Nguyen Nhan, Quang Tri Ho Vinh, Downes David, Tran Bao Nghi, Ngoc Dan Nguyen Vy, Velasco Emmanuel Mark M
Faculty of Medicine, University of Debrecen, 1 Egyetem ter, Debrecen, 4032, Hungary.
Department of Rural Medicine, The University of New England, Armidale, Australia.
Crit Care. 2025 May 6;29(1):181. doi: 10.1186/s13054-025-05397-5.
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.
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.
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.
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 (I < 25%).
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.
倡导对急性脑损伤（ABI）的神经重症患者采用宽松输血策略（LTS），并为优化临床指南中的输血阈值提供最新证据。
贫血常使ABI的治疗复杂化，常需输注红细胞。然而，输血的最佳血红蛋白（Hb）阈值仍存在争议。虽然早期的荟萃分析表明LTS与限制性输血策略（RTS）之间无显著差异，但新出现的随机对照试验（RCT）强调在神经重症监护中需要重新评估。
本荟萃分析纳入了5项RCT，涉及2399例ABI（蛛网膜下腔出血、创伤性脑损伤或脑出血）患者（1191例采用LTS；1208例采用RTS）。LTS定义为Hb≤10 - 9g/dL时输血，RTS定义为Hb≤7 - 8g/dL时输血。评估的结局包括败血症或感染性休克、重症监护病房（ICU）死亡率、6个月时不良功能结局、静脉血栓栓塞（VTE）、急性呼吸窘迫综合征（ARDS）和住院死亡率。
RTS显著增加了败血症或感染性休克的风险（相对风险[RR]：1.42；95%置信区间[CI] 1.08 - 1.86；p = 0.01）以及6个月时不良功能结局的风险（RR 1.13；95% CI 1.06 - 1.21；p = 0.0003）。在ICU死亡率（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）或住院死亡率（RR 0.98；95% CI 0.76 - 1.26；p = 0.89）方面未观察到显著差异。异质性最小（I²<25%）。
LTS通过降低败血症风险和促进良好的神经学结局，显示出提高ABI患者安全性和功能恢复的潜力。需要进一步开展大规模RCT来验证这些发现并完善输血方案。
