Hébert P C, Wells G, Blajchman M A, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E
Critical Care Program, University of Ottawa, ON, Canada.
N Engl J Med. 1999 Feb 11;340(6):409-17. doi: 10.1056/NEJM199902113400601.
To determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at 30 days and the severity of organ dysfunction.
We enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter.
Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill -- those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) -- and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05).
A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.
为了确定红细胞输注的限制性策略和宽松策略在重症患者中是否产生等效结果，我们比较了30天内各种原因导致的死亡率以及器官功能障碍的严重程度。
我们纳入了838例初始治疗后血容量正常的重症患者，这些患者在入住重症监护病房后72小时内血红蛋白浓度低于9.0 g/dL，并将418例患者随机分配至限制性输血策略组，即当血红蛋白浓度降至7.0 g/dL以下时输注红细胞，并将血红蛋白浓度维持在7.0至9.0 g/dL；将420例患者随机分配至宽松策略组，即当血红蛋白浓度降至10.0 g/dL以下时进行输血，并将血红蛋白浓度维持在10.0至12.0 g/dL。
总体而言，两组的30天死亡率相似（18.7%对23.3%，P = 0.11）。然而，在病情不太严重的患者中——急性生理与慢性健康状况评分II（APACHE II）≤20分的患者（限制性策略组为8.7%，宽松策略组为16.1%；P = 0.03）以及年龄小于55岁的患者中（分别为5.7%和13.0%；P = 0.02），限制性输血策略组的死亡率显著较低，但在有临床显著心脏病的患者中并非如此（分别为20.5%和22.9%；P = 0.69）。限制性策略组的住院死亡率显著较低（22.3%对28.1%，P = 0.05）。
在重症患者中，红细胞输注的限制性策略至少与宽松输血策略一样有效，甚至可能更优，急性心肌梗死和不稳定型心绞痛患者可能除外。
