Liberal Transfusion versus Restrictive Transfusion and Outcomes in Critically Ill Adults: A Meta-Analysis

Abstract

<b><i>Objective:</i></b> We aimed to determine whether the restrictive red-cell transfusion strategy was superior to the liberal one in reducing all-cause mortality in critically ill adults. <b><i>Methods:</i></b> The MEDLINE, EMBASE, PubMed, Web of Science, and Cochrane Library Central Register of Controlled Trials databases were searched from inception to January 2019 to identify meta-analyses or systematic reviews and published randomized controlled trials which were restrictive versus liberal blood transfusion with mortality as the endpoint in critically ill adults. We used two search routes whereby one search was restricted to systematic reviews, reviews, or meta-analysis, and the other was not restricted. There were no date restrictions, but language was limited to English and the population was restricted to critically ill adults. The data of study methods, participant characteristics, and outcomes were extracted and analyzed independently by 2 reviewers. The main outcome was all-cause mortality. <b><i>Results:</i></b> Through screening the obtained records, we enrolled 7 randomized clinical trials that included information on restrictive versus liberal red-cell transfusion and mortality of intensive care unit (ICU) patients. Involving a total of 7,363 ICU adult patients, ICU mortality (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.62, 1.08, <i>p</i> = 0.15), 28/30-day mortality (RR 0.98, 95% CI 0.84, 1.13, <i>p</i> = 0.74), 60-day mortality (RR 1.01, 95% CI 0.87, 1.16, <i>p</i> = 0.91), 90-day mortality (RR 1.02, 95% CI 0.92, 1.14, <i>p</i> = 0.69), 120-day mortality (RR 1.29, 95% CI 0.67, 2.47, <i>p</i> = 0.44), and 180-day mortality (RR 0.91, 95% CI 0.75, 1.12, <i>p</i> = 0.38) were not statistically significantly different when the restrictive transfusion strategy was compared with the liberal transfusion strategy. However, we surprisingly discovered that 112 out of 469 (24%) patients who received a unit RBC transfusion when hemoglobin was less than 7 g/dL, and 142 out of 469 (30.3%) who received a unit of RBC transfused with hemoglobin less than 9 g/dL, had died during hospitalization (RR 0.79, 95% CI 0.64, 0.97, <i>p</i> = 0.03). The results showed that the restrictive transfusion strategy could decrease in-hospital mortality compared with the liberal transfusion strategy. It was safe to utilize a restrictive transfusion threshold of less than 7 g/dL in stable critically ill adults. <b><i>Conclusions:</i></b> In this study, we found that the restrictive red-cell transfusion strategy potentially reduced in-hospital mortality in critically ill adults with anemia compared with the liberal strategy.