Liberal transfusion strategies reduce sepsis risk and improve neurological recovery in acute brain injury: an updated systematic review and meta-analysis.

PURPOSE: To advocate for a Liberal Transfusion Strategy (LTS) in neurocritical care patients with Acute Brain Injury (ABI) and provide updated evidence for optimizing transfusion thresholds in clinical guidelines.

BACKGROUND

Anemia frequently complicates ABI management, often necessitating red blood cell transfusions. However, the optimal hemoglobin (Hb) threshold for transfusion remains controversial. While earlier meta-analyses indicated no significant differences between LTS and restrictive transfusion strategies (RTS), emerging randomized controlled trials (RCTs) emphasize the need for reappraisal within neurocritical care.

METHODS

This meta-analysis included five RCTs involving 2399 patients (1,191 LTS; 1208 RTS) with ABI (subarachnoid hemorrhage, traumatic brain injury, or intracerebral hemorrhage). LTS was defined as transfusion at Hb ≤ 10-9 g/dL, and RTS as transfusion at Hb ≤ 7-8 g/dL. Outcomes assessed included sepsis or septic shock, ICU mortality, unfavorable functional outcomes at six months, venous thromboembolism (VTE), acute respiratory distress syndrome (ARDS), and in-hospital mortality.

RESULTS

RTS significantly increased the risk of sepsis or septic shock (relative risk [RR]: 1.42; 95% confidence interval [CI] 1.08-1.86; p = 0.01) and unfavorable functional outcomes at six months (RR 1.13; 95% CI 1.06-1.21; p = 0.0003). No significant differences were observed in ICU mortality (RR 1.00; 95% CI 0.84-1.20; p = 0.96), VTE (RR: 0.88; 95% CI 0.56-1.38; p = 0.58), ARDS (RR 1.05; 95% CI 0.69-1.61; p = 0.81), or in-hospital mortality (RR 0.98; 95% CI 0.76-1.26; p = 0.89). Heterogeneity was minimal (I2 < 25%).

CONCLUSION

LTS demonstrates the potential to enhance safety and functional recovery in ABI patients by mitigating sepsis risk and promoting favorable neurologic outcomes. Further high-powered RCTs are warranted to validate these findings and refine transfusion protocols.