Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
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.

PubMed Disclaimer

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

References

    1. Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg. 2019;130(4):1080–97. - DOI - PubMed
    1. Injury GB. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(1):56–87. - DOI - PMC - PubMed
    1. Sekhon MS, McLean N, Henderson WR, Chittock DR, Griesdale DE. Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic brain injury. Crit Care. 2012;16(4):R128. - DOI - PMC - PubMed
    1. Salim A, Hadjizacharia P, DuBose J, Brown C, Inaba K, Chan L, et al. Role of anemia in traumatic brain injury. J Am Coll Surg. 2008;207(3):398–406. - DOI - PubMed
    1. Litofsky NS, Martin S, Diaz J, Ge B, Petroski G, Miller DC, et al. The negative impact of anemia in outcome from traumatic brain Injury. World Neurosurg. 2016;90:82–90. - DOI - PubMed

MeSH terms

LinkOut - more resources