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

Summary

Across five RCTs (n=2399), restrictive transfusion thresholds increased sepsis/septic shock and worsened 6-month functional outcomes in acute brain injury without affecting ICU or in-hospital mortality, VTE, or ARDS. Liberal thresholds (Hb ≤10–9 g/dL) may be safer in neurocritical care.

Key Findings

• Restrictive transfusion strategy increased sepsis/septic shock risk (RR 1.42; 95% CI 1.08–1.86; p=0.01).
• Restrictive transfusion worsened 6-month functional outcomes (RR 1.13; 95% CI 1.06–1.21; p=0.0003).
• No differences between strategies in ICU mortality, in-hospital mortality, ARDS, or VTE.

Clinical Implications

Consider liberal hemoglobin thresholds in acute brain injury to reduce sepsis risk and improve functional recovery, pending local protocols. ARDS incidence was not increased, supporting safety from a pulmonary standpoint.

Limitations

• Heterogeneous ABI etiologies and transfusion thresholds across trials.
• No mortality benefit detected; ARDS outcome neutral.

Future Directions

Conduct large, CONSORT-compliant RCTs focused on infection and neurologic outcomes, exploring individualized transfusion thresholds (e.g., brain oxygenation-guided) and patient subgroups.