Restrictive versus liberal transfusion strategies for red blood cell transfusion after hip or knee surgery

Abstract

Background:Red blood cell (RBC) transfusions are commonly used in surgical patients, but accompanied by many risks such as metabolic derangement, and allergic and febrile reactions. Indications for transfusion in patients after hip or knee surgery have not been definitively evaluated and remain controversial. We performed a meta-analysis to compare the benefits and harms of restrictive versus liberal transfusion strategies in patients after hip or knee surgery.Methods:The PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies through September 2015. The main clinical outcomes reported in randomized controlled trials (RCTs) included 30-day mortality, infection rate, cardiogenic complications, and length of hospital stay. The meta-analysis program of the Cochrane Collaboration (RevMan version 5.3.0) was used for data analysis. Statistical heterogeneity was assessed by both Cochran chi-squared test (Q test) and I2 test. Begg and Egger test were used to assess potential publication bias.Results:We identified 10 eligible RCTs, involving 3788 patients in total. In patients undergoing hip or knee surgery, we found no differences in mortality, or the incidence rates of pneumonia, wound infection, myocardial infarction, or congestive heart failure, between restrictive and liberal thresholds for RBC transfusion (P > .05).Conclusion:Restrictive transfusion has no advantage over the liberal strategy. However, considerably less patients received blood transfusion via the restrictive strategy than with the liberal counterpart. Due to variations in the included studies, additional larger scale and well-designed studies are required to validate these conclusions.

Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review

“…Of note, our findings are supported by two recently published systematic reviews with meta-analyses on blood transfusion regimens within the scope of major orthopaedic surgeries [31,32] that did not find significant differences between the restrictive and the liberal treatment regimen regarding primary outcomes either.…”

“…Based on data originating from 8 RCTs, the results of this systematic review do not suggest an increased risk associated with either a restrictive or a more liberal transfusion regimen in patients undergoing major orthopaedic surgery which is in line with previous publications on this topic, including the 2015 Cochrane review on hip fracture surgery patients by Brunskill et al [13] and the aforementioned systematic reviews published in 2017 [31,32]. In this context, it is important to realise that our findings cannot easily be transferred to lower thresholds.…”

Estrategia restrictiva transfusional en cirugía ortopédica

“…Observando así una clara tendencia estadística (si bien no obtuvimos una diferencia significativa), para lo que seguramente necesitaríamos un mayor número de pacientes. La mayoría de las revisiones y metaanálisis se basan en ensayos clíni-cos heterogéneos en los que se analizan eventos como mortalidad, infarto de miocardio, falla cardíaca, infecciones y clase funcional, sin considerar las reacciones transfusionales propiamente dichas, pero es sensato pensar que estas disminuyen en la medida que disminuyen las transfusiones (6)(7)(8)10,11) . Con respecto a la evolución funcional no se comprobó diferencia entre los operados que se sometieron a la estrategia liberal frente a la restrictiva, lo que confirma los hallazgos obtenidos en experiencias previas.…”

“…Está claro que la situación clínica del paciente, más que las cifras de hemoglobina, es el elemento más importante a evaluar para la indicación de transfusión (5)(6)(7)9,12,13) . Mao T y colaboradores publicaron en 2017 una revisión sistemática y metaanálisis que concluye que la TRT no tiene ventajas sobre la estrategia liberal aunque claramente se transfunden menos pacientes (10) . Recientemente, la revista JAMA publicó una guía de práctica clínica basada en evidencia que recomienda la TRT y propone la cifra de 8 g/dl de hemoglobina como umbral para la transfusión en los pacientes intervenidos de artroplastia (15) .…”

“…El beneficio en el ahorro de recursos se acompaña además de un menor núme-ro de complicaciones relacionadas con la administración de sangre alogénica (7,(10)(11)(12) .…”