Jessica Ruel-Laliberté1, Paule Lessard Bonaventure1, Dean Fergusson2, Jacques Lacroix3, Ryan Zarychanski4, François Lauzier1,5,6, Alan Tinmouth2, Paul C Hébert7, Robert Green8, Donald Griesdale9, Robert Fowler10, Andreas Kramer11, Lauralyn A McIntyre2,12, David Zygun13, Tim Walsh14, Simon Stanworth15, Gilles Capellier16, Sébastien Pili-Floury16, Emmanuel Samain16, Lucy Clayton3, John Marshall7, Giuseppe Pagliarello12, Elham Sabri2, Xavier Neveu1, Caroline Léger1, Alexis F Turgeon17,18,19. 1. CHU de Québec - Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Quebec City, QC, Canada. 2. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada. 3. CHU Ste-Justine Research Centre, CHU Ste-Justine, Université de Montréal, Montréal, QC, Canada. 4. Department of Internal Medicine, Sections of Critical Care Medicine, of Haematology and of Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada. 5. Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada. 6. Department of Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada. 7. Department of Medicine, Centre Hospitalier Universitaire de Montréal, Université de Montréal, Montréal, QC, Canada. 8. Department of Emergency Medicine, Division of Critical Care Medicine, Dalhousie University, Halifax, NS, Canada. 9. Department of Anesthesiology, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada. 10. Department of Critical Care Medicine, Sunnybrook Health Services Centre, University of Toronto, Toronto, ON, Canada. 11. Department of Critical Care Medicine, Foothills Health Sciences Centre, University of Calgary, Calgary, AB, Canada. 12. Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Ontario, ON, Canada. 13. Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada. 14. University of Edinburgh, Edinburgh, UK. 15. Department of Hematology, University of Oxford, Oxford, UK. 16. Department of Anesthesiology and Critical Care Medicine, Université de Besançon, Besançon, France. 17. CHU de Québec - Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Quebec City, QC, Canada. alexis.turgeon@fmed.ulaval.ca. 18. Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada. alexis.turgeon@fmed.ulaval.ca. 19. Centre de recherche du CHU de Québec - Université Laval, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Hôpital de l'Enfant-Jésus, 1401, 18e Rue, Room Z-204, Quebec City, QC, G1J 1Z4, Canada. alexis.turgeon@fmed.ulaval.ca.
Abstract
BACKGROUND: Anemia is common in critically ill patients with traumatic brain injury, and often requires red blood cell transfusion. Studies suggest that prolonged storage causes lesions of the red blood cells, including a decreased ability to carry oxygen. Considering the susceptibility of the brain to hypoxemia, victims of traumatic brain injury may thus be more vulnerable to exposure to older red blood cells. METHODS: Our study aimed to ascertain whether the administration of fresh red blood cells (seven days or less) results in a better neurologic outcome compared with standard red blood cells in critically ill patients with traumatic brain injury requiring transfusion. The Age of Blood Evaluation in traumatic brain injury (ABLE-tbi) study was a nested study within the ABLE study (ISRCTN44878718). Our primary outcome was the extended Glasgow Outcome Scale (GOSe) at six months. RESULTS: In the ABLE study, 217 subjects suffered a traumatic brain injury: 110 in the fresh group, and 107 in the standard group. In the fresh group, 68 (73.1%) of the patients had an unfavourable neurologic outcome (GOSe ≤ 4) compared with 60 (64.5%) in the standard group (P = 0.21). Using a sliding dichotomy approach, we observed no overall effect of fresh red blood cells on neurologic outcome (odds ratio [OR], 1.34; 95% confidence interval [CI], 0.72 to 2.50; P = 0.35) but observed differences across prognostic bands with a decreased odds of unfavourable outcome in patients with the best prognosis at baseline (OR, 0.33; 95% CI, 0.11 to 0.96; P = 0.04) but an increased odds in those with intermediate and worst baseline prognosis (OR, 5.88; 95% CI,1.66 to 20.81; P = 0.006; and OR, 1.67; 95% CI, 0.53 to 5.30; P = 0.38, respectively). CONCLUSION:Overall, transfusion of fresh red blood cells was not associated with a better neurologic outcome at six months in critically ill patients with traumatic brain injury. Nevertheless, we cannot exclude a differential effect according to the patient baseline prognosis. TRIAL REGISTRATION: ABLE study (ISRCTN44878718); registered 22 August, 2008.
RCT Entities:
BACKGROUND:Anemia is common in critically illpatients with traumatic brain injury, and often requires red blood cell transfusion. Studies suggest that prolonged storage causes lesions of the red blood cells, including a decreased ability to carry oxygen. Considering the susceptibility of the brain to hypoxemia, victims of traumatic brain injury may thus be more vulnerable to exposure to older red blood cells. METHODS: Our study aimed to ascertain whether the administration of fresh red blood cells (seven days or less) results in a better neurologic outcome compared with standard red blood cells in critically illpatients with traumatic brain injury requiring transfusion. The Age of Blood Evaluation in traumatic brain injury (ABLE-tbi) study was a nested study within the ABLE study (ISRCTN44878718). Our primary outcome was the extended Glasgow Outcome Scale (GOSe) at six months. RESULTS: In the ABLE study, 217 subjects suffered a traumatic brain injury: 110 in the fresh group, and 107 in the standard group. In the fresh group, 68 (73.1%) of the patients had an unfavourable neurologic outcome (GOSe ≤ 4) compared with 60 (64.5%) in the standard group (P = 0.21). Using a sliding dichotomy approach, we observed no overall effect of fresh red blood cells on neurologic outcome (odds ratio [OR], 1.34; 95% confidence interval [CI], 0.72 to 2.50; P = 0.35) but observed differences across prognostic bands with a decreased odds of unfavourable outcome in patients with the best prognosis at baseline (OR, 0.33; 95% CI, 0.11 to 0.96; P = 0.04) but an increased odds in those with intermediate and worst baseline prognosis (OR, 5.88; 95% CI,1.66 to 20.81; P = 0.006; and OR, 1.67; 95% CI, 0.53 to 5.30; P = 0.38, respectively). CONCLUSION: Overall, transfusion of fresh red blood cells was not associated with a better neurologic outcome at six months in critically illpatients with traumatic brain injury. Nevertheless, we cannot exclude a differential effect according to the patient baseline prognosis. TRIAL REGISTRATION: ABLE study (ISRCTN44878718); registered 22 August, 2008.