Preoperative hemoglobin and perioperative blood transfusion in major head and neck surgery: a systematic review and meta-analysis
Journal of Otolaryngology - Head & Neck Surgery = Le Journal D'oto-Rhino-Laryngologie Et De Chirurgie Cervico-Faciale. 2023;52(1):3
BACKGROUND There is a growing concern with inappropriate, excessive perioperative blood transfusions. Understanding the influence of low preoperative hemoglobin (Hgb) on perioperative blood transfusion (PBT) in head and neck cancer (HNC) surgery with free flap reconstruction may help guide clinical practice to reduce inappropriate treatment among these patients. The objective is to synthesize evidence regarding the association between preoperative Hgb and PBT among major HNC free flap surgeries. METHODS Terms and synonyms for HNC surgical procedures, Hgb and PBT were used to search MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Reviews from inception to February 2020. Reference lists of included full texts and studies reporting the preoperative Hgb, anemia or hematocrit (exposure) and the PBT (outcome) in major HNC surgery with free flap reconstruction were eligible. Studies examining esophageal, thyroid and parathyroid neoplasms were excluded; as were case reports, case series (n < 20), editorials, reviews, perspectives, viewpoints and responses. Two independent, blinded reviewers screened titles, abstracts and full texts in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was followed. A random-effects model was used to pool reported data. The primary outcome was the proportion of patients who had a PBT. Subgroup analysis examined sources of heterogeneity for perioperative predictors of PBT (age, sex, flap type, flap site and preoperative Hgb). We also examined mean preoperative Hgb in the PBT and no PBT groups. RESULTS Patients with low preoperative Hgb were transfused more than those with normal Hgb (47.62%, 95% CI = 41.19-54.06, I(2) = 0.00% and 13.92%, 95% CI = 10.19-17.65, I(2) = 20.69%, respectively). None of the predictor variables explained PBT. The overall pooled mean preoperative Hgb was 12.96 g/dL (95% CI = 11.33-14.59, I(2) = 0.00%) and was 13.58 g/dL (95% CI = 11.95-15.21, I(2) = 0.00%) in the no PBT group and 12.05 g/dL (95% CI = 10.01 to 14.09, I(2) = 0.00%) in the PBT group. CONCLUSIONS The heterogeneity between studies, especially around the trigger for PBT, highlights the need for additional research to guide clinical practice of preoperative Hgb related to PBT to enhance patient outcomes and improve healthcare stewardship.
Transfusion Guidelines in Brain Tumor Surgery: A Systematic Review and Critical Summary of Currently Available Evidence
World neurosurgery. 2022
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.
Brain tumor patients undergoing surgery (7 studies).
Systematic review assessing red blood cell transfusion thresholds.
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.
The efficacy of platelet-rich plasma applicated in spinal fusion surgery: A meta-analysis
Frontiers in surgery. 2022;9:924753
OBJECTIVE The purpose of this meta-analysis is to evaluate the effect of the application of platelet-rich plasma (PRP) in spinal fusion surgery on the fusion rate of the spine. METHODS A comprehensive search of the PubMed, Embase, Cochrane Library, and Science Direct databases was conducted to identify randomized control trials (RCTs) or observational cohort studies that evaluated the efficacy and safety of PRP in spinal fusion. Data on final fusion rate, changes in the visual analog scale (VAS), estimated blood loss (EBL), and operative time was collected from the eligible studies for meta-analysis. Patients were divided into PRP and non-PRP groups according to whether PRP was used during the spinal fusion procedure. RESULTS According to the selection criteria, 4 randomized controlled trials and 8 cohort studies with 833 patients and 918 levels were included. The outcomes indicated that PRP application is associated with a lower fusion rat (OR = 0.62, 95% CI: (0.43, 0.89), P = 0.009) at final follow-up (>24 months). Subgroup analysis showed a lower rate of spinal fusion in the PRP group compared to the non-PRP group (OR = 0.35, 95% CI: (0.21, 0.58), P < 0.001) when spinal fusion was assessed using only anterior-posterior radiographs. When the bone graft material was a combination of autologous bone + artificial bone, the spinal fusion rate was lower in the PRP group than in the non-PRP group (OR = 0.34, 95% CI: (0.16, 0.71), P = 0.004). The PRP and non-PRP groups showed no significant differences in VAS changes at the 24th postoperative month (WMD = 0.36, 95% CI: (-0.37, 1.09), P = 0.33); Application of PRP does not reduce the estimated blood loss (WMD = -86.03, 95% CI: (-188.23, 16.17), P = 0.10). In terms of operation time, using PRP does not prolong operation time (WMD = -3.74, 95% CI: (-20.53, 13.04), P = 0.66). CONCLUSION Compared with bone graft fusion alone, PRP cannot increase the rate of spinal fusion. Inappropriate methods of spinal fusion assessment or mixing PRP with artificial/allograft bone may have been responsible for the lower rate of spinal fusion in the PRP group. SYSTEMATIC REVIEW REGISTRATION doi: 10.37766/inplasy2022.5.0055.
Is Platelet-Rich Plasma Effective in Enhancing Spinal Fusion? Systematic Overview of Overlapping Meta-Analyses
Global spine journal. 2021;:2192568220988278
STUDY DESIGN Systematic review. OBJECTIVES We performed this systematic overview on overlapping meta-analyses that analyzed the role of platelet-rich plasma(PRP) in enhancing spinal fusion and identify which study provides the current best evidence on the topic and generate recommendations for the same. MATERIALS AND METHODS We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Embase, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects till October-2020 for meta-analyses that analyzed the role of PRP in spinal fusion procedures. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring, and AMSTAR 2 grades. We then utilized the Jadad decision algorithm to identify the study with highest quality to represent the current best evidence to generate recommendations. RESULTS 3 meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of included studies varied from 5-8(mean:6.3) and all included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. The current best evidence showed that utilization of PRP was not associated with significant improvement in patient-reported outcomes such as Visual Analog Score for pain compared to the standard fusion procedure. Moreover, PRP was found to be associated with lower fusion rates. CONCLUSION Based on this systematic overview, the effectiveness of PRP as a biological agent in augmenting spinal fusion is limited. Current evidence does not support the use of PRP as an adjuvant to enhance spinal fusion.
Platelet-Rich Plasma Versus Corticosteroid Injection for Lumbar Spondylosis and Sacroiliac Arthropathy: A Systematic Review of Comparative Studies
This systematic review compares clinical outcomes between platelet-rich plasma (PRP) and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy. A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Pubmed, SCOPUS, and Ovid MEDLINE databases. All level I-III evidence comparative studies published in the English language investigating the clinical outcomes between PRP and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy were included. Five studies (242 patients, 114 PRP, 128 corticosteroid) were analyzed. One randomized study was level I evidence, two randomized studies were level II, and two non-randomized studies were level III. Final follow-up ranged from six weeks to six months. Four studies found that both PRP and corticosteroid treatment led to a statistically significant reduction in the visual analog scale (VAS). One found that only the PRP group led to a statistically significant reduction in VAS. Three studies found more significant improvements in one or more clinical outcome scores among PRP patients as compared with corticosteroid patients at the three- to six-month follow-up. Two studies found no difference in outcome score improvements between the two groups at six- to 12-week follow-up. There were no reports of major complications. There were no significant differences in minor complication rates between the two groups. In conclusion, both PRP and corticosteroid injections are safe and effective options for the treatment of lumbar spondylosis and sacroiliac arthropathy. There is some evidence that PRP injection is a more effective option at long-term follow-up compared with corticosteroid injection. Further randomized controlled trials with longer-term follow-up are necessary to compare its long-term efficacy.
Transfusion Guidelines in Adult Spine Surgery: A Systematic Review and Critical Summary of Currently Available Evidence
The spine journal : official journal of the North American Spine Society. 2021
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.
Adult spine surgery patients (22 studies).
Systematic review of studies on recommended thresholds for blood transfusion, and its associated complications.
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.
The effect of platelet-rich plasma on the fusion rate and clinical outcome of spinal fusion surgery: A systematic review and meta-analysis
PloS one. 2020;15(12):e0243204
BACKGROUND Platelet-rich plasma (PRP) is widely used in many orthopedic surgeries and spinal disease treatments; however, the effect of PRP on spinal fusion remains controversial. QUESTIONS/PURPOSES To assess the fusion rate and clinical results of PRP compared with non-PRP administration in the treatment of spinal fusion with regard to decreasing pain and improving healing and function. PATIENTS AND METHODS Studies comparing PRP to non-PRP treatment with respect to the fusion rate and clinical outcome in patients who underwent spinal fusion surgery were included. RESULT Three randomized controlled trials (RCTs) and 7 prospective cohort studies were identified. The spinal fusion rate was not significantly different between the groups in all RCTs or cohort studies at the final follow-up. In comparison, PRP significantly reduced pain after surgery as evaluated in the RCT analysis and the complication rate did not differ significantly between the two groups. CONCLUSION According to the available studies, PRP does not contribute to the union rate, relieve pain or increase the complication rate in spinal fusion surgery. As clinical heterogeneity exists in these studies, further large, well-designed RCTs that focus on the standard assessment of PRP are needed.
The impact of platelet-rich plasma on postoperative outcomes after spinal fusion: a systematic review and meta-analysis
J Neurosurg Spine. 2020;:1-8
OBJECTIVE Platelet-rich plasma (PRP) is a biological agent obtained by centrifuging a sample of blood and retrieving a high concentration of platelets and plasma components. The concentrate is then stimulated for platelet secretion of various growth factors and cytokines. Although it is not widely used in clinical practice, its role in augmenting bony union among patients undergoing spinal fusion has been assessed in several clinical studies. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to determine the efficacy of PRP use in spinal fusion procedures. METHODS A comprehensive literature search was conducted using PubMed, Scopus, and EMBASE for studies from all available dates. From eligible studies, data regarding the fusion rate and method of assessing fusion, estimated blood loss (EBL), and baseline and final visual analog scale (VAS) scores were collected as the primary outcomes of interest. Patients were grouped by those undergoing spinal fusion with PRP and bone graft (PRP group) and those only with bone graft (graft-only group). RESULTS The literature search resulted in 207 articles. Forty-five full-text articles were screened, of which 11 studies were included, resulting in a meta-analysis including 741 patients. Patients without PRP were more likely to have a successful fusion at the last follow-up compared with those with PRP in their bone grafts (OR 0.53, 95% CI 0.34-0.84; p = 0.006). There was no statistically significant difference with regard to change in VAS scores (OR 0.00, 95% CI -2.84 to 2.84; p > 0.99) or change in EBL (OR 3.67, 95% CI -67.13-74.48; p = 0.92) between the groups. CONCLUSIONS This study found that the additional use of PRP was not associated with any significant improvement in patient-reported outcomes and was actually found to be associated with lower fusion rates compared with standard grafting techniques. Thus, PRP may have a limited role in augmenting spinal fusion.
Role of Platelet-Rich Plasma in Spinal Fusion Surgery: Systematic Review and Meta-Analysis
Adv Orthop. 2020;2020:8361798
Background: Platelet-rich plasma (PRP) has been used very successfully in enhancing bone fusion in animal experiments. Also, the efficaciousness of PRP in other specialties of medicine such as dentistry, dermatology ophthalmology, and sports medicine is well documented. But the use of PRP to augment bone fusion after spinal surgery in humans is still controversial. We conducted a meta-analysis to determine the role of PRP in enhancing spinal fusion by fastening the rate of new bone formation and decreasing pain after spinal surgery in humans. Methods: We searched PubMed, EMBASE, and the Cochrane Library studies that compared PRP versus control in enhancing spinal fusion after deformity correction. Results: Five retrospective studies with 253 participants and nine prospective cohort studies with 460 participants were identified. The bone fusion rate was excellent for studies that used a high platelet concentration in PRP relative to control (odds ratio (OR) = 4.35, 95% confidence interval (CI) (2.13, 8.83), and P < 0.05) while bone fusion was poor to studies that used a low concentrate of platelet in PRP relative to control. The rate of new bone formation was high in the PRP group compared to the control group with the mean difference in Hounsfield unit (HU) 144.91 (95% CI (80.63, 209.18), P < 0.05). Time to bone fusion was short in the PRP group during the first six months of surgery relative to the control group with a mean difference of -2.03 (95% CI (-2.35, -1.7); P < 0.05). No difference was found in pain reduction by visual analog score (VAS) between the PRP group and control. Conclusion: PRP facilitates new bone formation and bone fusion with a minimum concentration of the growth factor 5 times that of the peripheral blood. PRP stimulatory effects are not continuous and are very effective within six months of implantation.
The efficacy of using platelet-rich plasma in spinal fusion surgery-A PRISMA-compliant meta-analysis
World Neurosurg. 2020
BACKGROUND Platelet-rich plasma (PRP) has been frequently used to enhance bone regeneration. A meta-analysis was conducted to systematically assess the fusion rate and pain relief of applying PRP in spinal fusion surgery. METHODS Studies investigating spinal fusion surgery combined with PRP procedure were retrieved from Medline and Web of Science according to inclusion and exclusion criteria. Quality evaluation was conducted using the Cochrane collaboration tool for randomized controlled trials and the Newcastle-Ottawa Scale quality assessment for cohort trials. Statistics were managed using RevMan 5.3. RESULTS A total of 12 studiesincluding 3 randomized controlled trials and 9 cohort studies, with 661 patients were enrolled in this meta-analysis. The mean age was 52.3+/-8.0 years. The over pooled results demonstrated that there was no statistically significant difference in fusion rates between PRP and non-PRP treatment groups. The risk ratio was 1.01 (95% confidence intervals (95%CIs): 0.95-1.06, p=0.83). There was no significant difference in pain relief as measured by the Visual Analog Scale between the two groups. The mean difference was -0.08 (95% CIs:-0.26 - 0.11, p=0.42). CONCLUSION Adding PRP could not increase fusion rates in spinal fusion surgery. Meanwhile, there was no significant difference in pain relief between PRP and non-PRP treatment groups.