Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis

Abstract

The current evidence does not support the notion that restrictive RBC transfusion strategies are inferior to liberal RBC strategies in patients undergoing cardiac surgery.

As clear as mud: new evidence regarding transfusion triggers in cardiac surgery

“…We trust the metaanalyses, which incorporate data from all available trials, rather than simply ''believing'' the results of one individual trial. Similarly, we have probably accepted without much skepticism the consensus from the systematic reviews [4][5][6] cited that unnecessary transfusion should be avoided because there is no strong evidence of harm in restrictive transfusion, without perhaps applying due diligence and asking the arguably more pertinent question: what is the evidence, if any, for improved outcomes with a restrictive transfusion strategy, and what is the risk? These questions are of course difficult to answer, not least of all because of the heterogeneity of the studies, patients, end points, and transfusion triggers used in the studies.…”

“…Nous faisons confiance aux méta-analyses, qui intègrent les données de toutes les études disponibles, plutôt que de simplement « croire » les résultats d'une étude individuelle. De la même manière, nous avons probablement accepté sans grand scepticisme le consensus des revues méthodiques [4][5][6] citées, selon lequel les transfusions non nécessaires devraient être évitées étant donné qu'il n'existe pas de données probantes convaincantes des conséquences négatives de seuil de transfusions restrictif et ce, sans peut-être avoir fait preuve de rigueur appropriée ni avoir demandé la question assurément plus pertinente : quelles sont les données probantes, si tant est qu'elles existent, de devenirs améliorés en cas de stratégies de transfusions restrictives, et quels en sont les risques? Il est bien entendu très difficile de répondre à ces questions, notamment en raison de l'hétérogénéité des études, des patients, des critères d'évaluation et des seuils de transfusion utilisés dans les études.…”

Commentary: Can a health care quality lens clarify transfusion practice in perioperative cardiac surgery?

“…When TRICS III was incorporated into an updated metaanalysis of 13 trials comparing restrictive versus liberal transfusion in more than 9000 cardiac surgical patients, the risk ratio for mortality was essentially 1. 4 In clinical practice, however, the decision to transfuse red blood cells is often based not exclusively on the hemoglobin concentration but also on best available physiologic indicators of endorgan tissue oxygenation. 5 Nonetheless, with literature converging on an ''answer'' that restrictive transfusion in cardiac surgery is at least as safe as a liberal approach, new questions arise: Is routine transfusion to a liberal hemoglobin target in cardiac surgical care simply wasteful?…”

How do I audit intraoperative blood component utilization in cardiac surgery?

“…Despite the growing evidence from 13 rigorously conducted, randomized trials in cardiac surgical patients (9092 patients) that a restrictive hemoglobin (Hb) transfusion trigger (7‐8 g/dL) is noninferior to a liberal Hb transfusion trigger (9‐10 g/dL), there remains uncertainty regarding appropriate practice for intraoperative transfusions. Because of the complexity and quickly changing environment such as active bleeding, hemodynamic instability, and other factors such as anesthetic depth and dilution with intravenous (IV) fluids, some patient blood management (PBM) programs exclude intraoperative transfusions when auditing for transfusion appropriateness .…”