• Shane W English, Anthony Delaney, Dean A Fergusson, Michaël Chassé, Alexis F Turgeon, François Lauzier, Angie Tuttle, Ofer Sadan, Donald E Griesdale, Gary Redekop, Martin Chapman, Mathew Hannouche, Andreas Kramer, Ian Seppelt, Andrew Udy, Demetrios J Kutsogiannis, Ryan Zarychanski, Frédérick D'Aragon, J Gordon Boyd, Gavin Salt, Judith Bellapart, Gordon Wood, Luis Cava, Gwynedd Pickett, Lauren Koffman, Irene Watpool, Frances Bass, Naomi Hammond, Tim Ramsay, Ranjeeta Mallick, Damon C Scales, Christopher R Andersen, Emily Fitzgerald, Phil Talbot, Dar Dowlatshahi, John Sinclair, Jason Acker, Shawn C Marshall, Lauralyn McIntyre, and SAHARA Trial Investigators on behalf of the Canadian Critical Care Trials Group.
• From Ottawa Hospital Research Institute, Ottawa (S.W.E., D.A.F., A.T., I.W., T.R., R.M., D.D., S.C.M., L.M.); the Department of Medicine, Division of Critical Care, Faculty of Medicine, University of Ottawa, Ottawa (S.W.E., L.M.); School of Epidemiology and Public Health University of Ottawa, Ottawa (S.W.E., D.A.F., L.M.); Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa (D.A.F., D.D., S.C.M.); George Institute for Global Health, Sydney (A.D., F.B., N.H., C.R.A., P.T.); Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St. Leonards, NSW, Australia (A.D., N.H., C.R.A., E.F.); the Faculty of Medicine and Health, University of Sydney Northern Clinical School, St. Leonards, NSW, Australia (A.D., C.R.A.); Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia (A.D., A.U.); the Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal (M. Chassé); the Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal (M. Chassé); the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Quebec, QC, Canada (A.F.T., F.L.); Population Health and Optimal Health Practice Research Unit, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC, Canada (A.F.T., F.L.); the Department of Anesthesia, Critical Care Medicine Service, Hôpital de L'Enfant-Jésus, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC, Canada (A.F.T., F.L.); the Department of Medicine, Faculty of Medicine, Université Laval, Quebec, QC, Canada (F.L.); the Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Emory University Hospital and Grady Memorial Hospital, Atlanta (O.S.); the Department of Medicine, Division of Critical Care Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, Canada (D.E.G.); the Division of Neurosurgery, Vancouver General Hospital, Vancouver, BC, Canada (G.R.); the Division of Neurosurgery, Department of Surgery, the University of British Columbia, Vancouver, Canada (G.R.); Neurocritical Care and Anesthesia, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto (M. Chapman); McGill University, Montreal (M.H.); the Departments of Critical Care Medicine and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.K.); Nepean Clinical School, University of Sydney, Sydney (I.S.); the Department of Clinical Medicine, Macquarie University, Sydney (I.S.); the Critical Care and Trauma Division, the George Institute for Global Health, Sydney (I.S.); the Department of Intensive Care and Hyperbaric Medicine, the Alfred, Melbourne, VIC, Australia (A.U.); the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada (D.J.K.); the Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada (R.Z.); the Department of Medical Oncology/Hematology and the Paul Albrechtsen Research Institute, Cancer Care Manitoba, Winnipeg, Canada (R.Z.); the Department of Anesthesiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada (F.D.); Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada (F.D.); the Department of Medicine, Division of Neurology, School of Medicine, Queen's University, Kingston, ON, Canada (J.G.B.); Department of Critical Care Medicine, School of Medicine, Queen's University, Kingston, ON, Canada (J.G.B.); the Intensive Care Unit, Prince of Wales Hospital, Randwick, NSW, Australia (G.S.); the Department of Intensive Care, Royal Brisbane and Women's Hospital, Herston, QLD, Australia (J.B.); University of Queensland, Brisbane, Australia (J.B.); the Department of Adult Intensive Care, Island Health Authority, Victoria, BC, Canada (G.W.); University of Colorado School of Medicine, Aurora (L.C.); the Department of Surgery, Division of Neurosurgery, Dalhousie University, Halifax, NS, Canada (G.P.); QEII Health Sciences Centre, Halifax, NS, Canada (G.P.); Lewis Katz School of Medicine, Temple University, Philadelphia (L.K.); Rush University Medical Center, Chicago (L.K.); Royal North Shore Hospital, Sydney (F.B.); the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto (D.C.S.); the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto (D.C.S.); the Kirby Institute, University of New South Wales, Kensington, Australia (C.R.A.); the Department of Surgery, Division of Neurosurgery, Faculty of Medicine, University of Ottawa, Ottawa (J.S.); Canadian Blood Services, Edmonton, AB, Canada (J.A.); the Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada (J.A.); and Physical Medicine and Rehabilitation, Bruyere Continuing Care, Ottawa (S.C.M.).
• N. Engl. J. Med. 2024 Dec 9.

BackgroundThe effect of a liberal red-cell transfusion strategy as compared with a restrictive strategy in patients during the critical care period after an aneurysmal subarachnoid hemorrhage is unclear.MethodsWe randomly assigned critically ill adults with acute aneurysmal subarachnoid hemorrhage and anemia to a liberal strategy (mandatory transfusion at a hemoglobin level of ≤10 g per deciliter) or a restrictive strategy (optional transfusion at a hemoglobin level of ≤8 g per deciliter). The primary outcome was an unfavorable neurologic outcome, defined as a score of 4 or higher on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at 12 months. Secondary outcomes included 12-month functional independence as assessed with the Functional Independence Measure (FIM; scores range from 18 to 126) and quality of life as assessed with the EuroQol five-dimension, five-level (EQ-5D-5L) utility index (scores range from -0.1 to 0.95) and a visual analogue scale (VAS; scores range from 0 to 100); on each assessment, higher scores indicate better health status or quality of life.ResultsA total of 742 patients underwent randomization at 23 centers. The analysis of the primary outcome at 12 months included 725 patients (97.7%). An unfavorable neurologic outcome occurred in 122 of 364 patients (33.5%) in the liberal-strategy group and in 136 of 361 patients (37.7%) in the restrictive-strategy group (risk ratio, 0.88; 95% confidence interval [CI], 0.72 to 1.09; P = 0.22). The mean (±SD) FIM score was 82.8±54.6 in the liberal-strategy group and 79.8±54.5 in the restrictive-strategy group (mean difference, 3.01; 95% CI, -5.49 to 11.51). The mean EQ-5D-5L utility index score was 0.5±0.4 in both groups (mean difference, 0.02; 95% CI, -0.04 to 0.09). The mean VAS score was 52.1±37.5 in the liberal-strategy group and 50±37.1 in the restrictive-strategy group (mean difference, 2.08; 95% CI, -3.76 to 7.93). The incidence of adverse events was similar in the two groups.ConclusionsIn patients with aneurysmal subarachnoid hemorrhage and anemia, a liberal transfusion strategy did not result in a lower risk of an unfavorable neurologic outcome at 12 months than a restrictive strategy. (Funded by the Canadian Institutes of Health Research and others; SAHARA ClinicalTrials.gov number, NCT03309579.).Copyright © 2024 Massachusetts Medical Society.

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