Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence

Abstract

Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.

Keywords: TBI; anemia; hemoglobin; systematic review; transfusion; traumatic brain injury.

FIG. 1.

PRISMA flow diagram detailing the methodology of the systemic review. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

FIG. 2.

(A) Comparison of mortality rate with restrictive and liberal transfusion thresholds. (B) Comparison of units of pRBCs transfused with restrictive and liberal transfusion thresholds. 95% CI, 95% confidence interval; IV, inverse variance; pRBCs, packed red blood cells; SD, standard deviation; Tx, treatment.

FIG. 3.

(A) Comparison of age in transfused and non-transfused patients. (B) Comparison of ISS at presentation in transfused and non-transfused patients. (C) Comparison of mortality rate in transfused and non-transfused patients. (D) Comparison of complications at presentation in transfused and non-transfused patients. (E) Comparison of GCS at presentation in transfused and non-transfused patients. 95% CI, 95% confidence interval; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; IV, inverse variance; SD, standard deviation; SE, standard error; Tx, treatment.