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Randomized Controlled Trial
. 2024 Jan 1;38(1):18-24.
doi: 10.1097/BOT.0000000000002696.

Orthopaedic Trauma and Anemia: Conservative versus Liberal Transfusion Strategy: A Prospective Randomized Study

Brian H Mullis  1 , Leilani S Mullis  1 , Laurence B Kempton  1 , Walter Virkus  1 , James E Slaven  1 , Jennifer Bruggers  2
Affiliations
Randomized Controlled Trial

Orthopaedic Trauma and Anemia: Conservative versus Liberal Transfusion Strategy: A Prospective Randomized Study

Brian H Mullis et al. J Orthop Trauma. .

Abstract

Objectives: To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period.

Methods: Design: Prospective, randomized, multicenter trial.

Setting: Three level 1 trauma centers.

Patient selection criteria: Patients aged 18-50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL.

Outcome measures and comparisons: Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds.

Results: Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P < 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2).

Conclusions: A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year.

Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Trial registration: ClinicalTrials.gov NCT02972593.

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Conflict of interest statement

The authors report no conflict of interest.

References

    1. Carson JL, Stanworth SJ, Dennis JA, et al. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev. 2021;12:CD002042.
    1. McIntyre L, Hebert PC, Wells G, et al. Is a restrictive transfusion strategy safe for resuscitated and critically ill trauma patients?. J Trauma Inj Infect Crit Care. 2004;57:563–568.
    1. Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. J Trauma Inj Infect Crit Care. 2009;67:1439–1442.
    1. Mullis B, Fisk E, Weaver D, et al. Anemia versus transfusion: does blood conservation increase the risk of complications?. Am J Orthop (Belle Mead NJ). 2015;44:E11–E16.
    1. Kola G, Sureshkumar S, Mohsina S, et al. Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: a randomized controlled trial. Saudi J Gastroenterol. 2021;27:13–19.

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