

Don’t break the (blood) bank just yet!
Many researchers have gotten a lot of mileage out of comparing ‘liberal’ and ‘restrictive’ blood transfusion strategies for various pathologies. This multicenter study tackled the same question for moderate to severe TBI (GCS ≤12), assessing whether a transfusion threshold of 10 g/dL resulted in better neurologic outcomes than the traditional 7 g/dL target. After ICU admission, 736 patients were randomized to the two thresholds, and neurologic outcomes using the Glasgow Outcome Scale-Extended (GOS-E) were compared at 6 months. Using a sliding dichotomy approach, investigators divided patients into 3 prognostic categories (worst, intermediate, and best) and defined favorable GOS-E scores for each group (3, 4, 5, respectively). 

Disappointingly, neurologic outcomes did not significantly differ between the transfusion strategies at 6 months. Rates of mortality and moderate to severe depression (PHQ-9 scale ≥10) were equivalent, although scores of motor function and quality of life using validated instruments were slightly higher in the liberal transfusion group.

Notably, patients in the liberal transfusion group received a median 3 units of blood during their admission compared to a median 0 units in the restrictive strategy cohort. Considering the study’s findings, transfusing to a liberal threshold does not seem an effective use of a strained blood supply.

How will this change my practice?
Ultimately, this study does not present a compelling reason to change the standard of care for trauma patients with TBI who require transfusion in the ED. For now, emergency clinicians should continue to target hemodynamic stability and standard hemoglobin thresholds for transfusion in this population.

Source
Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury. N Engl J Med. 2024 Jun 13. doi: 10.1056/NEJMoa2404360. Epub ahead of print. PMID 38869931.