Restrictive versus liberal transfusion strategies in burn patients: A systematic review and meta-analysis of clinical outcomes

Introduction: Optimal transfusion thresholds in burn patients remain a topic of debate. While liberal strategies aim to improve oxygen delivery, restrictive protocols may minimize transfusion-related risks. Evidence in general critical care supports restrictive approaches, but burn-specific data are sparse. Methods: This systematic review adhered to PRISMA guidelines. Electronic databases were searched through April 2025. Eligible studies enrolled burn patients (≥20% TBSA in adults; ≥15% in pediatric/elderly patients) undergoing surgical management and compared restrictive (Hb < 7–8 g/dL) versus liberal (Hb < 10–11 g/dL) transfusion strategies. Primary outcome was mortality. Secondary outcomes included ICU/hospital length of stay, ventilation duration, infection, sepsis, MODS, and transfusion-related events. Risk of bias was assessed using RoB 2.0 and ROBINS-I tools. Results: Five studies (2 RCTs, 3 cohort) totaling 3,199 patients were included. Mortality was lower in the restrictive group (RR = 0.85), though not statistically significant (p = 0.70; I2 = 79%). No significant differences were found for ICU stay (MD = 0.55 days), hospital stay (MD = –0.86 days), ventilation duration (MD = 3.38 days), wound infection (RR = 0.97), sepsis (RR = 0.97), or MODS (MD = 0.28). Risk of bias was low in one RCT, moderate in another, and serious in the cohort study. Conclusion: Restrictive transfusion thresholds do not increase adverse outcomes in burn patients and may be clinically safe when active bleeding is absent. Our findings support the consideration of restrictive protocols in burn care, but additional high-quality trials are warranted to confirm long-term efficacy and safety.