Patients with spontaneous intracerebral haemorrhage undergoing a liberal transfusion strategy appear to have better outcomes, including lower risk of mortality and organ failure, than those who have had a restrictive approach.
The international research group behind the findings have stressed their results, deduced from a secondary analysis of the phase 3 TRAIN trial, should be considered exploratory and hypothesis-generating due to a limited sample size.
The researchers focused on 144 patients (mean age 58, 54% female) with spontaneous intracerebral haemorrhage (ICH) who were among the wider cohort admitted to 72 intensive care units across 22 countries with brain injuries.
Patients were randomly assigned to undergo a restrictive (transfusion triggered by haemoglobin ≤7 g/dL) or a liberal (transfusion triggered by haemoglobin ≤9 g/dL) transfusion strategy over a 28-day period. When the haemoglobin level reached the specified threshold, patients received one unit of packed red blood cells.
The mean haemoglobin concentration at randomisation was 8.4 g/dL in both groups. A total of 151 blood transfusions were administered in the liberal group and a median 2 (1-3) units of blood transfusions compared with 54 blood transfusions administered in the restrictive group and a median of 0 (0-1) units.
Findings revealed that at 180 days after randomisation, patients in the liberal transfusion strategy had a nonsignificant decrease in the probability of unfavourable neurological outcome, measured through the Glasgow Outcome Scale Extended, versus patients in the restrictive group (71.8% versus 84.7%; risk ratio 0.85).
The composite outcome of death and organ failure at 28 days occurred in 71.8% of liberal-strategy patients versus 87.7% in the restrictive group, risk ratio 0.82.
Sepsis rates were also lower with liberal transfusion (9.9% versus 23.3%).
Writing in Stroke [link here], the researchers warned the study might have been underpowered to detect clinically relevant differences between the two strategies, but offered a foundation for future research to build on and guide clinical practice.
They also noted that the study addressed a critical gap, considering current guidelines provided no specific recommendations for specific haemoglobin thresholds that should trigger blood transfusion in brain haemorrhage patients.
“In this study, we reported that a liberal transfusion strategy in patients with ICH was safe, as both groups exhibited a similar incidence of most adverse events,” the researchers said.
“Notably, the incidence of transfusion-associated circulatory overload and transfusion-related acute lung injury was comparable between groups, which may be attributed to an overall restrictive approach to fluid administration.
“Conversely, the incidence of sepsis was higher in the restrictive group, potentially due to a higher prevalence of HIV-positive patients in this cohort.
“Further high-quality, randomised clinical trials are needed to provide definitive evidence and clear guidance on optimal transfusion thresholds for patients with ICH.”