Liberal transfusion strategy improves neurological outcome among patients with brain injury and anemia: JAMA

A new study published in the Journal of American Medical Association showed that patients with acute brain injury and anemia who received liberal transfusion were less likely to experience a worse neurological outcome. Blood transfusions are frequently given to individuals who have suffered acute brain damage. For this group of patients, there is uncertainty on the ideal hemoglobin transfusion threshold. Therefore, to determine how two alternative hemoglobin thresholds may affect the neurological outcomes of patients after receiving red blood cell transfusions for severe brain injuries, Fabio Silvio and colleagues undertook this study.

A multicenter, parallel-group, phase 3 open-label randomized clinical study was carried out in 72 critical care units across 22 countries. The hemoglobin levels below 9 g/dL during the first 10 days following damage, traumatic brain injury, aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage, as well as an anticipated minimum 72-hour stay in an intensive care unit were the criteria for eligibility. The period of enrolment was from September 1, 2017 to December 31, 2022 with the follow-up period ended on June 30, 2023.

During the course of 28 days, 852 individuals were randomized to receive either a liberal transfusion approach or a restrictive transfusion strategy. The main outcome was the occurrence of an unfavorable neurological result, as determined by the Glasgow Outcome Scale. 180 days after randomization, the extended score ranged from 1 to 5. There were 14 predetermined significant adverse events, including the incidence of cerebral ischemia following randomization.

A total of 806 patients, 393 were in the liberal strategy group and 413 were in the restricted strategy group had their data on the primary outcome that could be accessed of the 820 study participants. With an absolute mean difference of 1.0 unit, the restricted strategy group received 0 units of blood, while the liberal approach group received a median of 2 units. 180 days following randomization, 246 patients in the liberal strategy group and 300 patients in the restricted strategy group, respectively, experienced a negative neurological result. All predefined categories showed a similar neurological outcome after 180 days as a result of the transfusion criteria. When compared to 57 of 423 individuals in the restricted approach group, 35 of 397 patients in the liberal strategy group experienced at least one cerebral ischemic episode.

Overall, patients with anemia and acute brain injury who were randomly assigned to a liberal strategy of red blood cell transfusion at a hemoglobin threshold of 9 g/dL had a lower risk of unfavorable neurological effects at 180 days than patients assigned to a restrictive strategy of transfusion at a hemoglobin limit of 7 g/dL.

Source:

Taccone, F. S., Rynkowski Bittencourt, C., Møller, K., Lormans, P., Quintana-Díaz, M., Caricato, A., Cardoso Ferreira, M. A., Badenes, R., Kurtz, P., Søndergaard, C. B., Colpaert, K., Petterson, L., Quintard, H., Cinotti, R., Gouvêa Bogossian, E., Righy, C., Silva, S., Roman-Pognuz, E., Vandewaeter, C., … Citerio, G. (2024). Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury. In JAMA. American Medical Association (AMA). https://doi.org/10.1001/jama.2024.20424