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What blood conservation practices are effective at reducing blood sampling volumes and other clinical sequelae in intensive care? A systematic review
Keogh S, Mathew S, Ullman AJ, Rickard CM, Coyer F
Australian critical care : official journal of the Confederation of Australian Critical Care Nurses. 2023
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Editor's Choice
Abstract
OBJECTIVES The objective of this study was to critically appraise and synthesise evidence for blood conservation strategies in intensive care. Blood sampling is a critical aspect of intensive care to guide clinical decision-making. Repeated blood sampling can result in blood waste and contamination, leading to iatrogenic anaemia and systemic infection. REVIEW METHOD USED Cochrane systematic review methods were used including meta-analysis, and independent reviewers. DATA SOURCES A systematic search was conducted in Medline, CINAHL, PUBMED and EMBASE databases. The search was limited to randomised controlled trials (RCTs) and cluster RCTs, published in English between 2000 and 2021. REVIEW METHODS Paired authors independently assessed database search results and identified eligible studies. Trials comparing any blood conservation practice or product in intensive care were included. Primary outcomes were blood sample volumes and haemoglobin change. Secondary outcomes included proportion of patients receiving transfusions and infection outcomes. Quality appraisal employed the Cochrane Risk of Bias tool. Meta-analysis using random effects approach and narrative synthesis summarised findings. RESULTS Eight studies (n = 1027 patients), all RCTs were eligible. Six studies included adults, one studied paediatrics and one studied preterm infants. Seven studies evaluated a closed loop blood sampling system, and one studied a conservative phlebotomy protocol. Studies were of low to moderate quality. Meta-analysis was not possible for interventions targeting blood sample volumes or haemoglobin. Decreased blood sample volumes reported in four studies were attributable to a closed loop system or conservative phlebotomy. No study reported a significant change in haemoglobin. Meta-analysis demonstrated that use of a closed system (compared to open system) reduced the proportion of patients receiving transfusion [Risk Ratio (RR) 0.65, 95% CI 0.46-0.92; 287 patients] and reduced intraluminal fluid colonisation [RR 0.25, 95% CI 0.07-0.58; 500 patients]. CONCLUSIONS Limited evidence demonstrates closed loop blood sampling systems reduced transfusion use and fluid colonisation. Simultaneous effectiveness-implementation evaluation of these systems and blood conservation strategies is urgently required. PROSPERO PROTOCOL REGISTRATION REFERENCE CRD42019137227.
PICO Summary
Population
Patients (adults, neonates and paediatrics) admitted to an intensive care unit (8 randomised controlled trials, n= 1,027).
Intervention
Different blood sampling strategies and systems, including the standard open arterial blood sampling system.
Comparison
Various comparators, including the closed-loop arterial blood sampling system, and adding small-volume tubes to the closed-loop system.
Outcome
Seven studies evaluated a closed loop blood sampling system, and one studied a conservative phlebotomy protocol. Studies were of low to moderate quality. Meta-analysis was not possible for interventions targeting blood sample volumes or haemoglobin. Decreased blood sample volumes reported in four studies were attributable to a closed loop system or conservative phlebotomy. No study reported a significant change in haemoglobin. Meta-analysis demonstrated that use of a closed system (compared to open system) reduced the proportion of patients receiving transfusion (Risk Ratio (RR) 0.65, 95% CI: 0.46-0.92; 287 patients) and reduced intraluminal fluid colonisation (RR 0.25, 95% CI: 0.07-0.58; 500 patients).
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Prevention of cardiac surgery-associated acute kidney injury: a systematic review and meta-analysis of non-pharmacological interventions
Hariri, G., Collet, L., Duarte, L., Martin, G. L., Resche-Rigon, M., Lebreton, G., Bouglé, A., Dechartres, A.
Critical care (London, England). 2023;27(1):354
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Editor's Choice
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CSA-AKI) is frequent. While two network meta-analyses assessed the impact of pharmacological interventions to prevent CSA-AKI, none focused on non-pharmacological interventions. We aim to assess the effectiveness of non-pharmacological interventions to reduce the incidence of CSA-AKI. METHODS We searched PubMed, Embase, Central and clinical trial registries from January 1, 2004 (first consensus definition of AKI) to July 1, 2023. Additionally, we conducted manual screening of abstracts of major anesthesia and intensive care conferences over the last 5 years and reference lists of relevant studies. We selected all randomized controlled trials (RCTs) assessing a non-pharmacological intervention to reduce the incidence of CSA-AKI, without language restriction. We excluded RCTs of heart transplantation or involving a pediatric population. The primary outcome variable was CSA-AKI. Two reviewers independently identified trials, extracted data and assessed risk of bias. Random-effects meta-analyses were conducted to calculate risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence. RESULTS We included 86 trials (25,855 patients) evaluating 10 non-pharmacological interventions to reduce the incidence of CSA-AKI. No intervention had high-quality evidence to reduce CSA-AKI. Two interventions were associated with a significant reduction in CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion (RR, 0.55 [95% CI 0.40-0.76], I(2) = 0%; P(het) = 0.44) and remote ischemic preconditioning (RR, 0.86 [0.78-0.95]; I(2) = 23%; P(het) = 0.07). Pulsatile flow during cardiopulmonary bypass was associated with a significant reduction in CSA-AKI incidence but with very low quality of evidence (RR = 0.69 [0.48; 0.99]; I(2) = 53%; P(het) < 0.01). We found high quality of evidence for lack of effect of restrictive transfusion strategy (RR, 1.02 [95% CI 0.92; 1.12; P(het) = 0.67; I(2) = 3%) and tight glycemic control (RR, 0.86 [95% CI 0.55; 1.35]; P(het) = 0.25; I(2) = 26%). CONCLUSIONS Two non-pharmacological interventions are likely to reduce CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion and remote ischemic preconditioning.
PICO Summary
Population
Adult patients undergoing cardiac surgery such as coronary artery bypass grafting and/or valve surgery (86 randomised controlled trials (RCTs) n= 25,855).
Intervention
Non-pharmacological interventions to reduce the incidence of cardiac surgery-associated acute kidney injury (CSA-AKI): Goal directed perfusion (GDP), pulsatile flow during cardiopulmonary bypass (CPB), minimally invasive extracorporeal circulation (MECC), epidural analgesia, remote ischemic preconditioning (RIPc), tight glycemic control, kidney disease improving global outcomes care bundle, hyperoxia during CPB, restrictive transfusion strategy, high target arterial pressure.
Comparison
Usual care.
Outcome
No intervention had high-quality evidence to reduce CSA-AKI. From the included studies, the most frequent intervention was RIPc (31 RCTs, n= 7,738), MECC, (14 RCTs, n= 1,617) and pulsatile blood flow during CPB (10 RCTs, n= 1,993). Three interventions were associated with a significantly reduced risk of CSA-AKI: GDP, RIPc and pulsatile flow during CPB.
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Interventions for chronic kidney disease in people with sickle cell disease
Roy, N. B., Carpenter, A., Dale-Harris, I., Dorée, C., Estcourt, L. J.
The Cochrane database of systematic reviews. 2023;8(8):Cd012380
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Editor's Choice
Abstract
BACKGROUND Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta-globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end-stage renal disease. This is an update of a review first published in 2017. OBJECTIVES To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin-converting enzyme inhibitors (ACEIs), either alone or in combination. SEARCH METHODS We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). MAIN RESULTS We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m(2), 95% confidence interval (CI) -14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD-related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin-converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD -49.00 mg/day, 95% CI -124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all-cause mortality, or quality of life. Angiotensin-converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all-cause mortality, or quality of life. AUTHORS' CONCLUSIONS We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long-term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD.
PICO Summary
Population
Children and adults with sickle cell disease (3 randomised controlled trials, n= 385).
Intervention
Interventions to prevent or reduce kidney complications or chronic kidney disease, including: hydroxyurea, and angiotensin-converting enzyme inhibitors (ACEIs), either alone or in combination.
Comparison
Placebo.
Outcome
This systematic review is an update of a review first published in 2017. The authors rated the certainty of the evidence as low to very low across different outcomes. The authors are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. The authors are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. The authors are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria.
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Effective management of foetal anaemia in Rh(D) alloimmunised pregnant women with intrauterine transfusion: a Systematic Review
Prescott, B., Jackson, D. E.
Hematology, transfusion and cell therapy. 2023
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Editor's Choice
Abstract
BACKGROUND Foetal anaemia is caused by a severe pregnancy complication, haemolytic disease of the foetus and newborn. Intrauterine transfusions (IUTs) are performed to treat foetal anaemia in alloimmunised pregnant women. If left untreated hydrops can develop thereby reducing the chance of survival. Survival rates have improved but the procedure is not without complications. Procedure-related complications can be associated with early gestational age, hence delaying IUT could improve outcomes. This review aims to determine the effectiveness and safety of IUTs by examining survival and mortality rates, procedure-related complications with associated foetal mortality and the influence of hydrops. STUDY DESIGN AND METHOD A systematic review was conducted by searching keywords in four scientific databases from January 2000 to April 2022. A meta-analysis was performed with the OpenMeta-Analyst software using an arcsine transformed proportion with the binary random-effects model and maximum likelihood method. RESULTS Fifteen studies were identified as eligible and used in the meta-analysis. The forest plots all showed statistically significant outcomes with heterogeneity of data. Results indicated a greater foetal survival rate with IUT to treat anaemic foetuses, a low foetal mortality rate, and low risk of procedure-related complications associated with foetal loss but a higher risk of foetal mortality when hydrops is present. CONCLUSION The findings of this systematic review and meta-analysis provide evidence that IUT is a safe and effective treatment for foetal anaemia in the absence of hydrops when experienced personnel perform the procedure to minimise the risk of procedure-related complications.
PICO Summary
Population
Rh(D) alloimmunised pregnant women (15 studies).
Intervention
Systematic review and meta-analysis to determine the effectiveness and safety of intrauterine transfusions (IUTs).
Comparison
Outcome
The forest plots all showed statistically significant outcomes with heterogeneity of data. Results indicated a greater foetal survival rate with IUT to treat anaemic foetuses, a low foetal mortality rate, and low risk of procedure-related complications associated with foetal loss but a higher risk of foetal mortality when hydrops is present.
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Transfusion Guidelines in Brain Tumor Surgery: A Systematic Review and Critical Summary of Currently Available Evidence
Rail B, Hicks WH, Oduguwa E, Barrie U, Pernik MN, Montgomery E, Tao J, Kenfack YJ, Mofor P, Adeyemo E, et al
World neurosurgery. 2022
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Editor's Choice
Abstract
OBJECTIVE Red blood cell (RBC) transfusion is commonly indicated in brain tumor surgery due to risk of blood loss. Current transfusion guidelines are based on evidence derived from critically ill patients and may not be optimal for brain tumor surgeries. Our study is the first to synthesize available evidence to suggest RBC transfusion thresholds in brain tumor patients undergoing surgery. METHODS A systematic review was conducted using PubMed, EMBASE, and Google Scholar databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to critically assess RBC transfusion thresholds in adult patients with brain tumors and complications secondary to transfusion following blood loss in the operating room (OR) or the perioperative period. RESULTS Seven (7) articles meeting our search criteria were reviewed. Brain tumor patients who received blood transfusions were older, had greater rates of ASA class 3 or 4, and presented with increased number of comorbidities including diabetes, hypertension, and cardiovascular diseases. In addition, transfused patients had a prolonged surgical time. Transfusions were associated with multiple postoperative major and minor complications, including longer hospital length of stay (LOS), increased return to the OR, and elevated 30-day mortality. Analysis of transfusion thresholds showed that a restrictive hemoglobin (Hb) threshold of 8 g/dL is safe in patients, as evidenced by a reduction in LOS, mortality, and complications (Level C Class IIa). CONCLUSIONS A restrictive Hb threshold of 8 g/dL appears to be safe and minimizes potential complications of transfusion in brain tumor patients. LEVEL OF EVIDENCE Class C Level IIa.
PICO Summary
Population
Brain tumor patients undergoing surgery (7 studies).
Intervention
Systematic review assessing red blood cell transfusion thresholds.
Comparison
Outcome
Patients who received blood transfusions were older, had greater rates of American Society of Anesthesiologists class 3 or 4, and presented with increased number of comorbidities including diabetes, hypertension, and cardiovascular diseases. Transfused patients had a prolonged surgical time. Transfusions were associated with multiple postoperative major and minor complications, including longer hospital length of stay (LOS), increased return to the operating room, and elevated 30-day mortality. Analysis of transfusion thresholds showed that a restrictive haemoglobin (Hb) threshold of 8 g/dL was safe in patients, as evidenced by a reduction in LOS, mortality, and complications.
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Impact of restrictive red blood cell transfusion strategy on thrombosis-related events: A meta-analysis and systematic review
Maimaitiming M, Zhang C, Xie J, Zheng Z, Luo H, Ooi OC
Vox sanguinis. 2022
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Editor's Choice
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; I(2) = 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; I(2) = 0.0%, very low-quality evidence) or myocardial infarction (RR = 1.05; 95% CI 0.87-1.26; p = 0.620; I(2) = 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.
PICO Summary
Population
Adult patients in any clinical setting (30 studies, n= 17,334).
Intervention
Restrictive red blood cell transfusion.
Comparison
Liberal red blood cell transfusion.
Outcome
The pooled risk ratio (RR) for thromboembolic events was 0.65 (very low-quality evidence), favouring the restrictive strategy. There were no significant differences in cerebrovascular accidents (RR= 0.83, very low-quality evidence) or myocardial infarction (RR= 1.05, low-quality evidence). Subgroup analyses showed that a restrictive (relative to liberal) strategy reduced thromboembolic events in trials conducted in North America, and myocardial infarctions in the subgroup of trials 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).
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The impact of red blood cell transfusion on mortality and treatment efficacy in patients treated with radiation: A systematic review
Deschner M, Vasanthamohan L, Zayed S, Lazo-Langner A, Palma D, D'Souza D, Omar Gilani S, Gabriel Boldt R, Solh Z
Clinical and translational radiation oncology. 2022;33:23-29
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Editor's Choice
Abstract
INTRODUCTION Packed red blood cell (RBC) transfusion is frequently used in patients undergoing radiotherapy (RT) because retrospective data suggest that anemic patients may respond sub-optimally to RT. No high-quality evidence currently exists to guide transfusion practices and establish hemoglobin (Hb) transfusion thresholds for this patient population, and practice varies significantly across centers. This systematic review investigated whether maintaining higher Hb via transfusion in radiation oncology patients leads to improved outcomes. METHODS We performed a literature search of studies comparing RBC transfusion thresholds in radiation oncology patients. Included studies assessed patients receiving RT for malignancy of any diagnosis or stage. Excluded studies did not evaluate Hb or transfusion as an intervention or outcome. The primary outcome was overall survival. Secondary outcomes included locoregional control, number of transfusions and adverse events. RESULTS One study met inclusion criteria. The study pooled results from two randomized controlled trials that stratified anemic patients with head and neck squamous cell carcinoma to RBC transfusion versus no transfusion. The study found no significant differences in overall survival or locoregional control after five years, despite increased Hb levels in the transfused group. We conducted a narrative review by extracting data from 10 non-comparative studies involving transfusion in patients receiving RT. Results demonstrated no consistent conclusions regarding whether transfusions improve or worsen outcomes. CONCLUSIONS There is a lack of data on the effects of RBC transfusion on outcomes in patients undergoing RT. Well-designed prospective studies are needed in this area.
PICO Summary
Population
Patients undergoing radiotherapy (11 studies).
Intervention
Red blood cell transfusion.
Comparison
No transfusion.
Outcome
Only one study met the inclusion criteria which pooled results from two randomized controlled trials (DAHANCA 5 and 7). The study found no significant differences in overall survival or locoregional control after five years, despite increased haemoglobin levels in the transfused group (n= 235) vs. no transfused group (n= 230). A narrative review was conducted by extracting data from 10 other non-comparative studies involving transfusion in patients receiving radiotherapy. There were no consistent conclusions from these 10 studies on whether transfusions improve or worsen outcomes.
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Transfusion Guidelines in Adult Spine Surgery: A Systematic Review and Critical Summary of Currently Available Evidence
Barrie U, Youssef CA, Pernik MN, Adeyemo E, Elguindy M, Johnson ZD, Ahmadieh TYE, Akbik OS, Bagley CA, Aoun SG
The spine journal : official journal of the North American Spine Society. 2021
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Abstract
BACKGROUND CONTEXT Red blood cell transfusion can be associated with complications in medical and surgical patients. Acute anemia in ambulatory patients undergoing surgery can also impede wound healing and independent self-care. Current transfusion threshold guidelines are still based on evidence derived from critically-ill intensive care unit medical patients and may not apply to spine surgery candidates. PURPOSE We aimed to provide the reader with a synthesis of the best available evidence to recommend transfusion trigger thresholds and guidelines in adult patients undergoing spine surgery. STUDY DESIGN/SETTING This is a systematic review. OUTCOME MEASURES Physiological measure: Blood transfusion thresholds and associated posttransfusion complications (morbidity, mortality, length of stay, infections, etc…) of the published articles. PATIENT SAMPLE Adult spine surgery patients. METHODS A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Focus was set on papers discussing thresholds for blood transfusion in adult surgical spine patients, as well as complications associated with transfusion after acute surgical blood loss in the operating room or postoperative period. Publications discussing pediatric cases, blood type analyses, blood loss prevention strategies and protocols, systematic reviews and letters to the editor were excluded. RESULTS A total of 22 articles fitting our search criteria were reviewed. Patients who received blood transfusion in these studies were older, of female gender, had more severe comorbidities except for smoking, and had prolonged surgical time. Blood transfusion was associated with multiple adverse postoperative complications, including a higher rate of superficial or deep surgical site infections, sepsis, urinary and pulmonary infections, cardiovascular complications, return to the operating room, and increased postoperative length of stay and 30-day readmission. Analysis of transfusion thresholds from these studies showed that a pre-operative hemoglobin (Hb) of > 13 g/dL, and an intraoperative and post-operative Hb nadir above 9 and 8 g/dL, respectively, were associated with better outcomes and fewer wound infections than lower thresholds (Level B Class III). Additionally, it was generally recommended to transfuse autologous blood that was < 28 days old, if possible, with a limit of 2 to 3 units to minimize patient morbidity and mortality. CONCLUSION Blood transfusion thresholds in surgical patients may be specialty-specific and different than those used for critically-ill medical patients. For adult spine surgery patients, red blood cell transfusion should be avoided if Hb numbers remain > 9 and 8 g/dL in the intraoperative and direct post-operative periods, respectively.
PICO Summary
Population
Adult spine surgery patients (22 studies).
Intervention
Systematic review of studies on recommended thresholds for blood transfusion, and its associated complications.
Comparison
Outcome
Patients who received blood transfusion in the studies reviewed were older, female, had more severe comorbidities except for smoking, and had prolonged surgical time. Blood transfusion was associated with multiple adverse postoperative complications, including a higher rate of superficial or deep surgical site infections, sepsis, urinary and pulmonary infections, cardiovascular complications, return to the operating room, and increased postoperative length of stay and 30-day readmission. Analysis of transfusion thresholds showed that a pre-operative haemoglobin (Hb) of > 13 g/dL, and an intraoperative and post-operative Hb nadir above 9 and 8 g/dL, respectively, were associated with better outcomes and fewer wound infections than lower thresholds. Additionally, it was generally recommended to transfuse autologous blood that was < 28 days old, if possible, with a limit of 2 to 3 units to minimize patient morbidity and mortality.
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Hemoglobin levels as a transfusion criterion in moderate to severe traumatic brain injury: a systematic review and meta-analysis
Florez-Perdomo WA, García-Ballestas E, Martinez-Perez R, Agrawal A, Deora H, Joaquim AF, Quiñones-Ossa GA, Moscote-Salazar LR
British journal of neurosurgery. 2021;:1-7
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Abstract
BACKGROUND Several factors can influence the outcome of severe head injuries including the patient's hemoglobin levels. There has often been a dilemma regarding levels of hemoglobin at which red cell blood transfusion (RCBT) should be performed. OBJECTIVE To systematically review the literature to determine the usefulness of management protocols that have hemoglobin levels <10 g/dL vs <7 g/dL as an RCBT criterion. METHODS Following the PRISMA statement, the search was constructed using terms and descriptors of the Medical Subject Heading (MeSH), combined with Boolean operators. Full text of these articles was studied, and outcome measures at 3-6 months were considered for patients who were given a RCBT at <10 g/dL or at 7 g/dL hemoglobin levels. RESULTS A total of 4 articles were found suitable for inclusion in the meta-analysis. RCBT below 7 g/dL was not associated with an increased risk of mortality as compared to RCBT using the value of less than 10 g/dL. RCBT at lower levels of hemoglobin was also not associated with a poor neurological outcome (GOS 4-5) but rather RCBT at lower levels lead to better outcomes (GOS 1-3) and the association was significant. CONCLUSION Allogenic RCBT was associated with poorer neurological outcomes, within a wide range of reported differences in the hemoglobin threshold to decide for RCBT in TBI patients. Restrictive RCBT strategy may be useful in moderate to severe TBI cases although the risk of anemia-induced cerebral injury needs further investigation regarding the risks and complications inherent to RCBT.
PICO Summary
Population
Patients with traumatic brain injury (4 studies, n= 607).
Intervention
Liberal red cell blood transfusion (RCBT) criterion protocol of haemoglobin level <10 g/dL.
Comparison
Restrictive RCBT criterion protocol of haemoglobin level <7 g/dL.
Outcome
RCBT below 7 g/dL was not associated with an increased risk of mortality as compared to RCBT using the value of less than 10 g/dL. RCBT at lower levels of haemoglobin was also not associated with a poor neurological outcome (GOS 4-5) but rather RCBT at lower levels lead to better outcomes (GOS 1-3) and the association was significant.
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Anemia and Red Blood Cell Transfusions, Cerebral Oxygenation, Brain Injury and Development, and Neurodevelopmental Outcome in Preterm Infants: A Systematic Review
Kalteren WS, Verhagen EA, Mintzer JP, Bos AF, Kooi EMW
Frontiers in pediatrics. 2021;9:644462
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Editor's Choice
Abstract
Background: Anemia remains a common comorbidity of preterm infants in the neonatal intensive care unit (NICU). Left untreated, severe anemia may adversely affect organ function due to inadequate oxygen supply to meet oxygen requirements, resulting in hypoxic tissue injury, including cerebral tissue. To prevent hypoxic tissue injury, anemia is generally treated with packed red blood cell (RBC) transfusions. Previously published data raise concerns about the impact of anemia on cerebral oxygen delivery and, therefore, on neurodevelopmental outcome (NDO). Objective: To provide a systematic overview of the impact of anemia and RBC transfusions during NICU admission on cerebral oxygenation, measured using near-infrared spectroscopy (NIRS), brain injury and development, and NDO in preterm infants. Data Sources: PubMed, Embase, reference lists. Study Selection: We conducted 3 different searches for English literature between 2000 and 2020; 1 for anemia, RBC transfusions, and cerebral oxygenation, 1 for anemia, RBC transfusions, and brain injury and development, and 1 for anemia, RBC transfusions, and NDO. Data Extraction: Two authors independently screened sources and extracted data. Quality of case-control studies or cohort studies, and RCTs was assessed using either the Newcastle-Ottawa Quality Assessment Scale or the Van Tulder Scale, respectively. Results: Anemia results in decreased oxygen-carrying capacity, worsening the burden of cerebral hypoxia in preterm infants. RBC transfusions increase cerebral oxygenation. Improved brain development may be supported by avoidance of cerebral hypoxia, although restrictive RBC transfusion strategies were associated with better long-term neurodevelopmental outcomes. Conclusions: This review demonstrated that anemia and RBC transfusions were associated with cerebral oxygenation, brain injury and development and NDO in preterm infants. Individualized care regarding RBC transfusions during NICU admission, with attention to cerebral tissue oxygen saturation, seems reasonable and needs further investigation to improve both short-term effects and long-term neurodevelopment of preterm infants.
PICO Summary
Population
Preterm infants in neonatal intensive care unit (NICU), (38 studies).
Intervention
Systematic overview of the impact of anaemia and red blood cell (RBC) transfusions during NICU admission on cerebral oxygenation and neurodevelopmental outcome in preterm infants.
Comparison
Outcome
Anaemia resulted in decreased oxygen-carrying capacity, worsening the burden of cerebral hypoxia in preterm infants. RBC transfusions increased cerebral oxygenation. Improved brain development may be supported by avoidance of cerebral hypoxia, although restrictive RBC transfusion strategies were associated with better long-term neurodevelopmental outcomes.