A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care

Background To determine whether a restrictive strategy of red-cell transfus ion and a liberal strategy produced equivalent results in critically ill pa tients, we compared the rates of death from all causes at 30 days and the s everity of organ dysfunction. Methods We enrolled 838 critically ill patients with euvolemia after initia l treatment who had hemoglobin concentrations of less than 9.0 g per decili ter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which r ed cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfus ions were given when the hemoglobin concentration fell below 10.0 g per dec iliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter. Results Overall, 30-day mortality was similar in the two groups (18.7 perce nt vs. 23.3 percent, P = 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acu tely ill - those with an Acute Physiology and Chronic Health Evaluation II score of less than or equal to 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 significan t cardiac disease (20.5 percent and 22.9 percent, respectively; P = 0.69). The mortality rate during hospitalization was significantly lower in the re strictive-strategy group (22.2 percent vs. 28.1 percent, P = 0.05). Conclusions A restrictive strategy of red-cell transfusion is at least as e ffective as and possibly superior to a liberal transfusion strategy in crit ically ill patients, with the possible exception of patients with acute myo cardial infarction and unstable angina. (N Engl J Med 1999;340:409-17) (C) 1999. Massachusetts Medical Society.