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Original Investigation
December 10, 2019

Effect of Fresh vs Standard-issue Red Blood Cell Transfusions on Multiple Organ Dysfunction Syndrome in Critically Ill Pediatric Patients: A Randomized Clinical Trial

Author Affiliations
  • 1Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 2Division of Pediatric Critical Care, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal and Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
  • 3Ottawa Hospital Research Institute, Departments of Medicine & Surgery, University of Ottawa School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  • 4Département de médecine, Centre de recherche du CHUM and Chaire de médecine transfusionnelle Héma-Québec-Bayer de l'Université de Montréal, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
  • 5Université de Lille, EA 2694—Santé publique: épidémiologie et qualité des soins, CHU Lille, Réanimation Pédiatrique, Lille, France
  • 6Division of Biostatistics, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 7The Children’s Hospital of Philadelphia, Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia
  • 8London School of Economics, London, United Kingdom
  • 9Evidera, Boston, Massachusetts
  • 10Department of Anesthesia and Critical Care, Bambino Gesù Children’s Hospital, Rome, Italy
  • 11Division of Pediatric Critical, Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine Université de Montréal and Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
  • 12Division of Critical Care and Cardiology, Department of Pediatrics, University of Rochester Golisano Children’s Hospital, Rochester, New York
  • 13Department of Pediatrics, University of Alberta, Edmonton, Canada
  • 14Stollery Children’s Hospital, Edmonton, Alberta, Canada
  • 15Departments of Pathology and Pediatrics, Emory University School of Medicine, Atlanta, Georgia
  • 16Transfusion, Tissue, Apheresis Services, Children’s Healthcare of Atlanta, Atlanta, Georgia
  • 17Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
  • 18Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
  • 19Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, New York
  • 20Western University, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
  • 21Division of Pediatric Hematology and Oncology, Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis
  • 22Research CHU de Québec—Université Laval Centre, Population Health and Optimal Health Practices and Research Unit, Trauma, Emergency, Critical Care Medicine, Université Laval and Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
JAMA. 2019;322(22):2179-2190. doi:10.1001/jama.2019.17478
Visual Abstract.
Visual Abstract.
Fresh vs Standard-issue Red Blood Cell Transfusions on Multiple Organ Dysfunction Syndrome in Critically Ill Pediatric Patients
Fresh vs Standard-issue Red Blood Cell Transfusions on Multiple Organ Dysfunction Syndrome in Critically Ill Pediatric Patients
Key Points

Question  What is the effect of fresh red blood cells on organ dysfunction in critically ill pediatric patients?

Findings  In a randomized clinical trial involving 1538 critically ill pediatric patients, there were no significant differences in organ dysfunction between fresh (20.2%) and standard-issue red blood cell groups (18.2%).

Meaning  This study did not demonstrate a benefit in the use of fresh red blood cell transfusions for critically ill children.

Abstract

Importance  The clinical consequences of red blood cell storage age for critically ill pediatric patients have not been examined in a large, randomized clinical trial.

Objective  To determine if the transfusion of fresh red blood cells (stored ≤7 days) reduced new or progressive multiple organ dysfunction syndrome compared with the use of standard-issue red blood cells in critically ill children.

Design, Setting, and Participants  The Age of Transfused Blood in Critically-Ill Children trial was an international, multicenter, blinded, randomized clinical trial, performed between February 2014 and November 2018 in 50 tertiary care centers. Pediatric patients between the ages of 3 days and 16 years were eligible if the first red blood cell transfusion was administered within 7 days of intensive care unit admission. A total of 15 568 patients were screened, and 13 308 were excluded.

Interventions  Patients were randomized to receive either fresh or standard-issue red blood cells. A total of 1538 patients were randomized with 768 patients in the fresh red blood cell group and 770 in the standard-issue group.

Main Outcomes and Measures  The primary outcome measure was new or progressive multiple organ dysfunction syndrome, measured for 28 days or to discharge or death.

Results  Among 1538 patients who were randomized, 1461 patients (95%) were included in the primary analysis (median age, 1.8 years; 47.3% girls), in which there were 728 patients randomized to the fresh red blood cell group and 733 to the standard-issue group. The median storage duration was 5 days (interquartile range [IQR], 4-6 days) in the fresh group vs 18 days (IQR, 12-25 days) in the standard-issue group (P < .001). There were no significant differences in new or progressive multiple organ dysfunction syndrome between fresh (147 of 728 [20.2%]) and standard-issue red blood cell groups (133 of 732 [18.2%]), with an unadjusted absolute risk difference of 2.0% (95% CI, –2.0% to 6.1%; P = .33). The prevalence of sepsis was 25.8% (160 of 619) in the fresh group and 25.3% (154 of 608) in the standard-issue group. The prevalence of acute respiratory distress syndrome was 6.6% (41 of 619) in the fresh group and 4.8% (29 of 608) in the standard-issue group. Intensive care unit mortality was 4.5% (33 of 728) in the fresh group vs 3.5 % (26 of 732) in the standard-issue group (P = .34).

Conclusions and Relevance  Among critically ill pediatric patients, the use of fresh red blood cells did not reduce the incidence of new or progressive multiple organ dysfunction syndrome (including mortality) compared with standard-issue red blood cells.

Trial Registration  ClinicalTrials.gov Identifier: NCT01977547

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