Blood Transfusion Is Associated with Poor Outcome, Delayed Infraction and Nosocomial Infection In Patients With Subarachnoid Hemorrhage

Objective: Patients with subarachnoid hemorrhage (SAH) frequently develop delayed cerebral ischemia, and may be especially vulnerable to the effects of anemia. However, the potentially harmful effects of allogeneic packed red blood cells (PRBCs) are increasingly being recognized. The optimal transfusion threshold is unknown, but current practice most often utilizes a liberal approach. We assessed the association between anemia or transfusion and subsequent adverse outcomes. Design: Retrospective cohort study. Setting: Neuroscience intensive care unit of a university hospital. Patients: 245 consecutive patients with aneurysmal SAH. Interventions: None. Measurements: Logistic regression models were used to adjust for baseline differences in age, severity of neurological impairment, amount of blood on computed tomography (CT), and the presence or absence of clinical vasospasm. Main Results: Individually, anemia (defined as a nadir hemoglobin [Hb] concentration of less than 10 g/dL) and the use of blood transfusions were both associated with the combined outcome of death, severe disability or delayed infarction (adjusted OR for anemia: 2.6, p=0.008; adjusted OR for transfusion: 3.3, p=0.002) . When they were together introduced into a logistic regression model, only blood transfusion remained an independent predictor (adjusted OR 2.5, p=0.04). A significant association also existed between transfusion and the subsequent development of nosocomial infections (OR 2.9, p=0.0005). Among patients who developed clinical vasospasm, Hb concentration at the onset of symptoms did not predict outcome. There was also no difference in the III combined endpoint based on the duration of time that PRBCs had been stored prior to transfusion. Conclusion: Blood transfusion in patients with SAH is associated with death, severe disability, delayed infarction and nosocomial infection. These observational results should be interpreted with caution, but do not support current liberal transfusion practices. Randomized trials evaluating lower transfusion thresholds in patients with SAH, and other forms of brain injury, are urgently required.

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