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Meta-Analysis
. 2025 May 6;29(1):181.
doi: 10.1186/s13054-025-05397-5.

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

Nhan Nguyen  1 , Vinh Quang Tri Ho  2 , David Downes  3 , Bao Nghi Tran  2 , Vy Ngoc Dan Nguyen  4 , Emmanuel Mark M Velasco Jr #  5
Affiliations
Meta-Analysis

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

Nhan Nguyen et al. Crit Care. .

Abstract

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.

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Conflict of interest statement

Declarations. Ethical approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: All authors report no relationships that could be construed as a conflict of interest. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. Nothing to disclose.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram. PRISMA 2020 flow diagram for updated systematic reviews which included searches of databases and registers only
Fig. 2
Fig. 2
Sepsis or Septic shock risk
Fig. 3
Fig. 3
UNOs at 6-month risk
Fig. 4
Fig. 4
Mortality at ICU
Fig. 5
Fig. 5
Inclusion and Exclusion of “ROBERTSON 2014” for UNOs at 6 months
Fig. 6
Fig. 6
Sepsis or Septic shock risk
See this image and copyright information in PMC

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