Risks associated with red blood cell transfusion in the trauma population,a meta-analysis

Introduction

A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.

Objectives

To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).

Data sources

EMBASE (1947–2012) and MEDLINE (1946–2012).

Study eligibility criteria

Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).

Participants

Trauma patients.

Exposure

Red blood cell transfusion.

Methods

A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I² statistic. Study quality was assessed using the Newcastle-Ottawa Scale.

Results

40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04–1.10, I² 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02–1.14, I² 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03–1.10, I² 0%) also increased with each additional RBC unit transfused.

Conclusions

We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.     

High-dose antioxidant administration is associated with a reduction in post-injury complications in critically ill trauma patients

Background

We recently demonstrated a high-dose antioxidant (AO) protocol was associated with reduction in mortality. The purpose of this study was to evaluate the impact of AO on organ dysfunction and infectious complications following injury.

Patients and methods

High-dose AO protocol: ascorbic acid 1000 mg q 8 h, α-tocopherol 1000 IU q 8 h, and selenium 200 mcg qd for 7-day course. Retrospective cohort study evaluating all patients admitted after protocol implementation (AO+), October 1, 2005 to September 30, 2006. Comparison cohort (AO−): all patients admitted in the year prior to implementation, October 1, 2004 to September 30, 2005.

Results

2272 patients included in the AO+ group, 2022 patients in the AO− group. Demographics and injury severity were similar. Abdominal compartment syndrome (ACS) (2.9% vs. 0.7%, <0.001), surgical site infections (2.7% vs. 1.3%, p = 0.002), pulmonary failure (27.6% vs. 17.4%, p < 0.001), and ventilator-dependent respiratory failure (10.8% vs. 7.1%, p < 0.001) were significantly less in the AO+ group. Multivariate regression showed 53% odds reduction in abdominal wall complications and 38% odds reduction in respiratory failure in the AO+ group.

Conclusions

Implementation of a high-dose AO protocol was associated with a reduction in respiratory failure and ventilator-dependence. In addition, AO were associated with a marked decrease in abdominal wall complications, including ACS and surgical site infections.     

Early supplemental parenteral nutrition is associated with increased infectious complications in critically ill trauma patients

BACKGROUND: Parenteral nutrition (PN) is often used in severely injured patients when caloric goals are not achieved enterally. The purpose of this study is to determine whether early administration of parenteral nutrition is associated with an increased risk for infection after severe injury. STUDY DESIGN: Retrospective cohort study of severely injured blunt trauma patients enrolled from eight trauma centers participating in the "Inflammation and the Host Response to Injury" (Glue Grant) study. We compared patients receiving PN within 7 days after injury with a control group that did not receive early PN. We then focused on patients who tolerated at least some enteral nutrition (EN) during the first week and evaluated the potential influence of supplemental PN on outcomes in this "enteral tolerant" subgroup. Primary outcomes included occurrence of a nosocomial infection after the first postinjury week. Secondary outcomes included type of infection and hospital mortality. RESULTS: Of 567 patients enrolled, 95 (17%) received early PN. Early PN use was associated with a greater risk of nosocomial infection (relative risk [RR] = 2.1; 95% CI, 1.6 to 2.6; p < 0.001). In the enteral-tolerant subgroup (n = 249), early PN was also associated with an increase in nosocomial infections (RR = 1.6; 95% CI, 1.2 to 2.1; p = 0.005) in part because of an increased risk of bloodstream infection (RR = 2.8; 95% CI, 1.5 to 5.3; p = 0.002). Mortality tended to be higher in patients receiving additional EN and PN versus EN alone (RR = 2.3; 95% CI, 1.0 to 5.2; p = 0.06). CONCLUSIONS: In critically ill trauma patients who are able to tolerate at least some EN, early PN administration can contribute to increased infectious morbidity and worse clinical outcomes.     

急诊手术围手术期输血与术后感染及并发症的关系

目的 分析急诊手术患者围手术期输血与术后感染的关系。方法 收集2011年至2015年部分急诊手术住院患者病历资料,包括患者基线资料、围手术期临床和实验室数据以及住院期间并发症资料。输血的定义范围为从患者入院到出院的任何输血事件。主要记录术后感染性事件,包括切口和手术部位感染、伤口裂开、尿路感染、肺炎、败血症和感染性休克;次要记录包括住院时间、非计划气管插管、呼吸机使用超过48小时、急性肾衰竭,任何血栓栓塞事件和意外再次手术探查等。结果 在收集到的3153例急诊手术患者中,共242例（7.7%）接受输血治疗,接受输血患者年龄大于无输血患者,输血组BMI低于未输血组;输血患者ASA分类3级和4级低于未输血组;输血患者的平均总手术时间、总住院时间比无输血组长;输血患者发生血栓栓塞并发症的风险,如肺栓塞、深静脉血栓、呼吸功能障碍的风险增高;输血患者更有可能进行非计划气管插管。本组病例共594例患者（18.83%, 594/3135）发生术后感染事件,其中输血患者的感染率占所有输血者的39.7%（96/242）;糖尿病、COPD、慢性心脏病和高血压等慢性疾病史有显著性差异;体重减轻超过10%、较高ASA评分及污染严重伤口更容易感染;皮质类固醇使用、出血性疾病的也更容易感染。此外,低蛋白血症、低血细胞比容和也存在显著差异;开放手术感染率高于腹腔镜手术。结论 急诊手术患者接受输血与术后感染性并发症的风险增加有关。     

造血干细胞移植后并发感染121例的临床分析

目的探讨造血干细胞移植(HSCT)后并发感染的临床病原学特点和相关危险因素。方法共有121例造血系统疾病患者接受HSCT,其中51例行异基因外周造血干细胞移植,40例行异基因骨髓移植,4例行异基因外周血造血干细胞和骨髓混合移植,5例行脐带血移植,16例行自体造血干细胞移植,5例行自体CD34~+细胞移植。患者均采用化疗进行预处理。采用短程甲氨蝶呤联合环孢素A预防移植物抗宿主病(GVHD),部分病例加用达利珠单抗或抗淋巴细胞球蛋白。结果121例患者中,116例患者获得造血重建,3例移植失败,2例在移植物植活前因严重感染死亡。移植后60d内,83例(68．6%)共发生感染97次,64例(77．1%)发生感染时中性粒细胞＜0．5×10~9/L,患者均有不同程度的发热。口咽黏膜和呼吸道(上、下呼吸道)是最常见的感染部位,占64．9%。21例患者的23次感染中,共分离出20株细菌和7株真菌,65%为革兰氏阴性杆菌。10例患者并发巨细胞病毒感染。因感染死亡的患者共8例,均为异基因造血干细胞移植患者。发生Ⅱ～Ⅳ度急性GVHD患者的感染发生率(88．9%,24/27)高于0～Ⅰ度急性GVHD患者(60．3%,44/73,P＜0．01)。结论造血干细胞移植后60d内的感染多发生于粒细胞缺乏期；口咽黏膜炎和呼吸道是常见感染部位,下呼吸道感染者的死亡率高,侵袭性真菌感染者的预后不佳；发生Ⅱ～Ⅳ度急性GVHD者有较高的感染发生率。     

An evidence-based approach to red blood cell transfusions in asymptomatically anaemic patients

Introduction

Surgeons and physicians encounter blood transfusions on a daily basis but a robust evidence-based strategy on indications and timing of transfusion in asymptomatic anaemic patients is yet to be determined. For judicious use of blood products, the risks inherent to packed red blood cells, the patient’s co-morbidities and haemoglobin (Hb)/haematocrit levels should be considered. This review critiques and summarises the latest available evidence on the indications for transfusions in healthy and cardiac disease patients as well as the timing of transfusions relative to surgery.

Methods

An electronic literature search of the MEDLINE^®, Google Scholar™ and Trip databases was conducted for articles published in English between January 2006 and January 2015. Studies discussing timing and indications of transfusion in medical and surgical patients were retrieved. Bibliographies of studies were checked for other pertinent articles that were missed by the initial search.

Findings

Six level 1 studies (randomised controlled trials or systematic reviews) and six professional society guidelines were included in this review. In healthy patients without cardiac disease, a restrictive transfusion trigger of Hb 70–80g/l is safe and appropriate whereas in cardiac patients, the trigger is Hb 80–100g/l. The literature on timing of transfusions relative to surgery is limited. For the studies available, preoperative transfusions were associated with a decreased incidence of subsequent transfusions and timing of transfusions did not affect the rates of colorectal cancer recurrence.     

Incidence of infectious complications associated with the use of histamine2-receptor antagonists in critically ill trauma patients.

OBJECTIVE: To determine the impact of histamine2 (H2)-receptor antagonist use on the occurrence of infectious complications in severely injured patients. SUMMARY BACKGROUND DATA: Some previous studies suggest an increased risk of nosocomial pneumonia associated with the use of H2-receptor blockade in critically ill patients, but other investigations suggest an immune-enhancing effect of H2-receptor antagonists. The purpose of this study was to determine whether H2-receptor antagonist use affects the overall incidence of infectious complications. METHODS: Patients enrolled in a randomized trial comparing ranitidine with sucralfate for gastritis prophylaxis were examined for all infectious complications during their hospitalization. Data on the occurrence of pneumonia were prospectively collected, and other infectious complications were retrospectively obtained from the medical record. The relative risk of infectious complications associated with ranitidine use and total infectious complications were analyzed. RESULTS: Of 98 patients included, the charts of 96 were available for review. Sucralfate was given to 47, and 49 received ranitidine. Demographic factors were similar between the groups. Ranitidine use was associated with a 1.5-fold increased risk of developing any infectious complication (37 of 47 vs. 26 of 47; 95% confidence interval, 1.04 to 2.28). Infectious complications totaled 128 in the ranitidine-treated group and 50 in the sucralfate-treated group (p = 0.0014). These differences remained after excluding catheter-related infections (p = 0.0042) and secondary bacteremia (p = 0.0046). CONCLUSIONS: Ranitidine use in severely injured patients is associated with a statistically significant increase in overall infectious complications when compared with sucralfate. These results indicate that ranitidine should be avoided where possible in the prophylaxis of stress gastritis.     

Alterations of red blood cell shape in patients with severe trauma

BACKGROUND: Trauma is accompanied by a decrease in red blood cell (RBC) deformability, which may manifest itself earlier than secondary septic complications. The mechanisms of this phenomenon are not clear. The aim of this study is to determine when the alterations of RBC shape appear in trauma patients. METHODS: RBC shape was examined by scanning electron microscopy in 43 patients with multisystem trauma. Blood samples were taken at admission and every 24 hours afterward for 4 to 10 days. The patients were divided into two groups: the survivors and those who died of septic complications. The control group consisted of 10 healthy volunteers. RESULTS: A significant decrease in the percentage of discoid erythrocytes, compared with the volunteers, was observed in both groups of patients at admission (77.6 +/- 11.9 and 66.7 +/- 5.8 vs. 96.0 +/- 2.9%, p < 0.01). The percentage of irreversibly changed RBC (spherostomatocytes, spherocytes) was lower in survivors (12.9 +/- 2.0% vs. 20.3 +/- 9.4%, p < 0.01). This phenomenon remained constant until the end of the study. The survivors only showed a tendency toward the improvement of RBC shape. CONCLUSION: RBC shape alterations appear within the first hours after trauma and persist for at least 7 to 10 days. These changes are more severe in patients with secondary septic complications.     

The use of blood and blood products in aortic surgery is associated with adverse outcomes

ObjectiveTo report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products.MethodsAll patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival.ResultsA total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001).ConclusionsIn patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.     

Reducing red blood cell transfusion in elective surgical patients: the role of audit and practice guidelines

In 1996, we prospectively audited peri-operative transfusion practice in elective surgical patients over a 3-month period. Two-unit transfusions represented 60% of all transfusions. Haemoglobin was measured infrequently prior to transfusion and the main 'trigger' for transfusion was an estimated blood loss in excess of 500 ml. Transfusion guidelines that required the haemoglobin level to be measured immediately before transfusion were introduced. The audit was repeated in 1998; transfusion 'triggers' and the number of transfusions for the two periods were compared. In the second audit, the total number of transfusions decreased by 43%. The mean estimated blood loss associated with a 2-unit transfusion had increased from 608 (373) ml to 1320 (644) ml (p < 0.01) and the estimated haemoglobin concentration after transfusion had decreased from 12.4 (1.8) g.dl-1 to 9.9 (2.4) g.dl-1 (p < 0.01). These results suggest that transfusion guidelines can have a significant impact on clinical practice.     

Beta-blocker use is associated with improved outcomes in adult trauma patients

BACKGROUND: Beta-adrenoreceptor blocker (beta-blocker) therapy may improve outcomes in surgical patients by decreasing cardiac oxygen consumption and hypermetabolism. Because beta-blockers can lower the systemic blood pressure and cerebral perfusion pressure, there is concern regarding their use in patients with head injury. However, beta-blockers may protect beta-receptor rich brain cells by attenuating cerebral oxygen consumption and metabolism. We hypothesized that beta-blockers are safe in trauma patients, even if they have suffered a significant head injury. METHODS: Using pharmacy and trauma registry data of a Level I trauma center, we identified a cohort of trauma patients who received beta-blockers during their hospital stay (beta-cohort). Trauma admissions who did not receive beta-blockers were in the control cohort. beta-blocker status, in combination with other variables associated with mortality, were placed in a stepwise multivariate logistic regression to identify independent predictors of fatal outcome. RESULTS: In all, 303 (7%) of 4,117 trauma patients received beta-blockers. In the beta-cohort, 45% of patients were on beta-blockers preinjury. The most common reason to initiate beta-blocker therapy was blood pressure (60%) and heart rate (20%) control. The overall mortality rate was 5.6% and head injury was considered to be the major cause of death. After adjusting for age, Injury Severity Scale score, blood pressure, Glasgow Coma Scale score, respiratory status, and mechanism of injury, the odds ratio for fatal outcome was 0.3 (p < 0.001) for beta-cohort as compared with control. Decreased risk of fatal outcome was more pronounced in patients with a significant head injury. CONCLUSIONS: beta-blocker therapy is safe and may be beneficial in selected trauma patients with or without head injury. Further studies looking at beta-blocker therapy in trauma patients and their effect on cerebral metabolism are warranted.     

The effect of red blood cell age on coagulation

Background

Packed red blood cell (PRBC) units stored and unused at community hospitals are transferred to trauma centers near the end of their shelf storage life, because of a higher likelihood of utilization before expiration without consideration of coagulation system effects. This study was conducted to determine if the stored age of PRBC units has an effect on coagulation.

Methods

Single-donor citrate/phosphate/dextrose-preserved, PRBCs, and fresh frozen plasma (FFP) were recalcified in an in vitro model. The activated clotting time (ACT) was measured using the microsample method on days 3, 19, 20, and 33 from the date of donation.

Results

The ACT was prolonged as the age of PRBCs increased while other factors were held constant. ACTs on days 19, 20, and 33 were prolonged relative to day 3. Measurements taken on day 33 were significantly prolonged relative to day 20.

Conclusions

Increasing age of PRBCs measured from the date of donation adversely affects the global coagulation status. This study suggests that we should re-evaluate current blood banking and transfusion practices in trauma care.     

Preoperative factors associated with red blood cell transfusion in hip fracture patients

Introduction

Red blood cell (RBC) transfusion is a frequently used treatment in patients admitted with a fractured hip, but the use remains an area of much debate. The aim of this study was to determine preoperative factors associated with the risk of receiving a red blood cell transfusion in hip fracture patients.

Method

The study included 986 consecutive hip fracture patients (aged 60 years or above). The patients were identified from a database of all hip fracture patients admitted to Bispebjerg University Hospital. Data for the database are collected via chart review and data extraction from the hospitals laboratory system, public registries and from the Capital Region Blood Bank Database.

Results

Overall transfusion rate was 58.7 %. The univariate analyses showed that transfusion rate was higher among women (p = 0.004), older patients (p < 0.0001), patients with high ASA scores (p < 0.0001), patients with more severe fractures (p < 0.0001), patients with lower admission haemoglobin levels (p < 0.0001), patients not admitted from own home (p = 0.02) and patients taking aspirin (p = 0.007) or other platelet inhibitors (p = 0.01) on admission. In the multivariate analysis, increasing age, ASA ≥3, being admitted from own home, extracapsular fractures, decreasing admission haemoglobin and use of platelet inhibitors were all significantly associated with the risk of receiving a RBC transfusion.

Conclusion

Several readily available preoperative factors in the form of age, residence, ASA, admission haemoglobin, medication and type of fracture were independently associated with the likelihood of receiving a red blood cell transfusion in patients admitted with a fractured hip.     

The impact of leukoreduced red blood cell transfusion on mortality of neonates undergoing extracorporeal membrane oxygenation

Background

Blood products containing leukocytes have been associated with negative immunomodulatory and infectious effects. Transfusion-related acute lung injury is partially explained by leucocyte agglutination. The Food and Drug Administration has therefore recommended leukoreduction strategies for blood product transfusion. Our institution has been using leukocyte-reduced blood via filtration for neonates on Extracorporeal Membrane Oxygenation (ECMO). We hypothesized that the use of leukocyte-reduced blood would decrease mortality and morbidity of neonatal ECMO patients.

Methods

Retrospective review of noncardiac ECMO in neonates from 1984–2011, stratified into year groups I and II (≤1996 and ≥1997). Demographics, duration and type of ECMO, complications, and outcome data were collected. Blood product use data was collected. Univariate, bivariate, and multivariate analyses determined predictors of risk-adjusted mortality by year group.

Results

Patients (827) underwent ECMO with 65.3% (540) in group I. Overall median blood product use in mL/kg/d was 36.2 packed red blood cells (pRBC), 8.1 platelets, and 0 cyroprecipitate and/or fresh-frozen plasma. Overall mortality was 16.4%. Median pRBC used or transfused was 42.1 mL/kg/d in group I versus 19.1 mL/kg/d group II (P <0.001). On bivariate analysis, there was no difference in crude mortality between the 2 year groups (17.2% versus 16.0%, P = 0.66). However, on multivariate analysis adjusting for demographics, diagnosis, complications, and blood product use other than pRBCs, each additional transfusion of 10 mL/kg/d of pRBC was associated with a 33% increase in mortality in group I (P <0.05). Group II also showed an increase in mortality with each additional transfusion (21%) but this was not statistically significant (P = 0.07). Days on ECMO were not associated with pRBC transfusion in group I but increased in group II (additional 3 d for each 10 mL/kg/d transfused). There was no difference in infectious complications between groups I and II.

Conclusions

Blood transfusion requirement has diminished in newborns undergoing ECMO at our institution. Transfusion of non leukocyte-reduced blood is associated with an increase in mortality whereas transfusion of leukocyte-reduced blood provided no benefit with a trend toward increased mortality. Further research is recommended to understand these trends.     

Packed red blood cell donor age affects overall survival in transfused patients undergoing hepatectomy for non-hepatocellular malignancy

Background

Patients undergoing hepatectomy often require packed red blood cell (PRBC) transfusion, which has been associated with worse oncologic outcomes. However, limited data exist regarding the impact of PRBC donor factors. We hypothesized that PRBC donor age impacts survival after hepatectomy for non-hepatocellular malignancies.

Septic complications associated with the use of peritoneal drains in liver trauma

This study reviewed all 164 cases of liver trauma seen at the Charity Hospital of New Orleans from 1980 through 1984, in 12 of whom intra-abdominal abscesses formed. Thirty four per cent of the patients had no peritoneal drainage and an abscess rate of 1.8%, 18% had only closed suction drainage and 0% abscess rate, 15% had only open sump drainage and a rate of 8.3%, 14% had only open Penrose drainage with a rate of 8.7%, and 19% had a combination of both open Penrose and sump drainage with a rate of 22.5%. Certain findings or conditions were related to the development of postoperative sepsis. Gunshot wounds were associated with a 9.9% abscess rate, blunt trauma with 3.8%, and stabbings with 0%. Patients who presented in shock were at a threefold increased risk for intra-abdominal abscess formation, those who needed blood transfusions of greater than 6 units were at a tenfold increased risk, those with major liver injuries were at a sixfold increased risk, and those with a total of three or more abdominal organs injured were at a threefold increased risk for abscess formation. There was no significant relation between presence of gastrointestinal perforation and subsequent abscess formation. For patients without the specific risk factors mentioned above, the probability of developing an intra-abdominal abscess is low. This group of patients would therefore benefit little from the presence of a drain, but might very well be harmed by the introduction of external contaminant bacteria into the peritoneal cavity by the drain itself.(ABSTRACT TRUNCATED AT 250 WORDS)     

The best strategy for red blood cell transfusion in severe burn patients,restrictive or liberal: A randomized controlled trial

IntroductionAlthough blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold.Material and methodsEighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications.ResultThe mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups.ConclusionApplying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications.Clinical Trial Registration ReferenceIRCT20190209042660N1.