General Critical Care

https://www.nejm.org/doi/full/10.1056/NEJMoa2404360

Population:

- Adults with moderate or severe traumatic brain injury (TBI) and anemia

- Total of 742 patients, with 371 patients in each group

Intervention:

- Liberal transfusion strategy: Transfusions initiated at a hemoglobin level of ≤10 g/dL

Comparison:

- Restrictive transfusion strategy: Transfusions initiated at a hemoglobin level of ≤7 g/dL

Outcome:

- Primary Outcome: Unfavorable outcome at 6 months assessed by the Glasgow Outcome Scale–Extended (GOSE)

- Liberal strategy: 68.4% (249/364) unfavorable outcomes

- Restrictive strategy: 73.5% (263/358) unfavorable outcomes

- Adjusted absolute difference: 5.4 percentage points (95% CI, −2.9 to 13.7)

- **Secondary Outcomes:**

- Mortality: No significant difference

- Functional independence and quality of life: Higher scores on some scales in the liberal strategy group among survivors

- Depression: No significant difference

- Venous thromboembolic events: 8.4% in both groups

- Acute respiratory distress syndrome (ARDS): 3.3% in liberal group, 0.8% in restrictive group

Insights for Medical Intensivists

- Neurological Outcomes: The liberal transfusion strategy did not significantly reduce the risk of unfavorable neurological outcomes at 6 months compared to the restrictive strategy. Both strategies had high rates of unfavorable outcomes, but the difference was not statistically significant.

- Functional Outcomes: Among survivors, some improvement in functional independence and quality of life scores was observed with the liberal transfusion strategy, although this was not consistent across all measures.

- Safety Concerns: The occurrence of venous thromboembolic events was similar in both groups, but the liberal strategy was associated with a higher incidence of ARDS.

- Clinical Practice Implication: Given the lack of significant benefit in neurological outcomes and the increased risk of ARDS with the liberal strategy, a restrictive transfusion strategy might be preferable in critically ill TBI patients with anemia to avoid additional complications without compromising overall survival and functional outcomes.