Salford was the highest recruiting site in the UK (with 56 participants) to the Hemoglobin Transfusion Threshold in Traumatic Brain Injury Optimisation (HEMOTION) trial. This was an international randomised controlled trial investigating red cell transfusion thresholds in adults admitted to an intensive care unit with a moderate or severe traumatic brain injury. Intensive care units in Canada, the UK, France and Brazil participated to enrol 742 patients and Salford was the fourth highest recruiting unit overall. Our success was due to the integration of the trial into our protocol of care for TBI patients, and the diligence of the staff in the ICU and research teams.
Patients were randomised to receive either liberal red cell transfusion (to maintain Hb >100) or restrictive transfusion (Hb >70) during their stay in the ICU. Primary outcome measure was the Glasgow Outcome Score – Extended (GOS-E) – an 8 point scale ranging from death (1) to full recovery (8) – at 6 months. Secondary outcomes were mortality and several functional outcome measures.
Traumatic brain injury has severe consequences and in this trial over two thirds of patients had an “unfavourable” outcome, meaning death or significant disability. For all outcome measures there was no statistically significant difference between the liberal and restrictive red cell transfusion groups. But it was striking that most of the outcomes had a strong signal of benefit associated with a liberal transfusion strategy., despite not reaching statistical significance. The liberal group received a median of 3 units of red cells during their ICU admission.
The trial was presented at the international Critical Care Reviews meeting in June and published in the NEJM. Following local discussion at Salford, we are changing practice and adopting a higher transfusion threshold for patients with traumatic brain injury admitted to the ICU. Given the poor outcomes for many patients with TBI, interventions to ‘shift the dial’ can translate to very meaningful improvements in quality of life.
Principal Investigator Dr Jonathan Greenbaum