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Randomized Controlled Trial
. 2026 Feb;52(2):211-229.
doi: 10.1007/s00134-025-08290-5. Epub 2026 Mar 3.

Influence of multiple trauma on the effect of transfusion strategies in patients with traumatic brain injury: a sub-study of the HEMOTION trial

Marwan Bouras  1   2   3 , François Lauzier  1   2   4 , Dean A Fergusson  5   6   7 , Xavier Neveu  1 , Lucy Clayton  1   8 , Marie-Pier Patton  1 , Olivier Costerousse  1 , Shane W English  5   6   7 , Annemarie Docherty  9   10 , Luiz M S Malbouisson  11 , Ryan Zarychanski  12   13 , Lynne Moore  2   14 , Paule Lessard Bonaventure  2   15 , Vincent Laroche  1   4 , Michael Verret  1   2 , Damon C Scales  16   17 , Neill K J Adhikari  16   17 , Jonathan Greenbaum  18 , Andreas Kramer  19 , Vanesa Garnelo Rey  20 , Ian Ball  21 , Kosar Khwaja  22 , Matt Wise  23   24 , Daniel Harvey  25 , Russell Chabanne  26 , Julien Pottecher  27 , Jonathan Rhodes  9 , Andrea Rigamonti  17   28 , Karen E A Burns  17   29   30   31 , Donald E Griesdale  32 , Demetrios James Kutsogiannis  33 , Robert Green  34   35 , J Gordon Boyd  36   37 , Frederick Zeiler  38   39   40 , Alwyn Gomez  39   40 , Emmanuel Charbonney  41   42   43 , Timothy Astles  44 , Eric Sy  45   46 , Alexis F Turgeon  47   48 ; HEMOTION Trial investigators, the Canadian Critical Care Trials Group, the Canadian Perioperative Anesthesia Clinical Trials Group, the Canadian Traumatic Brain Injury Research Consortium
Collaborators, Affiliations
Randomized Controlled Trial

Influence of multiple trauma on the effect of transfusion strategies in patients with traumatic brain injury: a sub-study of the HEMOTION trial

Marwan Bouras et al. Intensive Care Med. 2026 Feb.

Abstract

Purpose: In moderate-to-severe traumatic brain injury (TBI), anemia may exacerbate secondary cerebral injury, and patients with multiple trauma may be especially vulnerable to cerebral hypoxia. We conducted a secondary analysis of the HEMOTION trial (liberal transfusion strategy > 10 g/dL vs. restrictive > 7 g/dL), to assess whether multiple trauma modifies the effect of transfusion strategy after moderate-to-severe TBI.

Methods: We included all HEMOTION trial participants (n = 742) and defined multiple trauma using three definitions: (1) extracranial injury with Injury Severity Score (ISS) > 15; (2) extracranial injury requiring emergency extracranial surgery; (3) spinal injury with neurological deficit. The primary outcome was the 6-month Glasgow Outcome Scale Extended (GOS-E). We tested interactions between transfusion strategy and multiple trauma status using sliding dichotomy and hierarchical Poisson regression, with sensitivity analyses using classical dichotomy (GOS-E ≤ 4) and proportional odds models. Secondary outcomes included mortality, quality of life (EQ-5D-5L, QOLIBRI), functional independence (FIM), and depression (PHQ-9).

Results: We found no interaction between multiple trauma status and transfusion strategies on the 6-month GOS-E across all three definitions. The adjusted relative risk (RR) of an unfavourable outcome with the liberal strategy was 0.87 (95% CI 0.71-1.07) for patients with ISS > 15, 0.79 (0.59-1.05) for emergency extracranial surgery, and 0.99 (0.42-2.33) for spinal cord injury. Sensitivity analyses suggested a potential interaction for patients undergoing emergency extracranial surgery (p-interaction = 0.02 for proportional odds analysis; 0.05 for classical dichotomy). A liberal strategy was associated with better FIM, EQ-5D-5L, and Qolibri scores for definitions 1 and 2, but not 3, with no consistent interaction. Mortality and PHQ-9 did not differ.

Conclusion: Multiple trauma status was not associated with the effect of liberal vs. restrictive transfusion strategies on the GOS-E. Patients requiring emergency extracranial surgery may warrant further investigation.

Keywords: Anemia; Extracranial surgery; Glasgow outcome scale extended; Multiple trauma; Transfusion strategy; Traumatic brain injury.

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Conflict of interest statement

Declarations. Conflicts of interest: Dr. Chabanne reports receiving consulting fees from Sophysa, LXO ans Cormedica Neuromedex. Dr. Pottecher reports receiving consulting fees from Masimo, LFB Biomedicaments, and Octapharma. Dr. Boyd reports receiving an in-kind donation of cerebral oximeters from Edwards Life Sciences for his research program. Dr English and Dr Docherty declare academic grants. All authors have completed and submitted the ICMJE disclosure form. No potential conflicts of interest relevant to this article were reported for the other authors. Ethical approval: The HEMOTION trial protocol was approved by the research ethics board at the Centre Hospitalier Universitaire de Québec-Université Laval and at all participating centers. A priori or deferred informed consent was obtained from surrogate decision makers for each participant. Consent was later obtained from patients if they regained capacity.

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