OBJECTIVES: Balancing oxygen requirements, neurologic outcomes, and systemic complications from transfusions in traumatic brain injury (TBI) patients is challenging. This review compares liberal and restrictive transfusion strategies in TBI patients.

DATA SOURCES: Electronic databases were searched from inception to October 2024.

STUDY SELECTION: We included randomized controlled trials comparing liberal and restrictive transfusion strategies in TBI patients.

DATA EXTRACTION: Data were extracted by two reviewers using predefined forms.

DATA SYNTHESIS: We included five studies with 1,533 patients: 769 (50.2%) in the liberal transfusion group and 764 (49.8%) in the restrictive group. There were no significant differences between groups favorable Glasgow Outcome Scale (risk ratio [RR], 1.16; 95% CI, 1.00-1.34), although a leave-one-out analysis demonstrated significance in this endpoint (RR, 1.24; 95% CI, 1.06-1.45). No significant difference was found regarding hospital mortality (RR, 0.98; 95% CI, 0.76-1.27), mortality at follow-up (RR, 1.03; 95% CI, 0.82-1.28), mortality in the ICU (RR, 1.00; 95% CI, 0.73-1.37), infection rates (RR, 1.08; 95% CI, 0.95-1.23), thromboembolic events (RR, 1.79; 95% CI, 0.74-4.31), hospital length of stay (LOS) (mean difference [MD], -1.45; 95% CI, -4.85 to 1.96), or ICU LOS (MD, -0.47; 95% CI, -3.84 to 2.91). The liberal transfusion strategy group had a significantly higher prevalence of acute respiratory distress syndrome (RR, 1.78; 95% CI, 1.06-2.98) and received more blood units per patient (MD, 2.62; 95% CI, 1.90-3.33).

CONCLUSIONS: Our findings suggest that a liberal transfusion strategy results in better neurologic outcomes than a restrictive approach. Future research should examine the complication profile and the effects of using a 9 g/dL threshold. We advocate for revising current guidelines to establish 9 g/dL as the standard threshold for transfusions in TBI patients.

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