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Multicenter Randomized Prospective Trial Of Blood Transfusion In Major Burn Injury
Tina L. Palmieri1, James Holmes2, Brett Arnoldo3, Michael Peck4, Bruce Potenza*5, Amalia Cochran*6, Booker King7, William Dominick*8, Robert Cartotto*9, Dhaval Havsar*10, Nathan Kemalyan*11, Edward Tredget12, Francois Stapelberg13, David Mozingo*14, David G. Greenhalgh1, Bradley Pollock15
1University of California Davis and Shriners Hospital for Children Northern California, Sacramento, CA;2Wake Forest Baptist Health, Winston-Salem, NC;3University of Texas Southwestern Medical Center, Dallas, TX;4The Arizona Burn Center, Maricopa Medical Center, Phoenix, AZ;5University of California San Diego, San Diego, CA;6University of Utah Department of Surgery, Salt Lake City, UT;7Institute of Surgical Research, San Antonio, TX;8Community Regional Medical Center, Fresno, CA;9Sunnybrook Health Sciences Centre, Toronto, ON, Canada10Kansas University Medical Center, Kansas City, KS;11Oregon Burn Center, Portland, OR;12University of Alberta, Edmonton, AB, Canada13New Zealand National Burn Centre, Middlemore Hospital, Middlemore, New Zealand14University of Florida Health Science Center, Gainesville, FL;15University of California Davis, Sacramento, CA

A Multicenter Prospective Randomized Trial of Blood Transfusion in Major Burns
Objective: Studies suggest superiority of a restrictive transfusion policy in stable critically ill patients. These studies excluded surgical patients with significant blood loss. Our objective was to compare outcomes of a restrictive red-cell transfusion strategy to a liberal strategy in ≥20% total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infections, organ dysfunction, and mortality.
Methods: Patients were block randomized by age and TBSA to a restrictive (maintaining hemoglobin 7-8g/dl) or liberal (maintaining hemoglobin 10-11g/dl) strategy throughout hospitalization, including surgery. Data collected included demographics, infections, transfusions, and outcomes.
Results: Eighteen burn centers enrolled 345 patients with ≥20% TBSA burn. A total of 7,054 units blood were transfused. Patients were similar in age, TBSA burn, and inhalation injury. (Table) The restrictive group received less blood: 31.8±44.3 (mean±sd), Median=16[IQR: 7, 40] vs. 20.3±32.7, Median=8[IQR: 3, 24] units, respectively (p<0.0001, Wilcoxon rank sum). There were no significant differences in 30-day mortality: 8.5% liberal vs. 9.5% restrictive (p=0.892, test of proportions), or in actuarial survival (p=0.555, log-rank). Similarly, blood stream infection (BSI) incidence, ventilator days, time to wound healing, and organ dysfunction were similar across groups (p>0.05).
Conclusions: A restrictive transfusion strategy reduced blood utilization but did not decrease blood stream infection, mortality, or organ dysfunction in major burn injury.
Table. Means ± SD or percentage (n) of selected variables for each treatment group
VariableLiberal
(n = 177)
Restrictive
(n = 168)
Age (years)43.8 ± 1742.1 ± 16.7
Gender (% male)78.5% (n = 139)79.8% (n = 134)
TBSA (%)39.1 ± 18.537 ± 16.6
Inhalation Injury (%)20.9% (n = 37)24.4% (n = 41)
Mortality (%)11.3% (n = 20)13.7% (n = 23)
Ventilator Days18.9 ± 36.717.3 ± 25
Days to Wound Healing36.4 ± 39.539.2 ± 50.5
BSI* (Y/N)23.7% (n = 42)23.8% (n = 40)
Number of BSI0.5 ± 1.40.4 ± 0.9
Worst MOD** score7.03 ± 4.317.60 ± 4.36
*BSI=blood stream infection; **MOD=multiple organ dysfunction score


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