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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.
Canadian Journal of Anesthesia ( IF 4.2 ) Pub Date : 2020-02-28 , DOI: 10.1007/s12630-020-01592-w
Hessam H Kashani 1 , Carly Lodewyks 2 , Morvarid S Kavosh 1 , Maya M Jeyaraman 3, 4 , Christine Neilson 5 , George Okoli 3, 4 , Rasheda Rabbani 3, 4 , Ahmed M Abou-Setta 3, 4 , Ryan Zarychanski 4, 6, 7 , Hilary P Grocott 1
Affiliation  

PURPOSE Blood transfusions are frequently administered in cardiac surgery. Despite a large number of published studies comparing a "restrictive" strategy with a "liberal" strategy, no clear consensus has emerged to guide blood transfusion practice in cardiac surgery patients. The purpose of this study was to identify, critically appraise, and summarize the evidence on the overall effect of restrictive transfusion strategies compared with liberal transfusion strategies on mortality, other clinical outcomes, and transfusion-related outcomes in adult patients undergoing cardiac surgery. SOURCE We searched MEDLINE (OvidSP), EMBASE (OvidSP) and Cochrane CENTRAL (Wiley) from inception to 1 December 2017 and queried clinical trial registries and conference proceedings for randomized-controlled trials of liberal vs restrictive transfusion strategies in cardiac surgery. PRINCIPAL FINDINGS From 7,908 citations, we included ten trials (9,101 patients) and eight companion publications. Overall, we found no significant difference in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; 95% confidence interval [CI], 0.76 to 1.54; I2 = 33%; seven trials; 8,661 patients). The use of a restrictive transfusion strategy did not appear to adversely impact any of the secondary clinical outcomes. As expected, the proportion of patients who received red blood cells (RBCs) in the restrictive group was significantly lower than in the liberal group (RR, 0.68; 95% CI, 0.64 to 0.73; I2 = 56%; 5 trials; 8,534 patients). Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy. CONCLUSIONS In adult patients undergoing cardiac surgery, a restrictive transfusion strategy reduces RBC transfusion without impacting mortality rate or the incidence of other perioperative complications. Nevertheless, further large trials in subgroups of patients, potentially of differing age, are needed to establish firm evidence to guide transfusion in cardiac surgery. TRIAL REGISTRATION PROSPERO (CRD42017071440); registered 20 April, 2018.

中文翻译:

限制性输血策略与自由输血策略对心脏手术后长期结果的影响:系统评价和荟萃分析与试验序贯分析。

目的 在心脏手术中经常进行输血。尽管有大量已发表的研究比较了“限制性”策略与“自由”策略,但尚未形成明确的共识来指导心脏手术患者的输血实践。本研究的目的是确定、批判性评价和总结限制性输血策略与自由输血策略相比对接受心脏手术的成年患者死亡率、其他临床结果和输血相关结果的总体影响的证据。SOURCE 我们搜索了 MEDLINE (OvidSP),EMBASE (OvidSP) 和 Cochrane CENTRAL (Wiley) 从成立到 2017 年 12 月 1 日,并查询了心脏手术中自由输血策略与限制性输血策略的随机对照试验的临床试验注册和会议记录。主要发现 从 7,908 次引用中,我们纳入了 10 项试验(9,101 名患者)和 8 篇伴随出版物。总体而言,我们发现限制性输血策略和自由输血策略之间的死亡率没有显着差异(风险比 [RR],1.08;95% 置信区间 [CI],0.76 至 1.54;I2 = 33%;7 项试验;8,661 名患者)。使用限制性输血策略似乎不会对任何次要临床结果产生不利影响。正如预期的那样,限制组接受红细胞(RBC)的患者比例显着低于自由组(RR,0.68; 95% CI,0.64 至 0.73;I2 = 56%;5次试验;8,534 名患者)。在输血患者中,与自由输血策略相比,限制性输血策略与每名患者输注的红细胞单位较少相关。结论 在接受心脏手术的成年患者中,限制性输血策略可减少红细胞输血,而不会影响死亡率或其他围手术期并发症的发生率。然而,需要在可能具有不同年龄的患者亚组中进行进一步的大型试验,以建立确凿的证据来指导心脏手术中的输血。试用注册 PROSPERO (CRD42017071440);于 2018 年 4 月 20 日注册。与自由输血策略相比,限制性输血策略与每位患者输注的红细胞单位数较少相关。结论 在接受心脏手术的成年患者中,限制性输血策略可减少红细胞输血,而不会影响死亡率或其他围手术期并发症的发生率。然而,需要在可能具有不同年龄的患者亚组中进行进一步的大型试验,以建立确凿的证据来指导心脏手术中的输血。试用注册 PROSPERO (CRD42017071440);于 2018 年 4 月 20 日注册。与自由输血策略相比,限制性输血策略与每位患者输注的红细胞单位数较少相关。结论 在接受心脏手术的成年患者中,限制性输血策略可减少红细胞输血,而不会影响死亡率或其他围手术期并发症的发生率。然而,需要在可能具有不同年龄的患者亚组中进行进一步的大型试验,以建立确凿的证据来指导心脏手术中的输血。试用注册 PROSPERO (CRD42017071440);于 2018 年 4 月 20 日注册。需要在可能具有不同年龄的患者亚组中进行进一步的大型试验,以建立确凿的证据来指导心脏手术中的输血。试用注册 PROSPERO (CRD42017071440);于 2018 年 4 月 20 日注册。需要在可能具有不同年龄的患者亚组中进行进一步的大型试验,以建立确凿的证据来指导心脏手术中的输血。试用注册 PROSPERO (CRD42017071440);于 2018 年 4 月 20 日注册。
更新日期:2020-04-20
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