A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care
Paul C. Hébert, M.D., George Wells, Ph.D., Morris A. Blajchman, M.D., John Marshall, M.D., Claudio Martin, M.D., Giuseppe Pagliarello, M.D., Martin Tweeddale, M.D., Ph.D., Irwin Schweitzer, M.Sc., Elizabeth Yetisir, M.Sc., for The Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group
Background To determine whether a restrictive strategy of red-celltransfusion and a liberal strategy produced equivalent resultsin critically ill patients, we compared the rates of death fromall causes at 30 days and the severity of organ dysfunction.
Methods We enrolled 838 critically ill patients with euvolemiaafter initial treatment who had hemoglobin concentrations ofless than 9.0 g per deciliter within 72 hours after admissionto the intensive care unit and randomly assigned 418 patientsto a restrictive strategy of transfusion, in which red cellswere transfused if the hemoglobin concentration dropped below7.0 g per deciliter and hemoglobin concentrations were maintainedat 7.0 to 9.0 g per deciliter, and 420 patients to a liberalstrategy, in which transfusions were given when the hemoglobinconcentration fell below 10.0 g per deciliter and hemoglobinconcentrations were maintained at 10.0 to 12.0 g per deciliter.
Results Overall, 30-day mortality was similar in the two groups(18.7 percent vs. 23.3 percent, P= 0.11). However, the rateswere significantly lower with the restrictive transfusion strategyamong patients who were less acutely ill — those withan Acute Physiology and Chronic Health Evaluation II score of20 (8.7 percent in the restrictive-strategy group and 16.1 percentin the liberal-strategy group, P=0.03) — and among patientswho were less than 55 years of age (5.7 percent and 13.0 percent,respectively; P=0.02), but not among patients with clinicallysignificant cardiac disease (20.5 percent and 22.9 percent,respectively; P=0.69). The mortality rate during hospitalizationwas significantly lower in the restrictive-strategy group (22.2percent vs. 28.1 percent, P=0.05).
Conclusions A restrictive strategy of red-cell transfusion isat least as effective as and possibly superior to a liberaltransfusion strategy in critically ill patients, with the possibleexception of patients with acute myocardial infarction and unstableangina.
Source Information
From the Critical Care Program (P.C.H., G.P.) and the Clinical Epidemiology Unit (P.C.H, G.W., I.S., E.Y.), University of Ottawa, Ottawa; the Department of Pathology, McMaster University, Hamilton, Ont. (M.A.B.); the Critical Care Program, University of Toronto, Toronto (J.M.); the Critical Care Program, University of Western Ontario, London (C.M.); and the Critical Care Program, University of British Columbia, Vancouver (M.T.) — all in Canada.
Address reprint requests to Dr. Hébert at the Department of Medicine, Ottawa General Hospital, 501 Smyth Rd., Box 205, Ottawa, ON K1H 8L6, Canada.
Blood Transfusions in Critical Care
Pilla M. A., Gemma M., Beretta L., Ledger W. J., Barach P., Small S. D., Hébert P. C., The Transfusion Requirements in Critical Care Trial
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N Engl J Med 1999;
341:123-124, Jul 8, 1999.
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A correction has been published: N Engl J Med 1999;340(13):1056.
20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group, P=0.03) — and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.2 percent vs. 28.1 percent, P=0.05). 
