Packed red blood cell transfusions in critically ill infants and children: is it time for a restructive transfusion strategy?

ABSTRACT

Although a restrictive transfusion policy is being increasingly advocated during critical illness in the past few years, the optimal hemoglobin level for red blood cell [RBC] transfusions is not known in critically ill infants and children. We conducted a prospective comparative randomized trial to test the hypothesis that a restrictive RBC transfusion strategy would be as safe as liberal transfusion strategy in the pediatric intensive care unit [PICU]. The primary outcome measure was PICU mortality following randomization, three hundred and nine patients with a hemoglobin concentration hemoglobin for RBC transfusions was set at 7 g/dL in the restrictive group and 9 g/dL in the liberal group. The application of a restrictive transfusion strategy resulted in 37.8% decrease in the number of transfused patients 821 [53.9%] in the restrictive transfusion group Vs 144 [91.7%] in the liberal transfusion group, p=0.000]. The PICU mortality following randomization; the primary outcome measure; was not different between the restrictive and the liberal transfusion strategy groups 36 [23.7%] Vs 41[26.1%] respectively, p=0. 722]. The number of patients in the restrictive transfusion group developing at least one organ dysfunction/failure following randomization was significantly lower 51 [33.6%] as compared to 71[45.2%] in the liberal transfusion group [p=0.048]. The two transfusion strategy groups were not different with respect to the development of ventilator associated pneumonia [VAP], catheter related sepsis, and cardiovascular system failure. Finally, length of PICU admission, the number of patients requiring vasopressor support or mechanical ventilation was similar in the two studied transfusion groups. The application of a restrictive transfusion strategy [hemoglobin threshold of 7 g/dL] in critically ill infant and children resulted in a significant decrease in transfusion exposure without increase in PICU mortality or morbidity. The finding of fewer patients developing organ dysfunction/failure in the restrictive transfusion group needs further assessment