A Liberal Transfusion Strategy Leads to Higher Infection Rates, ORthopaedic Trauma and Anemia: Conservative vs. Liberal Transfusion Strategy (ORACL), a Prospective Randomized Study 30 Day Inpatient Complications

Abstract

Purpose: There is ongoing debate what level of anemia should be used as a transfusion trigger for asymptomatic trauma patients no longer in a resuscitative phase immediately following trauma. A previous retrospective case-control study by one of the lead investigators showed there was a higher risk of complications with a more liberal strategy, and this appeared to be dose-dependent. Multiple previous studies have shown allogeneic blood transfusion is immunosuppressive and may increase infection rates in surgical patients. This study was completed to determine if a more conservative strategy was safe and might decrease the risk of infection. Methods: The ORACL pilot study randomized 100 patients ages 18-50 to a conservative transfusion strategy of 5.5 g/dL vs a liberal strategy of 7.0 g/dL in asymptomatic patients no longer being resuscitated who required inpatient admission for an associated musculoskeletal injury. Enrollment was performed at 3 level 1 trauma centers from 2014-2021. Ninety-nine patients completed 30 day follow up. Results: There was a significant association between a liberal transfusion strategy and higher rate of deep infection (defined as unplanned return to OR for debridement or admission for IV antibiotics) but superficial infection (defined as oral antibiotics alone needed without admission or debridement) did not reach statistical significance (Table 1). Multiple secondary outcomes or complications that might occur due to anemia or transfusion were not different between the two groups. Conclusion: This study shows a conservative transfusion strategy of 5.5 g/dL in an asymptomatic young Orthopaedic trauma patient leads to a lower deep infection rate without an increase in adverse outcomes.