review · Cureus
This systematic review and meta-analysis assessed the safety and efficacy of liberal versus restrictive blood transfusion strategies in patients suffering from acute brain injury, including traumatic brain injury, subarachnoid haemorrhage, and intracranial haemorrhage. Researchers synthesised data from six randomised controlled trials involving 2,645 patients. The primary analysis found no statistically significant difference between a liberal transfusion threshold of ten grams per decilitre or less and a restrictive threshold of eight grams per decilitre or less regarding unfavourable neurological outcomes at six months, mortality, acute respiratory distress syndrome, or infections. Although secondary sensitivity analyses indicated a potential neurological benefit with liberal transfusion when altering the analytical model or excluding one trial, the primary findings suggest that overall outcomes do not substantially differ. Consequently, adopting a restrictive transfusion approach remains a reasonable practice to preserve scarce blood supplies.
Determining blood transfusion thresholds for patients with acute brain injury is vital for clinical care. Higher thresholds theoretically deliver more oxygen to injured brain tissue but deplete limited blood supplies and carry risks of transfusion reactions. Demonstrating that restrictive strategies yield broadly similar outcomes helps clinicians and healthcare systems optimize blood utilisation without compromising general safety.
The findings are relevant to critical care clinicians, hospital blood banks, and healthcare policy makers developing clinical practice guidelines for neurocritical care. As this research synthesises existing clinical trials, the insights can be directly applied to hospital protocols to support blood conservation programmes, though the abstract does not indicate any commercial product or technology development pathway.
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Oxygen is critical for neurological function and survival, particularly in acute brain injury. Although transfusion at higher thresholds theoretically provides improved oxygen delivery to neurons, there is an associated risk of allogeneic reactions and increased utilization of limited blood resources. Conversely, although a lower threshold conserves resources, it may increase the risk of neuronal oxygen deprivation. The optimal transfusion strategy for patients with acute brain injury remains unclear. This systematic review and meta-analysis aimed to compare the efficacy and safety of liberal (hemoglobin threshold ≤10 g/dL) versus restrictive (≤8 g/dL) transfusion strategies in patients with acute brain injury (traumatic brain injury (TBI), subarachnoid hemorrhage, or intracranial hemorrhage), synthesizing evidence from randomized controlled trials (RCTs). We searched the PubMed, Excerpta Medica database (Embase), and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify RCTs comparing restrictive and liberal transfusion strategies in patients with acute brain injury. Eligible trials reported outcomes including (1) unfavorable neurological outcomes defined as a score ≤5 on the Glasgow Outcome Scale Extended (GOSE) at six months, (2) mortality, (3) acute respiratory distress syndrome (ARDS), and (4) infections. Statistical heterogeneity was assessed using I² statistics. To account for statistical heterogeneity, a random-effects model was used to analyze all outcomes. We included six RCTs comprising 2,645 patients, of whom 1,303 (49.2%) were randomized to a liberal transfusion strategy. A reduction in unfavorable neurological endpoints (55.7% vs. 61.4%; risk ratios (RR) 0.92; 95% CI 0.84-1.01) was observed in the liberal group, although this difference was not statistically significant. In sensitivity analyses of unfavorable neurologic outcomes, statistical significance was achieved by removing a single paper (54.7% vs. 61.6%; RR 0.89; 95% CI 0.84-0.95) or by employing a fixed-effects model (RR 0.91; 95% CI 0.85-0.97). This meta-analysis suggests that there is no substantial difference in outcomes between a liberal and a restrictive transfusion strategy in patients with acute brain injury. While our primary analysis showed no statistically significant difference between strategies, sensitivity analyses suggested a potential benefit of liberal transfusion in reducing unfavorable neurologic outcomes. However, given the non-significant primary results and the importance of blood conservation, a restrictive strategy may be reasonable until further evidence emerges.
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DOI: 10.7759/cureus.83847
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