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Lenet T, Berthelot P, Grudzinski AL, Banks A, Tropiano J, McIsaac DI, Tinmouth A, Patey AM, Fergusson DA, Martel G. Nonclinical factors affecting intraoperative red blood cell transfusion: a systematic review. Can J Anaesth 2024:10.1007/s12630-024-02739-9. [PMID: 38509437 DOI: 10.1007/s12630-024-02739-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 03/22/2024] Open
Abstract
PURPOSE There is significant variability in intraoperative red blood cell (RBC) transfusion practice. We aimed to use the theoretical domains framework (TDF) to categorize nonclinical and behavioural factors driving intraoperative RBC transfusion practice in a systematic review of the literature. SOURCE We searched electronic databases from inception until August 2021 to identify studies evaluating nonclinical factors affecting intraoperative RBC transfusion. Using the Mixed Methods Appraisal Tool, we assessed the quality of included studies and identified relevant nonclinical factors, which were coded into TDF domains by two independent reviewers using NVivo (Lumivero, QSR International, Burlington, MA, USA). We identified common themes within domains and sorted domains based on the frequency of reported factors. PRINCIPAL FINDINGS Our systematic review identified 18 studies: nine retrospective cohort studies, six cross-sectional surveys, and three before-and-after studies. Factors related to the social influences, behavioural regulation, environmental context/resources, and beliefs about consequences domains of the TDF were the most reported factors. Key factors underlying the observed variability in transfusion practice included the social effects of peers, patients, and institutional culture on decision-making (social influences), and characteristics of the practice environment including case volume, geographic location, and case start time (environmental context/resources). Studies reported variable beliefs about the consequences of both intraoperative transfusion and anemia (beliefs about consequences). Provider- and institutional-level audits, educational sessions, and increased communication between surgeons/anesthesiologists were identified as strategies to optimize intraoperative transfusion decision-making (behavioural regulation). CONCLUSION Our systematic review has synthesized the literature on nonclinical and behavioural factors impacting intraoperative transfusion decision-making, categorized using the TDF. These findings can inform evidence-based interventions to reduce intraoperative RBC transfusion variability. STUDY REGISTRATION Open Science Framework ( https://osf.io/pm8zs/?view_only=166299ed28964804b9360c429b1218c1 ; first posted, 3 August 2022).
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Affiliation(s)
- Tori Lenet
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Alexa L Grudzinski
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexander Banks
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Joseph Tropiano
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Alan Tinmouth
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Andrea M Patey
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Guillaume Martel
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Rd, CCW 1667, Ottawa, ON, K1H 8L6, Canada.
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Czarnecka J, Neuschwander A, Aujoulat T, Balmier A, Belcour D, Boulanger B, Bourgain C, Caron M, Kiss G, Larghi M, Lebard C, Mellano V, Larson J, Megroian B, Lefrançois A, Fox S, Pollet A, Bourgoin P, Biland G, Braunberger E, Maccio G, Delmas B. Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study. J Cardiothorac Vasc Anesth 2024; 38:73-79. [PMID: 37953174 DOI: 10.1053/j.jvca.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES Anemia and transfusion are common in cardiac surgery patients, and are associated with significant morbidity and mortality. Multiple perioperative interventions have been described to reduce blood transfusion, but are rarely combined altogether. The aim of this study was to compare the incidence of red blood cell (RBC) transfusion in adult patients undergoing cardiac surgery before and after the implementation of a perioperative patient blood management (PBM) program. DESIGN Before-and-after observational study. SETTING Single-center French university teaching hospital. PARTICIPANTS Adult patients scheduled for cardiac surgery. INTERVENTIONS Perioperative patient blood management program including pre-, intra-, and postoperative interventions aimed at identifying and correcting anemia, minimizing blood loss during surgery, and optimizing coagulation. MEASUREMENTS AND MAIN RESULTS Four hundred thirty-four patients were included in the study from January 2021 to July 2022. The incidence of perioperative RBC transfusion (intraoperatively and during the first 2 postoperative days) was significantly reduced from 43% (90/213) in the pre-PBM period to 27% (60/221) in the post-PBM period (p < 0.001). The application of a PBM program was associated with a reduction in perioperative RBC transfusion by multivariate analysis (odds ratio 0.55, 95% CI 0.36-0.85, p = 0.007), and was associated with a reduction in the median number of RBC units transfused within transfused patients (p = 0.025). These effects persisted at day 30 after surgery (p = 0.029). CONCLUSION A perioperative PBM program in adult patients undergoing cardiac surgery was associated with a significant reduction in perioperative RBC transfusion, which persisted at day 30.
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Affiliation(s)
- Jeremie Czarnecka
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arthur Neuschwander
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France.
| | - Thomas Aujoulat
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Adrien Balmier
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Dominique Belcour
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Boris Boulanger
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Caroline Bourgain
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Margot Caron
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Gabor Kiss
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Mathilde Larghi
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Christophe Lebard
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Vincent Mellano
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Jonathan Larson
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Blandine Megroian
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Anaelle Lefrançois
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Sylvain Fox
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arnaud Pollet
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Pierre Bourgoin
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France; Department of anesthesiology, University Hospital, Nantes, France
| | - Guillaume Biland
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Eric Braunberger
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Guillaume Maccio
- French Blood Establishment, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Benjamin Delmas
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
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Muacevic A, Adler JR, Murata H, Sekino M, Hara T. Management of Combined Cardiac Surgery Using Cardiopulmonary Bypass With Acute Normovolemic Hemodilution in a Jehovah's Witness: A Case Report. Cureus 2023; 15:e33442. [PMID: 36751150 PMCID: PMC9897691 DOI: 10.7759/cureus.33442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Combined cardiac surgery under cardiopulmonary bypass (CPB) has a high risk of requiring blood transfusion. Performing this surgery on Jehovah's Witnesses (JWs) is challenging as they strictly refuse allogeneic blood transfusions due to their religious beliefs. A 73-year-old female JW patient underwent combined surgery involving coronary artery bypass grafting and mitral valvuloplasty under CPB. Preoperative hematopoiesis maintained the hemoglobin (Hb) level at >12 g/dL preoperatively; the Hb level was maintained at >7 g/dL during CPB for effective acute normovolemic hemodilution (ANH). Compared with the values obtained immediately after CPB weaning, the Hb level and coagulation functions (measured using viscoelastic tests) improved after autologous transfusion at the end of the surgery. When cardiac surgery under CPB is performed on JWs, ANH can be useful for maintaining postoperative Hb levels and coagulation factors. Sufficient preoperative hematopoiesis and determination of an appropriate volume for intraoperative ANH may be important for effective ANH.
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Moore CC, Yu S, Aljure O. A comprehensive review of cerebral oximetry in cardiac surgery. J Card Surg 2022; 37:5418-5433. [PMID: 36423259 DOI: 10.1111/jocs.17232] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 09/03/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients who undergo cardiac surgery are at increased risk of stroke, postoperative cognitive decline, and delirium. These neurocognitive complications have led to increased costs, intensive care unit stays, morbidity, and mortality. As a result, there is a significant push to mitigate any neurological complications in cardiac surgery patients. Near-infrared spectroscopy to measure regional cerebral oxygen saturations has gained consideration due to its noninvasive and user-friendly nature. Cerebral oximetry desaturations during cardiac surgery have been linked to an array of adverse clinical outcomes. However, the most effective intraoperative interventions to protect this vulnerable patient population have yet to be ascertained. AIM OF STUDY To provide a comprehensive summary of the intraoperative management for cerebral oximetry desaturations during cardiac surgery. The review highlights clinical outcomes from cerebral oximetry use to quantify the importance of identifying cerebral desaturations during cardiac surgery. The review then interrogates possible interventions for cerebral oximetry desaturations in an effort to determine which interventions are most efficacious and to enlighten possible areas for further research. METHODS A narrative review of randomized controlled trials, observational studies, and systematic reviews with metanalyses was performed through August 2021. RESULTS There is significant heterogeneity among patient populations for which cerebral oximetry monitoring has been studied in cardiac surgery. Further, the definition of a clinically significant cerebral desaturation and the assessment of neurocognitive outcomes varied substantially across studies. As a result, metanalysis is challenging and few conclusions can be drawn. Cerebral oximetry use during cardiac surgery has not been associated with improvements in neurocognitive outcomes, morbidity, or mortality to date. The evidence to support a particular intervention for an acute desaturation is equivocal. CONCLUSIONS Future research is needed to quantify a clinically significant cerebral desaturation and to determine which interventions for an acute desaturation effectively improve clinical outcomes.
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Affiliation(s)
- Christina C Moore
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Oscar Aljure
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
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Gerber D, Erdoes G. Be part of the game! J Cardiothorac Vasc Anesth 2022; 36:3047-3048. [DOI: 10.1053/j.jvca.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 11/11/2022]
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Maimaitiming M, Zhang C, Xie J, Zheng Z, Luo H, Ooi OC. Impact of restrictive red blood cell transfusion strategy on thrombosis-related events: A meta-analysis and systematic review. Vox Sang 2022; 117:887-899. [PMID: 35332942 DOI: 10.1111/vox.13274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES There is an ongoing controversy regarding the risks of restrictive and liberal red blood cell (RBC) transfusion strategies. This meta-analysis assessed whether transfusion at a lower threshold was superior to transfusion at a higher threshold, with regard to thrombosis-related events, that is, whether these outcomes can benefit from a restrictive transfusion strategy is debated. MATERIALS AND METHODS We searched PubMed, Cochrane Central Register of Controlled Trials and Scopus from inception up to 31 July 2021. We included randomized controlled trials (RCTs) in any clinical setting that evaluated the effects of restrictive versus liberal RBC transfusion in adults. We used random-effects models to calculate the risk ratios (RRs) and 95% confidence intervals (CIs) based on pooled data. RESULTS Thirty RCTs involving 17,334 participants were included. The pooled RR for thromboembolic events was 0.65 (95% CI 0.44-0.94; p = 0.020; I2 = 0.0%, very low-quality evidence), favouring the restrictive strategy. There were no significant differences in cerebrovascular accidents (RR = 0.83; 95% CI 0.64-1.09; p = 0.180; I2 = 0.0%, very low-quality evidence) or myocardial infarction (RR = 1.05; 95% CI 0.87-1.26; p = 0.620; I2 = 0.0%, low-quality evidence). Subgroup analyses showed that a restrictive (relative to liberal) strategy reduced (1) thromboembolic events in RCTs conducted in North America and (2) myocardial infarctions in the subgroup of RCTs where the restrictive transfusion threshold was 7 g/dl but not in the 8 g/dl subgroup (with a liberal transfusion threshold of 10 g/dl in both subgroups). CONCLUSIONS A restrictive (relative to liberal) transfusion strategy may be effective in reducing venous thrombosis but not arterial thrombosis.
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Affiliation(s)
- Mairehaba Maimaitiming
- School of Management, University of Science and Technology of China, Hefei, Anhui, China
| | - Chenxiao Zhang
- Lee Kong Chian School of Business, Singapore Management University, Singapore
| | - Jingui Xie
- School of Management, Technical University of Munich, Heilbronn, Germany.,Munich Data Science Institute, Technical University of Munich, Munich, Germany
| | - Zhichao Zheng
- Lee Kong Chian School of Business, Singapore Management University, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
| | - Oon Cheong Ooi
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
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7
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Lenet T, Baker L, Park L, Vered M, Zahrai A, Shorr R, Davis A, McIsaac DI, Tinmouth A, Fergusson DA, Martel G. A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Intraoperative Red Blood Cell Transfusion Strategies. Ann Surg 2022; 275:456-466. [PMID: 34319671 PMCID: PMC8820777 DOI: 10.1097/sla.0000000000004931] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of this work was to carry out a meta-analysis of RCTs comparing intraoperative RBC transfusion strategies to determine their impact on postoperative morbidity, mortality, and blood product use. SUMMARY OF BACKGROUND DATA RBC transfusions are common in surgery and associated with widespread variability despite adjustment for casemix. Evidence-based recommendations guiding RBC transfusion in the operative setting are limited. METHODS The search strategy was adapted from a previous Cochrane Review. Electronic databases were searched from January 2016 to February 2021. Included studies from the previous Cochrane Review were considered for eligibility from before 2016. RCTs comparing intraoperative transfusion strategies were considered for inclusion. Co-primary outcomes were 30-day mortality and morbidity. Secondary outcomes included intraoperative and perioperative RBC transfusion. Meta-analysis was carried out using random-effects models. RESULTS Fourteen trials (8641 patients) were included. One cardiac surgery trial accounted for 56% of patients. There was no difference in 30-day mortality [relative risk (RR) 0.96, 95% confidence interval (CI) 0.71-1.29] and pooled postoperative morbidity among the studied outcomes when comparing restrictive and liberal protocols. Two trials reported worse composite outcomes with restrictive triggers. Intraoperative (RR 0.53, 95% CI 0.43-0.64) and perioperative (RR 0.70, 95% CI 0.62-0.79) blood transfusions were significantly lower in the restrictive group compared to the liberal group. CONCLUSIONS Intraoperative restrictive transfusion strategies decreased perioperative transfusions without added postoperative morbidity and mortality in 12/14 trials. Two trials reported worse outcomes. Given trial design and generalizability limitations, uncertainty remains regarding the safety of broad application of restrictive transfusion triggers in the operating room. Trials specifically designed to address intraoperative transfusions are urgently needed.
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Affiliation(s)
- Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Laura Baker
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lily Park
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Michael Vered
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Amin Zahrai
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Dean A Fergusson
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Sanfilippo F, La Via L, Murabito P, Astuto M. Mortality in Critically Ill Patients Does Not Differ according to Transfusion Strategy. Transfus Med Hemother 2022; 49:62-64. [PMID: 35221868 PMCID: PMC8832246 DOI: 10.1159/000520476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/26/2021] [Indexed: 08/29/2023] Open
Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy
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Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N, Fergusson DA, Triulzi D, Dorée C, Hébert PC. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev 2021; 12:CD002042. [PMID: 34932836 PMCID: PMC8691808 DOI: 10.1002/14651858.cd002042.pub5] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The optimal haemoglobin threshold for use of red blood cell (RBC) transfusions in anaemic patients remains an active field of research. Blood is a scarce resource, and in some countries, transfusions are less safe than in others because of inadequate testing for viral pathogens. If a liberal transfusion policy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach could be recognised as the standard of care. OBJECTIVES: The aim of this review update was to compare 30-day mortality and other clinical outcomes for participants randomised to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all clinical conditions. The restrictive transfusion threshold uses a lower haemoglobin concentration as a threshold for transfusion (most commonly, 7.0 g/dL to 8.0 g/dL), and the liberal transfusion threshold uses a higher haemoglobin concentration as a threshold for transfusion (most commonly, 9.0 g/dL to 10.0 g/dL). SEARCH METHODS We identified trials through updated searches: CENTRAL (2020, Issue 11), MEDLINE (1946 to November 2020), Embase (1974 to November 2020), Transfusion Evidence Library (1950 to November 2020), Web of Science Conference Proceedings Citation Index (1990 to November 2020), and trial registries (November 2020). We checked the reference lists of other published reviews and relevant papers to identify additional trials. We were aware of one trial identified in earlier searching that was in the process of being published (in February 2021), and we were able to include it before this review was finalised. SELECTION CRITERIA We included randomised trials of surgical or medical participants that recruited adults or children, or both. We excluded studies that focused on neonates. Eligible trials assigned intervention groups on the basis of different transfusion schedules or thresholds or 'triggers'. These thresholds would be defined by a haemoglobin (Hb) or haematocrit (Hct) concentration below which an RBC transfusion would be administered; the haemoglobin concentration remains the most commonly applied marker of the need for RBC transfusion in clinical practice. We included trials in which investigators had allocated participants to higher thresholds or more liberal transfusion strategies compared to more restrictive ones, which might include no transfusion. As in previous versions of this review, we did not exclude unregistered trials published after 2010 (as per the policy of the Cochrane Injuries Group, 2015), however, we did conduct analyses to consider the differential impact of results of trials for which prospective registration could not be confirmed. DATA COLLECTION AND ANALYSIS: We identified trials for inclusion and extracted data using Cochrane methods. We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two review authors independently extracted data and assessed risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as being in the 'restrictive transfusion' group and those randomly allocated to the higher transfusion threshold as being in the 'liberal transfusion' group. MAIN RESULTS A total of 48 trials, involving data from 21,433 participants (at baseline), across a range of clinical contexts (e.g. orthopaedic, cardiac, or vascular surgery; critical care; acute blood loss (including gastrointestinal bleeding); acute coronary syndrome; cancer; leukaemia; haematological malignancies), met the eligibility criteria. The haemoglobin concentration used to define the restrictive transfusion group in most trials (36) was between 7.0 g/dL and 8.0 g/dL. Most trials included only adults; three trials focused on children. The included studies were generally at low risk of bias for key domains including allocation concealment and incomplete outcome data. Restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.53 to 0.66; 42 studies, 20,057 participants; high-quality evidence), with a large amount of heterogeneity between trials (I² = 96%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.99, 95% CI 0.86 to 1.15; 31 studies, 16,729 participants; I² = 30%; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (all high-quality evidence)). High-quality evidence shows that the liberal transfusion threshold did not affect the risk of infection (pneumonia, wound infection, or bacteraemia). Transfusion-specific reactions are uncommon and were inconsistently reported within trials. We noted less certainty in the strength of evidence to support the safety of restrictive transfusion thresholds for the following predefined clinical subgroups: myocardial infarction, vascular surgery, haematological malignancies, and chronic bone-marrow disorders. AUTHORS' CONCLUSIONS Transfusion at a restrictive haemoglobin concentration decreased the proportion of people exposed to RBC transfusion by 41% across a broad range of clinical contexts. Across all trials, no evidence suggests that a restrictive transfusion strategy impacted 30-day mortality, mortality at other time points, or morbidity (i.e. cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. Despite including 17 more randomised trials (and 8846 participants), data remain insufficient to inform the safety of transfusion policies in important and selected clinical contexts, such as myocardial infarction, chronic cardiovascular disease, neurological injury or traumatic brain injury, stroke, thrombocytopenia, and cancer or haematological malignancies, including chronic bone marrow failure. Further work is needed to improve our understanding of outcomes other than mortality. Most trials compared only two separate thresholds for haemoglobin concentration, which may not identify the actual optimal threshold for transfusion in a particular patient. Haemoglobin concentration may not be the most informative marker of the need for transfusion in individual patients with different degrees of physiological adaptation to anaemia. Notwithstanding these issues, overall findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds between the range of 7.0 g/dL and 8.0 g/dL. Some patient subgroups might benefit from RBCs to maintain higher haemoglobin concentrations; research efforts should focus on these clinical contexts.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Simon J Stanworth
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Nareg Roubinian
- Kaiser Permanente Division of Research Northern California, Oakland, California, USA
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darrell Triulzi
- The Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Paul C Hébert
- Centre for Research, University of Montreal Hospital Research Centre, Montreal, Canada
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10
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STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:97-124. [PMID: 34194077 DOI: 10.1182/ject-2100053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022]
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11
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Ann Thorac Surg 2021; 112:981-1004. [PMID: 34217505 DOI: 10.1016/j.athoracsur.2021.03.033] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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12
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. J Cardiothorac Vasc Anesth 2021; 35:2569-2591. [PMID: 34217578 DOI: 10.1053/j.jvca.2021.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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13
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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14
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Boxma RPJ, Garnier RP, Bulte CSE, Meesters MI. The effect of non-point-of-care haemostasis management protocol implementation in cardiac surgery: A systematic review. Transfus Med 2021; 31:328-338. [PMID: 34096120 PMCID: PMC8597010 DOI: 10.1111/tme.12790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/11/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022]
Abstract
Objectives This systematic review aims to outline the evidence on the implementation of a non‐point‐of‐care (non‐point‐of‐care [POC]) haemostasis management protocol compared to experience‐based practice in adult cardiac surgery. Background Management of coagulopathy in cardiac surgery is complex and remains highly variable among centres and physicians. Although various guidelines recommend the implementation of a transfusion protocol, the literature on this topic has never been systematically reviewed. Methods PubMed, Embase, Cochrane Library, and Web of Science were searched from January 2000 till May 2020. Results A total of seven studies (one randomised controlled trial [RCT], one prospective cohort study, and five retrospective studies) met the inclusion criteria. Among the six non‐randomised, controlled studies, the risk of bias was determined to be serious to critical, and the one RCT was determined to have a high risk of bias. Five studies showed a significant reduction in red blood cells, fresh frozen plasma, and/or platelet transfusion after the implementation of a structural non‐POC algorithm, ranging from 2% to 28%, 2% to 19.5%, and 7% to17%, respectively. One study found that fewer patients required transfusion of any blood component in the protocol group. Another study had reported a significantly increased transfusion rate of platelet concentrate in the haemostasis algorithm group. Conclusion Owing to the high heterogeneity and a substantial risk of bias of the included studies, no conclusion can be drawn on the additive value of the implementation of a cardiac‐surgery‐specific non‐POC transfusion and haemostasis management algorithm compared to experience‐based practice. To define the exact impact of a transfusion protocol on blood product transfusion, bleeding, and adverse events, well‐designed prospective clinical trials are required.
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Affiliation(s)
- Reinier P J Boxma
- Department of Anesthesiology, Amsterdam University Medical Center, Location VU Medical Center, Amsterdam, The Netherlands
| | - Robert P Garnier
- Department of Anesthesiology, Amsterdam University Medical Center, Location VU Medical Center, Amsterdam, The Netherlands
| | - Carolien S E Bulte
- Department of Anesthesiology, Amsterdam University Medical Center, Location VU Medical Center, Amsterdam, The Netherlands
| | - Michael I Meesters
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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15
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Wissenschaftliche Erläuterungen zur Stellungnahme Transfusionsassoziierte Immunmodulation (TRIM) des Arbeitskreises Blut vom 13. Februar 2020. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1025-1053. [PMID: 32719887 PMCID: PMC7384277 DOI: 10.1007/s00103-020-03183-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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16
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Martin J, Bainbridge D. Randomized Trials in Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2020; 34:2884-2888. [PMID: 32653271 DOI: 10.1053/j.jvca.2020.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Janet Martin
- Department of Anesthesia and Perioperative Medicine and Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel Bainbridge
- Department of Anesthesiology and Perioperative Medicine, Western University, London, ON, Canada
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17
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Kato H, Chasovskyi K, Gandhi SK. Are Blood Products Routinely Required in Pediatric Heart Surgery? Pediatr Cardiol 2020; 41:932-938. [PMID: 32170329 DOI: 10.1007/s00246-020-02338-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/05/2020] [Indexed: 11/24/2022]
Abstract
A restrictive blood transfusion strategy has emerged in adult cardiac surgery. However, the feasibility in children is poorly investigated. 352 consecutive patients undergoing open-heart surgery were retrospectively reviewed, excluding patients requiring extracorporeal membrane oxygenation. Patient demographics, perioperative blood product usage, and clinical outcome parameters were investigated. Variables predicting the need for blood products were delineated. Of the 352 study patients, 148 patients (42%) underwent bloodless surgery and 204 (58%) were transfused. Of the 204 transfused patients, 170 (83.4%) patients received one blood transfusion and 34 (16.6%) received two or more blood transfusions. Patient's weight and preoperative hematocrit (Hct) were statistically significant in predicting the need for blood priming the CPB circuit (AUC 0.99, p < 0.001, sensitivity 96.6%, specificity 95.2%). A body weight of 8.5 kg carried a sensitivity of 100% and specificity of 94.5% (p < 0.001) for a blood prime. Among patients with a weight less than 8.5 kg (n = 171), only 27 patients (15.8%, p < 0.001) required additional transfusion of PRBCs. Factors impacting the need for a blood transfusion during CPB included redo surgery [odds ratio (OR) 4.61, p = 0.001] and the highest lactate level on CPB (OR 1.65, p = 0.006). Redo surgery had the highest impact (OR 7.27, p = 0.012) for requiring a postoperative PRBC transfusion. A restrictive transfusion strategy can be safely implemented in pediatric cardiac surgery. The majority of children with a BW > 8.5 kg required no blood products and those with a BW ≤ 8.5 kg required only 1 unit of blood, to prime the cardiopulmonary bypass circuit.
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Affiliation(s)
- Hideyuki Kato
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
| | - Kyrylo Chasovskyi
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada. .,Division of Cardiovascular and Thoracic Surgery, Perfusion Services, BC Children's Hospital, 4480 Oak Street, Suite AB307, Vancouver, BC, V6H 3V4, Canada.
| | - Sanjiv K Gandhi
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
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18
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Vlaar AP, Oczkowski S, de Bruin S, Wijnberge M, Antonelli M, Aubron C, Aries P, Duranteau J, Juffermans NP, Meier J, Murphy GJ, Abbasciano R, Muller M, Shah A, Perner A, Rygaard S, Walsh TS, Guyatt G, Dionne JC, Cecconi M. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med 2020; 46:673-696. [PMID: 31912207 PMCID: PMC7223433 DOI: 10.1007/s00134-019-05884-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/26/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To develop evidence-based clinical practice recommendations regarding transfusion practices in non-bleeding, critically ill adults. DESIGN A task force involving 13 international experts and three methodologists used the GRADE approach for guideline development. METHODS The task force identified four main topics: red blood cell transfusion thresholds, red blood cell transfusion avoidance strategies, platelet transfusion, and plasma transfusion. The panel developed structured guideline questions using population, intervention, comparison, and outcomes (PICO) format. RESULTS The task force generated 16 clinical practice recommendations (3 strong recommendations, 13 conditional recommendations), and identified five PICOs with insufficient evidence to make any recommendation. CONCLUSIONS This clinical practice guideline provides evidence-based recommendations and identifies areas where further research is needed regarding transfusion practices and transfusion avoidance in non-bleeding, critically ill adults.
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Affiliation(s)
- Alexander P Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
- Department of Intensive Care Medicine, University of Amsterdam, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sanne de Bruin
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Marije Wijnberge
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Massimo Antonelli
- Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anaesthesiology e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cecile Aubron
- Department of Intensive Care Medicine, Centre Hospitalier Régional et Universitaire de Brest, Université de Bretagne Occidentale, Site La Cavale Blanche, Brest, France
| | - Philippe Aries
- Department of Intensive Care Medicine, Centre Hospitalier Régional et Universitaire de Brest, Université de Bretagne Occidentale, Site La Cavale Blanche, Brest, France
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud (HUPS), Orsay, France
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Kepler University, Linz, Austria
| | - Gavin J Murphy
- Cardiovascular, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, College of Life Sciences, University of Leicester, Leicester, LE3 9QP, UK
| | - Riccardo Abbasciano
- Cardiovascular, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, College of Life Sciences, University of Leicester, Leicester, LE3 9QP, UK
| | - Marcella Muller
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sofie Rygaard
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Timothy S Walsh
- Anaesthetics, Critical Care, and Pain Medicine, University of Edinburgh, Edinburgh, Scotland
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Canada
- Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - J C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada
- Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Centre-IRCCS, Rozzano, Milan, Italy
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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19
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The effect of restrictive versus liberal transfusion strategies on longer-term outcomes after cardiac surgery: a systematic review and meta-analysis with trial sequential analysis. Can J Anaesth 2020; 67:577-587. [DOI: 10.1007/s12630-020-01592-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/25/2019] [Accepted: 11/03/2019] [Indexed: 02/03/2023] Open
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20
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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21
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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22
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Yu X, Wang Z, Wang Y, Huang Y, Xin S, Sun H, Zhang X, Wang Y, Han W, Xue F, Wang L, Hu Y, Xu M, Li L, He J, Jiang J. Cost-effectiveness comparison of routine transfusion with restrictive and liberal transfusion strategies for surgical patients in China. Vox Sang 2019; 114:721-739. [PMID: 31373018 DOI: 10.1111/vox.12817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/13/2019] [Accepted: 05/22/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES A health industry standard recommending restrictive transfusion is to be in effect in China in April 2019. We aim to explore its potential economic and clinical impacts among surgical patients. MATERIALS AND METHODS A decision tree model was applied to compare cost-effectiveness of current routine transfusion in China, a restrictive (transfusion at Hb < 8 g/dl or ischaemic symptoms) and a liberal (transfusion at Hb < 10 g/dl) strategy. Parameters were estimated from empirical data of 25 227 surgical inpatients aged ≥30 years in a multicenter study and supplemented by meta-analysis when necessary. Results are shown for cardio-cerebral-vascular (CCV) surgery and non-CCV (orthopaedics, general, thoracic) surgery separately. RESULTS Per 10 000 patients in routine, restrictive, liberal transfusion scenarios, total spending (transfusion and length of stay related) was 7·67, 7·58 and 9·39 million CNY (1 CNY × 0.157 = 1 US dollar) for CCV surgery and 6·35, 6·70 and 8·09 million CNY for non-CCV surgery; infectious and severe complications numbered 354, 290, and 290 (CCV) and 315, 286, and 330 (non-CCV), respectively. Acceptability curves showed high probabilities for restrictive strategy to be cost-effective across a wide range of willingness-to-pay values. Such findings were mostly consistent in sensitivity and subgroup analyses except for patients with cardiac problems. CONCLUSION We showed strong rationale, succeeding previous findings only in cardiac or joint procedures, to comply with the new standard as restrictive transfusion has high potential to save blood, secure safety, and is cost-effective for a wide spectrum of surgical patients. Experiences should be further summarized to pave the way towards individualized transfusion.
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Affiliation(s)
- Xiaochu Yu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zixing Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yipeng Wang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuguang Huang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shijie Xin
- First Hospital of China Medical University, Shenyang, China
| | - Hong Sun
- Xiangya Hospital, Central South University, Changsha, China
| | - Xu Zhang
- First Hospital of China Medical University, Shenyang, China
| | - Yaolei Wang
- Xiangya Hospital, Central South University, Changsha, China
| | - Wei Han
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fang Xue
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lei Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yaoda Hu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mei Xu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Li
- First Hospital of China Medical University, Shenyang, China
| | - Jiqun He
- Xiangya Hospital, Central South University, Changsha, China
| | - Jingmei Jiang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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23
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Should Transfusion Trigger Thresholds Differ for Critical Care Versus Perioperative Patients? A Meta-Analysis of Randomized Trials. Crit Care Med 2019; 46:252-263. [PMID: 29189348 PMCID: PMC5770109 DOI: 10.1097/ccm.0000000000002873] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Supplemental Digital Content is available in the text. Objective: To address the significant uncertainty as to whether transfusion thresholds for critical care versus surgical patients should differ. Design: Meta-analysis of randomized controlled trials. Setting: Medline, EMBASE, and Cochrane Library searches were performed up to 15 June 2016. Patients: Trials had to enroll adult surgical or critically ill patients for inclusion. Interventions: Studies had to compare a liberal versus restrictive threshold for the transfusion of allogeneic packed RBCs. Measurements and Main Results: The primary outcome was 30-day all-cause mortality, sub-grouped by surgical and critical care patients. Secondary outcomes included myocardial infarction, stroke, renal failure, allogeneic blood exposure, and length of stay. Odds ratios and weighted mean differences were calculated using random effects meta-analysis. To assess whether subgroups were significantly different, tests for subgroup interaction were used. Subgroup analysis by trials enrolling critically ill versus surgical patients was performed. Twenty-seven randomized controlled trials (10,797 patients) were included. In critical care patients, restrictive transfusion resulted in significantly reduced 30-day mortality compared with liberal transfusion (odds ratio, 0.82; 95% CI, 0.70–0.97). In surgical patients, a restrictive transfusion strategy led to the opposite direction of effect for mortality (odds ratio, 1.31; 95% CI, 0.94–1.82). The subgroup interaction test was significant (p = 0.04), suggesting that the effect of restrictive transfusion on mortality is statistically different for critical care (decreased risk) versus surgical patients (potentially increased risk or no difference). Regarding secondary outcomes, for critically ill patients, a restrictive strategy resulted in reduced risk of stroke/transient ischemic attack, packed RBC exposure, transfusion reactions, and hospital length of stay. In surgical patients, restrictive transfusion resulted in reduced packed RBC exposure. Conclusions: The safety of restrictive transfusion strategies likely differs for critically ill patients versus perioperative patients. Further trials investigating transfusion strategies in the perioperative setting are necessary.
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24
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Shehata N, Mistry N, da Costa BR, Pereira TV, Whitlock R, Curley GF, Scott DA, Hare GMT, Jüni P, Mazer CD. Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis. Eur Heart J 2019; 40:1081-1088. [PMID: 30107514 PMCID: PMC6441852 DOI: 10.1093/eurheartj/ehy435] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/05/2018] [Accepted: 07/09/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS To determine whether a restrictive strategy of red blood cell (RBC) transfusion at lower haemoglobin concentrations is inferior to a liberal strategy of RBC transfusion at higher haemoglobin concentrations in patients undergoing cardiac surgery. METHODS AND RESULTS We conducted a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials of the effect of restrictive and liberal RBC transfusion strategies on mortality within 30 days of surgery as the primary outcome. Secondary outcomes were those potentially resulting from anaemia-induced tissue hypoxia and transfusion outcomes. We searched the electronic databases MEDLINE, EMBASE, and the Cochrane Library until 17 November 2017. Thirteen trials were included. The risk ratio (RR) of mortality derived from 4545 patients assigned to a restrictive strategy when compared with 4547 transfused according to a liberal strategy was 0.96 [95% confidence interval (CI) 0.76-1.21, I2 = 0]. A restrictive strategy did not have a statistically significant effect on the risk of myocardial infarction (RR 1.01, 95% CI 0.81-1.26; I2=0), stroke (RR 0.93, 95% CI 0.68-1.27, I2 = 0), renal failure (RR 0.96, 95% CI 0.76-1.20, I2 = 0), or infection (RR 1.12, 95% CI 0.98-1.29, I2 = 0). Subgroup analysis of adult and paediatric trials did not show a significant interaction. At approximately 70% of the critical information size, the meta-analysis of mortality crossed the futility boundary for inferiority of the restrictive strategy. CONCLUSION The current evidence does not support the notion that restrictive RBC transfusion strategies are inferior to liberal RBC strategies in patients undergoing cardiac surgery.
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Affiliation(s)
- Nadine Shehata
- Division of Hematology, Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, Canada
| | - Nikhil Mistry
- Department of Anesthesia, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada
| | - Bruno R da Costa
- Applied Health Research Center (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Tiago V Pereira
- Applied Health Research Center (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, ON, Canada
| | - Richard Whitlock
- Department of Surgery, Population Health Research Institute, McMaster University, David Braley Cardiac Vascular and Stroke Research Institute, 237 Barton Street East, Hamilton, ON, Canada
| | - Gerard F Curley
- Department of Anesthesia and Critical Care, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - David A Scott
- Department of Anesthesia and Acute Pain Medicine, St Vincent’s Hospital, University of Melbourne, 41 Victoria Parade, Fitzroy, Victoria, Australia
| | - Gregory M T Hare
- Departments of Anesthesia and Physiology and Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada
| | - Peter Jüni
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada
| | - C David Mazer
- Departments of Anesthesia and Physiology and Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada
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Hemoglobin Optimization for Coronary Bypass: A 10-Year Canadian Multicenter Experience. Ann Thorac Surg 2019; 107:711-717. [DOI: 10.1016/j.athoracsur.2018.10.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/08/2018] [Accepted: 10/22/2018] [Indexed: 11/23/2022]
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Kheiri B, Abdalla A, Osman M, Haykal T, Chintalapati S, Cranford J, Sotzen J, Gwinn M, Ahmed S, Hassan M, Bachuwa G, Bhatt DL. Restrictive versus liberal red blood cell transfusion for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2018; 47:179-185. [DOI: 10.1007/s11239-018-1784-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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27
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Dhir A, Tempe DK. Anemia and Patient Blood Management in Cardiac Surgery—Literature Review and Current Evidence. J Cardiothorac Vasc Anesth 2018; 32:2726-2742. [DOI: 10.1053/j.jvca.2017.11.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Indexed: 12/24/2022]
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28
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Tantawy H, Li A, Dai F, Elgammal M, Sukumar N, Elefteriades J, Akhtar S. Association of red blood cell transfusion and short- and longer-term mortality after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2018; 32:1225-1232. [DOI: 10.1053/j.jvca.2017.12.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Indexed: 11/11/2022]
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Carson JL, Stanworth SJ, Alexander JH, Roubinian N, Fergusson DA, Triulzi DJ, Goodman SG, Rao SV, Doree C, Hebert PC. Clinical trials evaluating red blood cell transfusion thresholds: An updated systematic review and with additional focus on patients with cardiovascular disease. Am Heart J 2018; 200:96-101. [PMID: 29898855 DOI: 10.1016/j.ahj.2018.04.007] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/03/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Several new trials evaluating transfusion strategies in patients with cardiovascular disease have recently been published, increasing the number of enrolled patients by over 30%. The objective was to evaluate transfusion thresholds in patients with cardiovascular disease. METHODS We conducted an updated systematic review of randomized trials that compared patients assigned to maintain a lower (restrictive transfusion strategy) or higher (liberal transfusion strategy) hemoglobin concentration. We focused on new trial data in patients with cardiovascular disease. The primary outcome was 30-day mortality. Specific subgroups were patients undergoing cardiac surgery and with acute myocardial infarction. RESULTS A total of 37 trials that enrolled 19,049 patients were appraised. In cardiac surgery, mortality at 30days was comparable between groups (risk ratio 0.99; 95% confidence interval 0.74-1.33). In 2 small trials (n=154) in patients with myocardial infarction, the point estimate for the mortality risk ratio was 3.88 (95% CI, 0.83-18.13) favoring the liberal strategy. Overall, from 26 trials enrolling 15,681 patients, 30-day mortality was not different between restrictive and liberal transfusion strategies (risk ratio 1.0, 95% CI, 0.86-1.16). Overall and in the cardiovascular disease subgroup, there were no significant differences observed across a range of secondary outcomes. CONCLUSIONS New trials in patients undergoing cardiac surgery establish that a restrictive transfusion strategy of 7 to 8g/dL is safe and decreased red cell use by 24%. Further research is needed to define the optimal transfusion threshold in patients with acute myocardial infarction.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers Biomedical Health Sciences, New Brunswick, NJ, USA.
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, United Kingdom
| | - John H Alexander
- The Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darrell J Triulzi
- The Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shaun G Goodman
- Centre for Research, Terrence Donnely Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Canada and Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Sunil V Rao
- The Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, United Kingdom
| | - Paul C Hebert
- University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
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Chen QH, Wang HL, Liu L, Shao J, Yu J, Zheng RQ. Effects of restrictive red blood cell transfusion on the prognoses of adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. Crit Care 2018. [PMID: 29848364 DOI: 10.1186/s13054-018-2062-5.pmid:29848364;pmcid:pmc5977455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
PURPOSE Restrictive red blood cell transfusion strategies remain controversial in patients undergoing cardiac surgery. We performed a meta-analysis to assess the prognostic benefits of restrictive red blood cell transfusion strategies in patients undergoing cardiac surgery. METHODS We identified randomized clinical trials through the 9th of December 2017 that investigated a restrictive red blood cell transfusion strategy versus a liberal transfusion strategy in patients undergoing cardiac surgery. Individual patient data from each study were collected. Meta-analyses were performed for the primary and secondary outcomes. The risk of bias was assessed using the Cochrane Risk of Bias Tool. A trial sequential analysis (TSA)-adjusted random-effects model was used to pool the results from the included studies for the primary outcomes. RESULTS Seven trials involving a total of 8886 patients were included. The TSA evaluations suggested that this meta-analysis could draw firm negative results, and the data were sufficient. There was no evidence that the risk of 30-day mortality differed between the patients assigned to a restrictive blood cell transfusion strategy and a liberal transfusion strategy (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.77 to 1.24; p = 0.87). Furthermore, the study suggested that the restrictive transfusion strategy was not associated with significant increases in pulmonary morbidity (OR 1.09; 95% CI 0.88 to 1.34; p = 0.44), postoperative infection (OR 1.11; 95% CI 0.95 to 1.3; p = 0.58), acute kidney injury (OR 1.03; 95% CI 0.92 to 1.14; p = 0.71), acute myocardial infarction (OR 1.01; 95% CI 0.80 to 1.27; p = 0.78), or cerebrovascular accidents (OR 0.97; 95% CI 0.72 to 1.30; p = 0.66). CONCLUSIONS Our meta-analysis demonstrates that the restrictive red blood cell transfusion strategy was not inferior to the liberal strategy with respect to 30-day mortality, pulmonary morbidity, postoperative infection, cerebrovascular accidents, acute kidney injury, or acute myocardial infarction, and fewer red blood cells were transfused.
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Affiliation(s)
- Qi-Hong Chen
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Hua-Ling Wang
- Department of Cardiology, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China.
| | - Lei Liu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Jun Shao
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Jiangqian Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Rui-Qiang Zheng
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
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31
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Chen QH, Wang HL, Liu L, Shao J, Yu J, Zheng RQ. Effects of restrictive red blood cell transfusion on the prognoses of adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:142. [PMID: 29848364 PMCID: PMC5977455 DOI: 10.1186/s13054-018-2062-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 05/10/2018] [Indexed: 01/01/2023]
Abstract
PURPOSE Restrictive red blood cell transfusion strategies remain controversial in patients undergoing cardiac surgery. We performed a meta-analysis to assess the prognostic benefits of restrictive red blood cell transfusion strategies in patients undergoing cardiac surgery. METHODS We identified randomized clinical trials through the 9th of December 2017 that investigated a restrictive red blood cell transfusion strategy versus a liberal transfusion strategy in patients undergoing cardiac surgery. Individual patient data from each study were collected. Meta-analyses were performed for the primary and secondary outcomes. The risk of bias was assessed using the Cochrane Risk of Bias Tool. A trial sequential analysis (TSA)-adjusted random-effects model was used to pool the results from the included studies for the primary outcomes. RESULTS Seven trials involving a total of 8886 patients were included. The TSA evaluations suggested that this meta-analysis could draw firm negative results, and the data were sufficient. There was no evidence that the risk of 30-day mortality differed between the patients assigned to a restrictive blood cell transfusion strategy and a liberal transfusion strategy (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.77 to 1.24; p = 0.87). Furthermore, the study suggested that the restrictive transfusion strategy was not associated with significant increases in pulmonary morbidity (OR 1.09; 95% CI 0.88 to 1.34; p = 0.44), postoperative infection (OR 1.11; 95% CI 0.95 to 1.3; p = 0.58), acute kidney injury (OR 1.03; 95% CI 0.92 to 1.14; p = 0.71), acute myocardial infarction (OR 1.01; 95% CI 0.80 to 1.27; p = 0.78), or cerebrovascular accidents (OR 0.97; 95% CI 0.72 to 1.30; p = 0.66). CONCLUSIONS Our meta-analysis demonstrates that the restrictive red blood cell transfusion strategy was not inferior to the liberal strategy with respect to 30-day mortality, pulmonary morbidity, postoperative infection, cerebrovascular accidents, acute kidney injury, or acute myocardial infarction, and fewer red blood cells were transfused.
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Affiliation(s)
- Qi-Hong Chen
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Hua-Ling Wang
- Department of Cardiology, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China.
| | - Lei Liu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Jun Shao
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Jiangqian Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
| | - Rui-Qiang Zheng
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China
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Cortés-Puch I, Wiley BM, Sun J, Klein HG, Welsh J, Danner RL, Eichacker PQ, Natanson C. Risks of restrictive red blood cell transfusion strategies in patients with cardiovascular disease (CVD): a meta-analysis. Transfus Med 2018; 28:335-345. [PMID: 29675833 DOI: 10.1111/tme.12535] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 01/28/2023]
Abstract
AIM To evaluate the risks of restrictive red blood cell transfusion strategies (haemoglobin 7-8 g dL-1 ) in patients with and without known cardiovascular disease (CVD). BACKGROUND Recent guidelines recommend restrictive strategies for CVD patients hospitalised for non-CVD indications, patients without known CVD and patients hospitalised for CVD corrective procedures. METHODS/MATERIALS Database searches were conducted through December 2017 for randomised clinical trials that enrolled patients with and without known CVD, hospitalised either for CVD-corrective procedures or non-cardiac indications, comparing effects of liberal with restrictive strategies on major adverse coronary events (MACE) and death. RESULTS In CVD patients not undergoing cardiac interventions, a liberal strategy decreased (P = 0·01) the relative risk (95% CI) (RR) of MACE [0·50 (0·29-0·86)] (I2 = 0%). Among patients without known CVD, the incidence of MACE was lower (1·7 vs 3·9%), and the effect of a liberal strategy on MACE [0·79, (0·39-1·58)] was smaller and non-significant but not different from CVD patients (P = 0·30). Combining all CVD and non-CVD patients, a liberal strategy decreased MACE [0·59, (0·39-0·91); P = 0·02]. Conversely, among studies reporting mortality, a liberal strategy decreased mortality in CVD patients (11·7% vs·13·3%) but increased mortality (19·2% vs 18·0%) in patients without known CVD [interaction P = 0·05; ratio of RR 0·73, (0·53-1·00)]. A liberal strategy also did not benefit patients undergoing cardiac surgery; data were insufficient for percutaneous cardiac procedures. CONCLUSIONS In patients hospitalised for non-cardiac indications, liberal transfusion strategies are associated with a decreased risk of MACE in both those with and without known CVD. However, this only provides a survival benefit to CVD patients not admitted for CVD-corrective procedures.
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Affiliation(s)
- I Cortés-Puch
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - B M Wiley
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - J Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - H G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - J Welsh
- National Institutes of Health Library, National Institutes of Health, Bethesda, Maryland, USA
| | - R L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - P Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - C Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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Reeves BC, Pike K, Rogers CA, Brierley RC, Stokes EA, Wordsworth S, Nash RL, Miles A, Mumford AD, Cohen A, Angelini GD, Murphy GJ. A multicentre randomised controlled trial of Transfusion Indication Threshold Reduction on transfusion rates, morbidity and health-care resource use following cardiac surgery (TITRe2). Health Technol Assess 2018; 20:1-260. [PMID: 27527344 DOI: 10.3310/hta20600] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uncertainty about optimal red blood cell transfusion thresholds in cardiac surgery is reflected in widely varying transfusion rates between surgeons and cardiac centres. OBJECTIVE To test the hypothesis that a restrictive compared with a liberal threshold for red blood cell transfusion after cardiac surgery reduces post-operative morbidity and health-care costs. DESIGN Multicentre, parallel randomised controlled trial and within-trial cost-utility analysis from a UK NHS and Personal Social Services perspective. We could not blind health-care staff but tried to blind participants. Random allocations were generated by computer and minimised by centre and operation. SETTING Seventeen specialist cardiac surgery centres in UK NHS hospitals. PARTICIPANTS Patients aged > 16 years undergoing non-emergency cardiac surgery with post-operative haemoglobin < 9 g/dl. Exclusion criteria were: unwilling to have transfusion owing to beliefs; platelet, red blood cell or clotting disorder; ongoing or recurrent sepsis; and critical limb ischaemia. INTERVENTIONS Participants in the liberal group were eligible for transfusion immediately after randomisation (post-operative haemoglobin < 9 g/dl); participants in the restrictive group were eligible for transfusion if their post-operative haemoglobin fell to < 7.5 g/dl during the index hospital stay. MAIN OUTCOME MEASURES The primary outcome was a composite outcome of any serious infectious (sepsis or wound infection) or ischaemic event (permanent stroke, myocardial infarction, gut infarction or acute kidney injury) during the 3 months after randomisation. Events were verified or adjudicated by blinded personnel. Secondary outcomes included blood products transfused; infectious events; ischaemic events; quality of life (European Quality of Life-5 Dimensions); duration of intensive care or high-dependency unit stay; duration of hospital stay; significant pulmonary morbidity; all-cause mortality; resource use, costs and cost-effectiveness. RESULTS We randomised 2007 participants between 15 July 2009 and 18 February 2013; four withdrew, leaving 1000 and 1003 in the restrictive and liberal groups, respectively. Transfusion rates after randomisation were 53.4% (534/1000) and 92.2% (925/1003). The primary outcome occurred in 35.1% (331/944) and 33.0% (317/962) of participants in the restrictive and liberal groups [odds ratio (OR) 1.11, 95% confidence interval (CI) 0.91 to 1.34; p = 0.30], respectively. There were no subgroup effects for the primary outcome, although some sensitivity analyses substantially altered the estimated OR. There were no differences for secondary clinical outcomes except for mortality, with more deaths in the restrictive group (4.2%, 42/1000 vs. 2.6%, 26/1003; hazard ratio 1.64, 95% CI 1.00 to 2.67; p = 0.045). Serious post-operative complications excluding primary outcome events occurred in 35.7% (354/991) and 34.2% (339/991) of participants in the restrictive and liberal groups, respectively. The total cost per participant from surgery to 3 months postoperatively differed little by group, just £182 less (standard error £488) in the restrictive group, largely owing to the difference in red blood cells cost. In the base-case cost-effectiveness results, the point estimate suggested that the restrictive threshold was cost-effective; however, this result was very uncertain partly owing to the negligible difference in quality-adjusted life-years gained. CONCLUSIONS A restrictive transfusion threshold is not superior to a liberal threshold after cardiac surgery. This finding supports restrictive transfusion due to reduced consumption and costs of red blood cells. However, secondary findings create uncertainty about recommending restrictive transfusion and prompt a new hypothesis that liberal transfusion may be superior after cardiac surgery. Reanalyses of existing trial datasets, excluding all participants who did not breach the liberal threshold, followed by a meta-analysis of the reanalysed results are the most obvious research steps to address the new hypothesis about the possible harm of red blood cell transfusion. TRIAL REGISTRATION Current Controlled Trials ISRCTN70923932. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 60. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Katie Pike
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachel Cm Brierley
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachel L Nash
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Alice Miles
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Alan Cohen
- Division of Specialised Services, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
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Shehata N, Whitlock R, Fergusson DA, Thorpe KE, MacAdams C, Grocott HP, Rubens F, Fremes S, Lellouche F, Bagshaw S, Royse A, Rosseel PM, Hare G, Medicis ED, Hudson C, Belley-Cote E, Bainbridge D, Kent B, Shaw A, Byrne K, Syed S, Royse CF, McGuiness S, Hall J, Mazer CD. Transfusion Requirements in Cardiac Surgery III (TRICS III): Study Design of a Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2018; 32:121-129. [DOI: 10.1053/j.jvca.2017.10.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Indexed: 11/11/2022]
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DeMaria S, Bennett-Guerrero E. Examining the Methodology of the Transfusion Requirements in Cardiac Surgery-III (TRICS-III) Trial: Third Time’s a Charm? J Cardiothorac Vasc Anesth 2018; 32:130-131. [DOI: 10.1053/j.jvca.2017.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Indexed: 01/28/2023]
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Evidence-Based Red Blood Cell Transfusion Practices in Cardiac Surgery. Transfus Med Rev 2017; 31:230-235. [DOI: 10.1016/j.tmrv.2017.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/21/2017] [Accepted: 06/17/2017] [Indexed: 01/28/2023]
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A Randomized Clinical Trial of Red Blood Cell Transfusion Triggers in Cardiac Surgery. Ann Thorac Surg 2017; 104:1243-1250. [DOI: 10.1016/j.athoracsur.2017.05.048] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/19/2017] [Accepted: 05/15/2017] [Indexed: 11/23/2022]
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Møller A, Nielsen HB, Wetterslev J, Pedersen OB, Hellemann D, Shahidi S. Low vs. high haemoglobin trigger for transfusion in vascular surgery: protocol for a randomised trial. Acta Anaesthesiol Scand 2017; 61:952-961. [PMID: 28782109 DOI: 10.1111/aas.12953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 06/30/2017] [Accepted: 07/07/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND In patients with cardiovascular disease, guidelines for administration of red blood cells (RBC) are mainly based on studies outside the vascular surgical setting with the recommendation to use a haemoglobin (hb) trigger-level lower than by guidelines from The European Society for Vascular Surgery. Restricting RBC transfusion may affect blood O2 transport with a risk for development of tissue ischaemia and postoperative complications. METHODS In a single-centre, open-label, assessor blinded trial, 58 vascular surgical patients (> 40 years of age) awaiting open surgery of the infrarenal aorta or infrainguinal arterial bypass surgery undergo a web-based randomisation to one of two groups: perioperative RBC transfusion triggered by hb < 8 g/dl or hb < 9.7 g/dl. Administration of fluid follows an individualised strategy by optimising cardiac stroke volume and near-infrared spectroscopy determines tissue oxygenation. Serious adverse event rates are: myocardial injury (troponin-I ≥ 45 ng/l or ischaemic electrocardiographic findings at day 30), acute kidney injury, death, stroke and severe transfusion reactions. A follow-up visit takes place 30 days after surgery and a follow-up of serious adverse events in the Danish National Patient Register within 90 days is pending. DISCUSSION This trial is expected to determine whether a RBC transfusion triggered by hb < 9.7 g/dl compared with hb < 8 g/dl results in adequate separation of postoperative hb levels, transfusion of more RBC units and maintains a higher tissue oxygenation. The results will inform the design of a multicentre trial for evaluation of important postoperative outcomes.
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Affiliation(s)
- A. Møller
- Trial site: Department of Anaesthesia and Intensive care; Slagelse Hospital; Slagelse Denmark
| | - H. B. Nielsen
- Nordic Bioscience, Biomarkers & Research - ProScion; Herlev Denmark
- Department of Anaesthesia; Abdominalcentre; Rigshospitalet; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Department 7812; Rigshospitalet; Copenhagen Denmark
| | - O. B. Pedersen
- Department of Clinical Immunology; Naestved Sygehus; Naestved Denmark
| | - D. Hellemann
- Trial site: Department of Anaesthesia and Intensive care; Slagelse Hospital; Slagelse Denmark
| | - S. Shahidi
- Department of General and Vascular Surgery; Slagelse Hospital; Slagelse Denmark
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Yazer MH, van de Watering L, Lozano M, Sirdesai S, Rushford K, Wood EM, Yokoyama AP, Kutner JM, Lin Y, Callum J, Cserti-Gazdewich C, Lieberman L, Pendergrast J, Pendry K, Murphy MF, Selleng K, Greinacher A, Marwaha N, Sharma R, Jain A, Orlin Y, Yahalom V, Perseghin P, Incontri A, Masera N, Okazaki H, Ikeda T, Nagura Y, Zwaginga JJ, Pogłod R, Rosiek A, Letowska M, Yuen J, Cid J, Harm SK, Adhikari P. Development of RBC transfusion indications and the collection of patient-specific pre-transfusion information: summary. Vox Sang 2017; 112:487-494. [PMID: 28524235 DOI: 10.1111/vox.12496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M H Yazer
- The Institute for Transfusion Medicine, University of Pittsburgh and University of Southern Denmark, 3636 Blvd of the Allies, Pittsburgh, PA, 15213, USA
| | - L van de Watering
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin - LUMC, Plesmaniaan 1a, Leiden, 2333 BZ, the Netherlands
| | - M Lozano
- Department of Hemotherapy and Hemostasis, University Clinic Hospital, Villaroel 170, Barcelona, 08036, Spain
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Desborough MJR, Colman KS, Prick BW, Duvekot JJ, Sweeney C, Odutayo A, Jairath V, Doree C, Trivella M, Hopewell S, Estcourt LJ, Stanworth SJ. Effect of restrictive versus liberal red cell transfusion strategies on haemostasis: systematic review and meta-analysis. Thromb Haemost 2017; 117:889-898. [PMID: 28251234 DOI: 10.1160/th17-01-0015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/02/2017] [Indexed: 01/28/2023]
Abstract
Red cells play a key role in normal haemostasis in vitro but their importance clinically is less clear. The objective of this meta-analysis was to assess if correction of anaemia by transfusing red cells at a high haemoglobin threshold (liberal transfusion) is superior to transfusion at a lower haemoglobin threshold (restrictive transfusion) for reducing the risk of bleeding or thrombotic events. We searched for randomised controlled trials in any clinical setting that compared two red cell transfusion thresholds and investigated the risk of bleeding. We searched for studies published up to October 19, 2016 in The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, and the Transfusion Evidence Library and ISI Web of Science. Relative risks (RR) or Peto Odds Ratios (pOR) were pooled using a random-effect model. Nineteen randomised trials with 9852 participants were eligible for inclusion in this review. Overall there was no difference in the risk of any bleeding between transfusion strategies (RR 0.91, 95 % confidence interval [CI] 0.74 to 1.12). The risk of severe or life-threatening bleeding was lower with a restrictive strategy (RR 0.75, 95 % CI 0.57 to 0.99). There was no difference in the risk of thrombotic events (RR 0.83, 95 % CI 0.61 to 1.13). The risk of any bleeding was not reduced with liberal transfusion and there was no overall difference in the risk of thrombotic events. Data from the included trials do not support aiming for a high haemoglobin threshold to improve haemostasis. PROSPERO registration number CRD42016035519.
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Affiliation(s)
- Michael J R Desborough
- Dr. Michael J. R. Desborough, MRCP FRCPath, NHS Blood and Transplant, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK, Tel.: +44 1865 447900, Fax: +44 1865 387957, E-mail:
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Experimental assessment of oxygen homeostasis during acute hemodilution: the integrated role of hemoglobin concentration and blood pressure. Intensive Care Med Exp 2017; 5:12. [PMID: 28251580 PMCID: PMC5332316 DOI: 10.1186/s40635-017-0125-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 02/21/2017] [Indexed: 11/12/2022] Open
Abstract
Background Low hemoglobin concentration (Hb) and low mean arterial blood pressure (MAP) impact outcomes in critically ill patients. We utilized an experimental model of “normotensive” vs. “hypotensive” acute hemodilutional anemia to test whether optimal tissue perfusion is dependent on both Hb and MAP during acute blood loss and fluid resuscitation, and to assess the value of direct measurements of the partial pressure of oxygen in tissue (PtO2). Methods Twenty-nine anesthetized rats underwent 40% isovolemic hemodilution (1:1) (or sham-hemodilution control, n = 4) with either hydroxyethyl starch (HES) (n = 14, normotensive anemia) or saline (n = 11, hypotensive anemia) to reach a target Hb value near 70 g/L. The partial pressure of oxygen in the brain and skeletal muscle tissue (PtO2) were measured by phosphorescence quenching of oxygen using G4 Oxyphor. Mean arterial pressure (MAP), heart rate, temperature, arterial and venous co-oximetry, blood gases, and lactate were assessed at baseline and for 60 min after hemodilution. Cardiac output (CO) was measured at baseline and immediately after hemodilution. Data were analyzed by repeated measures two-way ANOVA. Results Following “normotensive” hemodilution with HES, Hb was reduced to 66 ± 6 g/L, CO increased (p < 0.05), and MAP was maintained. These conditions resulted in a reduction in brain PtO2 (22.1 ± 5.6 mmHg to 17.5 ± 4.4 mmHg, p < 0.05), unchanged muscle PO2, and an increase in venous oxygen extraction. Following “hypotensive” hemodilution with saline, Hb was reduced to 79 ± 5 g/L and both CO and MAP were decreased (P < 0.05). These conditions resulted in a more severe reduction in brain PtO2 (23.2 ± 8.2 to 10.7 ± 3.6 mmHg (p < 0.05), a reduction in muscle PtO2 (44.5 ± 11.0 to 19.9 ± 12.4 mmHg, p < 0.05), a further increase in venous oxygen extraction, and a threefold increase in systemic lactate levels (p < 0.05). Conclusions Acute normotensive anemia (HES hemodilution) was associated with a subtle decrease in brain tissue PtO2 without clear evidence of global tissue hypoperfusion. By contrast, acute hypotensive anemia (saline hemodilution) resulted in a profound decrease in both brain and muscle tissue PtO2 and evidence of inadequate global perfusion (lactic acidosis). These data emphasize the importance of maintaining CO and MAP to ensure adequacy of vital organ oxygen delivery during acute anemia. Improved methods of assessing PtO2 may provide an earlier warning signal of vital organ hypoperfusion.
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Steinbicker AU. Patient Blood Management in der Herzchirurgie – eine Kontradiktion? ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-016-0116-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Carson JL, Stanworth SJ, Roubinian N, Fergusson DA, Triulzi D, Doree C, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10:CD002042. [PMID: 27731885 PMCID: PMC6457993 DOI: 10.1002/14651858.cd002042.pub4] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is considerable uncertainty regarding the optimal haemoglobin threshold for the use of red blood cell (RBC) transfusions in anaemic patients. Blood is a scarce resource, and in some countries, transfusions are less safe than others because of a lack of testing for viral pathogens. Therefore, reducing the number and volume of transfusions would benefit patients. OBJECTIVES The aim of this review was to compare 30-day mortality and other clinical outcomes in participants randomized to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all conditions. The restrictive transfusion threshold uses a lower haemoglobin level to trigger transfusion (most commonly 7 g/dL or 8 g/dL), and the liberal transfusion threshold uses a higher haemoglobin level to trigger transfusion (most commonly 9 g/dL to 10 g/dL). SEARCH METHODS We identified trials by searching CENTRAL (2016, Issue 4), MEDLINE (1946 to May 2016), Embase (1974 to May 2016), the Transfusion Evidence Library (1950 to May 2016), the Web of Science Conference Proceedings Citation Index (1990 to May 2016), and ongoing trial registries (27 May 2016). We also checked reference lists of other published reviews and relevant papers to identify any additional trials. SELECTION CRITERIA We included randomized trials where intervention groups were assigned on the basis of a clear transfusion 'trigger', described as a haemoglobin (Hb) or haematocrit (Hct) level below which a red blood cell (RBC) transfusion was to be administered. DATA COLLECTION AND ANALYSIS We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two people extracted the data and assessed the risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as 'restrictive transfusion' and to the higher transfusion threshold as 'liberal transfusion'. MAIN RESULTS A total of 31 trials, involving 12,587 participants, across a range of clinical specialities (e.g. surgery, critical care) met the eligibility criteria. The trial interventions were split fairly equally with regard to the haemoglobin concentration used to define the restrictive transfusion group. About half of them used a 7 g/dL threshold, and the other half used a restrictive transfusion threshold of 8 g/dL to 9 g/dL. The trials were generally at low risk of bias .Some items of methodological quality were unclear, including definitions and blinding for secondary outcomes.Restrictive transfusion strategies reduced the risk of receiving a RBC transfusion by 43% across a broad range of clinical specialties (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.49 to 0.65; 12,587 participants, 31 trials; high-quality evidence), with a large amount of heterogeneity between trials (I² = 97%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.97, 95% CI 0.81 to 1.16, I² = 37%; N = 10,537; 23 trials; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (high-quality evidence)). Liberal transfusion did not affect the risk of infection (pneumonia, wound, or bacteraemia). AUTHORS' CONCLUSIONS Transfusing at a restrictive haemoglobin concentration of between 7 g/dL to 8 g/dL decreased the proportion of participants exposed to RBC transfusion by 43% across a broad range of clinical specialities. There was no evidence that a restrictive transfusion strategy impacts 30-day mortality or morbidity (i.e. mortality at other points, cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. There were insufficient data to inform the safety of transfusion policies in certain clinical subgroups, including acute coronary syndrome, myocardial infarction, neurological injury/traumatic brain injury, acute neurological disorders, stroke, thrombocytopenia, cancer, haematological malignancies, and bone marrow failure. The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.
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Affiliation(s)
- Jeffrey L Carson
- Rutgers Robert Wood Johnson Medical SchoolDivision of General Internal Medicine125 Paterson StreetNew BrunswickNew JerseyUSA08903
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Nareg Roubinian
- Ottawa Hospital Research Institute725 Parkdale Ave.OttawaONCanadaK1Y 4E9
| | - Dean A Fergusson
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Darrell Triulzi
- University of PittsburghThe Institute for Transfusion MedicineFive Parkway Center875 Greentree RoadPittsburghPAUSA15220
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Paul C Hebert
- University of Montreal Hospital Research CentreCentre for Research900 rue St‐Denis, local R04‐402 Tour VigerMontrealQCCanadaH2X 0A9
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Stokes EA, Wordsworth S, Bargo D, Pike K, Rogers CA, Brierley RCM, Angelini GD, Murphy GJ, Reeves BC. Are lower levels of red blood cell transfusion more cost-effective than liberal levels after cardiac surgery? Findings from the TITRe2 randomised controlled trial. BMJ Open 2016; 6:e011311. [PMID: 27481621 PMCID: PMC4985876 DOI: 10.1136/bmjopen-2016-011311] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To assess the incremental cost and cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery. DESIGN A within-trial cost-effectiveness analysis with a 3-month time horizon, based on a multicentre superiority randomised controlled trial from the perspective of the National Health Service (NHS) and personal social services in the UK. SETTING 17 specialist cardiac surgery centres in UK NHS hospitals. PARTICIPANTS 2003 patients aged >16 years undergoing non-emergency cardiac surgery with a postoperative haemoglobin of <9 g/dL. INTERVENTIONS Restrictive (transfuse if haemoglobin <7.5 g/dL) or liberal (transfuse if haemoglobin <9 g/dL) threshold during hospitalisation after surgery. MAIN OUTCOME MEASURES Health-related quality of life measured using the EQ-5D-3L to calculate quality-adjusted life years (QALYs). RESULTS The total costs from surgery up to 3 months were £17 945 and £18 127 in the restrictive and liberal groups (mean difference is -£182, 95% CI -£1108 to £744). The cost difference was largely attributable to the difference in the cost of red blood cells. Mean QALYs to 3 months were 0.18 in both groups (restrictive minus liberal difference is 0.0004, 95% CI -0.0037 to 0.0045). The point estimate for the base-case cost-effectiveness analysis suggested that the restrictive group was slightly more effective and slightly less costly than the liberal group and, therefore, cost-effective. However, there is great uncertainty around these results partly due to the negligible differences in QALYs gained. CONCLUSIONS We conclude that there is no clear difference in the cost-effectiveness of restrictive and liberal thresholds for red blood cell transfusion after cardiac surgery. TRIAL REGISTRATION NUMBER ISRCTN70923932; Results.
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Affiliation(s)
- E A Stokes
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - S Wordsworth
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - D Bargo
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK Eli Lilly and Company Limited, Lilly House, Basingstoke, Hampshire, UK
| | - K Pike
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - C A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - R C M Brierley
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - G D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - G J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - B C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Pike K, Maishman RL, Brierley RCM, Rogers CA, Murphy GJ, Reeves BC. Adherence to transfusion strategies in a randomized controlled trial: experiences from the TITRe2 trial. Br J Haematol 2016; 179:346-349. [PMID: 27378402 PMCID: PMC5655708 DOI: 10.1111/bjh.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Katie Pike
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, BS2 8HW, UK
| | - Rachel L Maishman
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, BS2 8HW, UK
| | - Rachel C M Brierley
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, BS2 8HW, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, BS2 8HW, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, BS2 8HW, UK
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Restrictive versus Liberal Transfusion Strategy in the Perioperative and Acute Care Settings. Anesthesiology 2016; 125:46-61. [DOI: 10.1097/aln.0000000000001162] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Abstract
Background
Blood transfusions are associated with morbidity and mortality. However, restrictive thresholds could harm patients less able to tolerate anemia. Using a context-specific approach (according to patient characteristics and clinical settings), the authors conducted a systematic review to quantify the effects of transfusion strategies.
Methods
The authors searched MEDLINE, EMBASE, CENTRAL, and grey literature sources to November 2015 for randomized controlled trials comparing restrictive versus liberal transfusion strategies applied more than 24 h in adult surgical or critically ill patients. Data were independently extracted. Risk ratios were calculated for 30-day complications, defined as inadequate oxygen supply (myocardial, cerebral, renal, mesenteric, and peripheral ischemic injury; arrhythmia; and unstable angina), mortality, composite of both, and infections. Statistical combination followed a context-specific approach. Additional analyses explored transfusion protocol heterogeneity and cointerventions effects.
Results
Thirty-one trials were regrouped into five context-specific risk strata. In patients undergoing cardiac/vascular procedures, restrictive strategies seemed to increase the risk of events reflecting inadequate oxygen supply (risk ratio [RR], 1.09; 95% CI, 0.97 to 1.22), mortality (RR, 1.39; 95% CI, 0.95 to 2.04), and composite events (RR, 1.12; 95% CI, 1.01 to 1.24—3322, 3245, and 3322 patients, respectively). Similar results were found in elderly orthopedic patients (inadequate oxygen supply: RR, 1.41; 95% CI, 1.03 to 1.92; mortality: RR, 1.09; 95% CI, 0.80 to 1.49; composite outcome: RR, 1.24; 95% CI, 1.00 to 1.54—3465, 3546, and 3749 patients, respectively), but not in critically ill patients. No difference was found for infections, although a protective effect may exist. Risk estimates varied with successful/unsuccessful transfusion protocol implementation.
Conclusions
Restrictive transfusion strategies should be applied with caution in high-risk patients undergoing major surgery.
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Hogervorst EK, Rosseel PM, van de Watering LM, Brand A, Bentala M, van der Bom JG, van der Meer NJ. Intraoperative Anemia and Single Red Blood Cell Transfusion During Cardiac Surgery: An Assessment of Postoperative Outcome Including Patients Refusing Blood Transfusion. J Cardiothorac Vasc Anesth 2016; 30:363-72. [DOI: 10.1053/j.jvca.2015.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Indexed: 12/28/2022]
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Impact of surgeon experience on the rate of blood transfusion in off-pump coronary artery bypass. J Formos Med Assoc 2016; 115:145-51. [PMID: 26776760 DOI: 10.1016/j.jfma.2015.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/17/2015] [Accepted: 11/21/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/PURPOSE Off-pump coronary artery bypass (OPCAB) reduces the rate of blood transfusion. No studies have focused on the effect of surgeon experience on the transfusion rate. We sought to assess the transfusion rate in OPCAB and to evaluate the effect of surgeon experience. METHODS Retrospective review of 1055 consecutive patients undergoing OPCAB between 2000 and 2012. Patients were divided into tripartites by the year of operation (2000-2004, 2005-2008, and 2009-2012). Surgeon experience was evaluated with revascularization index and conversion rate. RESULTS Mode of intervention was elective in 768, urgency in 185, and emergency in 102 patients (10%). Blood transfusion was associated with increased rates of hospital mortality and sternal wound/bloodstream infections. Revascularization index was 1.22 ± 0.29 per patient and increased over time, from 1.05 ± 0.21 in 2000-2004 to 1.39 ± 0.26 in 2009-2012. Conversion rate was 10% and decreased over time, from 17% in 2000-2004 to 6% in 2009-2012. The average rate of blood transfusion was 58% and decreased over time, from 74% in 2000-2004 to 41% in 2009-2012. Rate of red blood cell transfusion was 56% and decreased from 72% in 2000-2004 to 40% in 2009-2012. Rate of platelet transfusion was 21% and decreased from 25% in 2000-2004 to 15% in 2009-2012.The most significant decrease in the transfusion rate was observed in nonemergency cases. CONCLUSION Surgeon experience reduced the need of blood transfusion after OPCAB. Increasing surgeon experience was associated with a 33% reduction in blood transfusion rate.
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Abstract
Blood transfusion is the most common procedure in cardiac surgery. Increasing evidence exists that excess transfusions are harmful to patients. Transfusion reactions and complications, including infection, immune modulation, and lung injury, are known complications but underreported; hence, their significance is often disregarded. Furthermore, a number of randomized trials have shown that a restrictive transfusion strategy is equal to if not better than a liberal transfusion strategy. Despite the evidence for the use of restrictive transfusion triggers, its dissemination in the cardiac surgical community has met with resistance. In this review, we outline the risks of transfusion, compare restrictive and liberal transfusion strategies in cardiac surgery, and finally outline perioperative interventions to minimize transfusion in the cardiac surgical patient.
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Patel NN, Avlonitis VS, Jones HE, Reeves BC, Sterne JAC, Murphy GJ. Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2015; 2:e543-53. [DOI: 10.1016/s2352-3026(15)00198-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 01/23/2023]
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