Liberal versus restrictive red blood cell transfusion strategy in sepsis or septic shock: a systematic review and meta-analysis of randomized trials

Abstract

Background We assessed the effect of liberal versus restrictive red blood cell transfusion strategy on survival outcome in sepsis or septic shock by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). Methods We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases. We included RCTs that compared mortality between a liberal transfusion strategy with a hemoglobin threshold of 9 or 10 g/dL and a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL in adults with sepsis or septic shock. Two investigators independently screened citations and conducted data extraction. The primary outcome was 28- or 30-day mortality. Secondary outcomes were 60- and 90-day mortality, use of life support at 28 days of admission, and number of patients transfused during their intensive care unit stay. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs). Results A total of 1516 patients from three RCTs were included; 749 were randomly assigned to the liberal transfusion group and 767 to the restrictive strategy group. Within 28–30 days, 273 patients (36.4%) died in the liberal transfusion group, while 278 (36.2%) died in the restrictive transfusion group (pooled OR, 0.99; 95% confidence interval [CI], 0.67–1.46). For the primary outcome, heterogeneity was observed among the studies ( I 2 = 61.0%, χ 2 = 5.13, p = 0.08). For secondary outcomes, only two RCTs were included. There were no significant differences in secondary outcomes between the two groups. Conclusions We could not show any difference in 28- or 30-day mortality between the liberal and restrictive transfusion strategies in sepsis or septic shock patients by meta-analysis of RCTs. Our results should be interpreted with caution due to the existence of heterogeneity. As sepsis complicates a potentially wide range of underlying diseases, further trials in carefully selected populations are anticipated. Trial registration This present study was registered in the PROSPERO database ( CRD42018108578 ). Electronic supplementary material The online version of this article (10.1186/s13054-019-2543-1) contains supplementary material, which is available to authorized users.

Risk factors for blood transfusion in traumatic and postpartum hemorrhage patients: Analysis of the CRASH-2 and WOMAN trials

“…The higher frequency of single unit transfusions in low income countries may be driven by both lower blood donation rates and the higher frequency of anemia in low income countries. While restrictive transfusion practices in a range of settings have been shown to be beneficial, single unit transfusions may be insufficient to treat patients suffering from severe traumatic and postpartum hemorrhage [51][52][53].…”

Prevalence of and Recovery From Anemia Following Hospitalization for Critical Illness Among Adults

“…2 Clinicians have generally become more tolerant of anemia given similar short-term mortality rates with restrictive vs liberal red blood cell (RBC) transfusion strategies. [3][4][5] As such, the incidence of transfusion has decreased over time with a corresponding increase in the proportion of patients discharged with anemia. 6,7 Consequences associated with anemia remain incompletely defined, although recent data suggest that anemia at ICU discharge is associated with reduced physical function 3 months later in critical illness survivors.…”

Sepsis‐related anemia in a pediatric intensive care unit: transfusion‐associated outcomes

“…Most of the published large systematic reviews found that restrictive policy is comparable to liberal one. A recent meta‐analysis by Hirano et al in patients with sepsis could not show any difference in mortality between liberal and restrictive transfusion strategies. However, these results should be interpreted with caution because of population heterogeneity.…”