• LarciprettiAnna Laura LimaALL0000-0002-0522-7007School of Medicine, Federal University of Ouro Preto, Ouro Preto, Brazil., Ofonime Chantal Udoma-Udofa, Fernando Cotrim Gomes, Jéssica Sales de Oliveira, Elizabet Taylor Pimenta Weba, CavalcanteDeivyd Vieira SilvaDVSFederal University of Maranhão, São Luís, Brazil., Madhav Kiritbhai Dharaiya, and Matheus de Andrade Bannach.
• School of Medicine, Federal University of Ouro Preto, Ouro Preto, Brazil.
• Crit. Care Med. 2025 Jan 29.

ObjectivesBalancing 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 SourcesElectronic databases were searched from inception to October 2024.Study SelectionWe included randomized controlled trials comparing liberal and restrictive transfusion strategies in TBI patients.Data ExtractionData were extracted by two reviewers using predefined forms.Data SynthesisWe 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).ConclusionsOur 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.Copyright © 2025 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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