Towards safer and more effective hemotherapy: addressing critical unmet needs in restrictive and liberal blood transfusion strategies
Résumé
Blood transfusion is still among the most commonly used life-saving procedures in contemporary medicine, but identifying the ideal transfusion threshold remains a significant clinical hurdle across various patient groups. In the last twenty years, growing evidence has moved clinical practice from liberal to restrictive transfusion approaches, backed by randomized controlled trials showing similar or better outcomes with reduced hemoglobin thresholds in various clinical situations. Nonetheless, considerable uncertainties remain concerning the relevance of restrictive strategies in at-risk groups, such as patients experiencing acute coronary syndromes, traumatic brain injuries, chronic cardiovascular conditions, blood cancers, obstetric bleeding, and critically ill patients with multiple comorbidities. Additionally, a heightened awareness of complications from transfusions, shortages of donor blood, effects of storage lesions, immunomodulatory responses, and economic limitations has strengthened initiatives to enhance patient blood management while maintaining sufficient oxygen delivery. This narrative review thoroughly analyzes the changing evidence regarding restrictive and liberal blood transfusion approaches, emphasizing their physiological foundations, clinical effectiveness, safety characteristics, and difficulties in implementation across key medical and surgical fields. The review combines results from key randomized clinical trials, modern international guidelines, and recent meta-analyses, highlighting both the advantages and shortcomings of existing evidence. Special focus is placed on ongoing controversies, such as personalized transfusion limits, targeted hemotherapy, indicators of tissue oxygen levels, transfusion practices in resource-constrained environments, and the application of artificial intelligence in clinical decision-making.
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