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1.
Transfusion Strategies for Pediatric Cardiac Surgery: A Meta-Analysis and Trial Sequential Analysis
Duan ZX, Chen DX, Yang BZ, Zhang XQ
Pediatric cardiology. 2021
Abstract
This study aimed to compare the effects of restrictive and liberal red blood cell (RBC) transfusion strategies on pediatric patients undergoing cardiac surgery, including cyanotic and non-cyanotic children. A literature search of the MEDLINE, EMBASE, PubMed, and the Cochrane Library database was conducted. Meta-analyses were carried out comparing restrictive and liberal transfusion strategies. Subgroup analyses were performed based on the basis of cyanotic status. Five randomized controlled trials with a total of 497 children were included. There was no significant difference in the risk of in-hospital mortality between the two transfusion strategies (risk ratio 1.21; 95% confidence interval 0.49 to 2.99; P = 0.68). The trial sequential analysis suggested that the current meta-analysis had an absence of evidence for in-hospital mortality, and the data were insufficient. Moreover, no significant differences existed between groups in terms of risk of infection, blood loss, duration of mechanical ventilation, pediatric intensive care unit (PICU) stay duration, or hospital stay duration. Cyanotic children treated with a liberal transfusion strategy had a shorter ventilator duration, but the transfusion strategy did not affect in-hospital mortality, infection, hospital stay, or PICU stay duration. On the basis of the available data, our analysis indicates that a liberal transfusion strategy did not lead to a better outcomes, but the data are extremely sparse, which highlights the need for clearer transfusion guidelines specific to this specific population.Trial registration number CRD42018102283.
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2.
Comparison of fibrin sealants in peripheral vascular surgery: A systematic review and network meta-analysis
Danker Iii W, DeAnglis A, Ferko N, Garcia D, Hogan A
Annals of medicine and surgery (2012). 2021;61:161-168
Abstract
BACKGROUND Evidence comparing fibrin sealants (FSs) in surgery are limited. This study evaluated the efficacy and safety of FSs, and manual compression in peripheral vascular surgery. METHODS A systematic review of randomized trials was conducted in Medline, Embase, and Cochrane databases within the last 15 years. Data were available to conduct a network meta-analysis (NMA) in peripheral vascular surgery. Fibrin sealant treatment arms were further broken-down and assessed by clotting time (i.e., 2-min [2C] or 1-min [1C]). The primary efficacy outcome was the proportion of patients achieving hemostasis by 4 min (T4). Treatment-related serious and non-serious adverse events (AEs) were qualitatively assessed. RESULTS Five studies (n = 693), were included in the NMA. Results predicted VISTASEAL 2C, followed by EVICEL 1C, had the highest probability of achieving T4. Compared with manual compression, significant improvements in T4 were found with VISTASEAL 2C (relative risk [RR] = 2.67, 95% CrI: 2.13-3.34), EVICEL 1C (RR = 2.58, 95% CrI: 2.04-3.23), VISTASEAL 1C (RR = 2.00, 95% CrI: 1.45-2.65), and TISSEEL 2C (RR = 1.99, 95% CrI: 1.48-2.60). TISSEEL 1C was not significantly different than manual compression (RR = 1.40, 95% CrI: 0.70-2.33). Among FSs, VISTASEAL 2C was associated with a significant improvements in T4 compared with VISTASEAL 1C (RR = 1.33, 95% CrI: 1.02-1.82), TISSEEL 2C (RR = 1.34, 95% CrI: 1.05-1.77), and TISSEEL 1C (RR = 1.90, 95% CrI: 1.18-3.74). Treatment-related serious and non-serious AE rates were typically lower than 2%. CONCLUSIONS In peripheral vascular surgeries, VISTASEAL 2C and EVICEL 1C were shown to have the highest probabilities for achieving rapid hemostasis among the treatments compared. Future studies should expand networks across surgery types as data become available.
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3.
Systematic review of plasma to packed red blood cell ratio on survival in ruptured abdominal aortic aneurysms
Phillips AR, Tran L, Foust JE, Liang NL
Journal of vascular surgery. 2020
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Abstract
BACKGROUND The ideal perioperative fluid resuscitation for ruptured abdominal aortic aneurysms (rAAA) is unknown. It has been shown in the trauma literature that a higher ratio of plasma and platelets to packed red blood cells confers a mortality benefit. There remains controversy whether this is true also in the ruptured aneurysm population. The objective of this study is to investigate the benefit of higher ratio of plasma to packed red blood cells in patients with ruptured abdominal aortic aneurysms. METHODS A health sciences librarian searched four electronic databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov using concepts for the terms fluid resuscitation, survival, and ruptured abdominal aortic aneurysm. Two reviewers independently screened the studies that were identified through the search strategy and read in full any study that was potentially relevant. Papers were included if they compared mortality of patients with rAAA who received a higher ratio of plasma to other component therapy to patients who received a lower ratio. Risk of bias was assessed using the ROBINS-I validated tool and evidence quality was rated using the GRADE profile. No data synthesis or meta-analysis was planned or performed given the anticipated paucity of research on this topic and the high degree of heterogeneity of available studies. RESULTS Our search identified seven observational studies to be included in this review. Of these seven studies, three found an associated decrease in mortality with a higher ratio of plasma to packed red blood cells and the remaining four found no significant difference. The overall risk of bias was serious and the evidence quality was very low. CONCLUSIONS Overall, the available studies would suggest that for patients that have undergone open surgery for a ruptured abdominal aortic aneurysm, mortality rates tend to decrease when the amount of plasma transfused perioperatively is similar to the amount of packed red blood cells. However, this is very low-quality evidence based solely off of highly heterogenous observational studies and further research is warranted.
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Platelet Transfusion in Cardiac Surgery: A Systematic Review and Meta-Analysis
Yanagawa B, Ribeiro R, Lee J, Mazer CD, Cheng D, Martin J, Verma S, Friedrich JO
Ann Thorac Surg. 2020
Abstract
BACKGROUND Blood transfusion is a well-established independent risk factor for mortality in patients undergoing cardiac surgery but the impact of platelet transfusion is less clear. We performed a systematic review and meta-analysis of observational studies comparing outcomes of patients who received platelet transfusion following cardiac surgery. METHODS We searched MEDLINE and EMBASE databases to January 2019 for studies comparing peri-operative outcomes in patients undergoing cardiac surgery with and without platelet transfusion. RESULTS There were 9 observational studies reporting on 101,511 patients: 12% with and 88% without platelet transfusion. In unmatched/unadjusted studies, patients who received platelet transfusion were older with greater incidence of renal, peripheral and cerebrovascular disease, myocardial infarction, left ventricular dysfunction, and anemia. They were more likely to have non-elective, combined surgery; pre-operative hemodynamic instability and endocarditis; and more likely to be on clopidogrel preoperatively. Perioperative complications were significantly increased without adjusting for these baseline differences. After pooling only matched/adjusted data, differences were not found in patients who did vs did not receive platelets for operative mortality (risk ratio [RR] 1.26, 95%CI:0.69-2.32, p=0.46, 5 studies), stroke (RR 0.94, 95%CI:0.62-1.45, p=0.79, 5 studies), myocardial infarction (RR1.29, 95%CI:0.95-1.77, p=0.11, 3 studies), reoperation for bleeding (RR1.20, 95%CI:0.46-3.18, p=0.71, 3 studies), infection (RR1.02, 95%CI:0.86-1.20, p=0.85, 6 studies), and peri-operative dialysis (RR0.91, 95%CI:0.63-1.32, p=0.62, 3 studies). CONCLUSIONS After accounting for baseline differences, platelet transfusion was not linked with perioperative complications in cardiac surgery patients. Given the small number of observational studies, these findings should be considered hypothesis generating.
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5.
Cerebral Revascularization for Moyamoya syndrome associated with Sickle Cell Disease: A systematic review of literature on the role of EC-IC bypass in treating neurological manifestations of pediatric patients with Sickle Cell Disease
Terrell D, Savardekar AR, Whipple SG, Dossani RH, Spetzler RF, Sun H
World neurosurgery. 2020
Abstract
Moyamoya syndrome (MMS) in patients with sickle cell disease (SCD) accentuates the risk of recurrent strokes. Chronic transfusion therapy (CTT) is an excellent option for preventing recurrent strokes in most SCD patients. In SCD with MMS, CTT may fail as a long-term solution. Cerebral revascularization, in the form of EC-IC bypass, has been shown to prevent recurrent strokes in this cohort. We review the evolution of this paradigm shift in the management of SCD-associated MMS. A systematic review, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol, was conducted. Our primary objectives were: 1.) to study the evolution of cerebral revascularization techniques in management of MMS in SCD; and 2.) to analyze the impact of neurosurgical intervention in this high-risk population. Four patients with SCD-associated MMS, who underwent indirect cerebral revascularization at our institute were retrospectively reviewed. A summary of 13 articles chronicling the advent and subsequent evolution of cerebral revascularization as a viable treatment strategy for stroke prevention in SCD-associated MMS, is presented. Literature review suggests early detection and surgical intervention (in addition to CTT) could significantly reduce stroke recurrence and improve neuro-cognitive outcome. Our short series of 4 patients also had a good outcome and no recurrence of strokes post-operatively. Current literature emphasizes the use of a traditional standardized protocol for early identification (TCDs, selective MRA, and CTT). Early treatment and screening that involves early MR angiography and referral to neurosurgery for revascularization may be considered for this high-risk population.
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6.
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
Kashani HH, Lodewyks C, Kavosh MS, Jeyaraman MM, Neilson C, Okoli G, Rabbani R, Abou-Setta AM, Zarychanski R, Grocott HP
Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2020
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Editor's Choice
Abstract
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; I(2) = 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; I(2) = 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.
PICO Summary
Population
Adult patients undergoing cardiac surgery (10 studies, n= 9101).
Intervention
Restrictive transfusion strategies.
Comparison
Liberal transfusion strategies.
Outcome
No significant difference was found in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; I2 (2) = 33%. 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; I2 (2) = 56%. Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy.
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7.
Association Between Adverse Clinical Outcomes After Coronary Artery Bypass Grafting and Perioperative Blood Transfusions
Mirzaei S, Hershberger PE, DeVon HA
Critical care nurse. 2019;39(1):26-35
Abstract
BACKGROUND Bleeding is a serious complication of coronary artery bypass grafting that often leads to blood transfusion. Approximately 50% of patients who have the surgery receive blood products, and blood transfusions play a role in adverse outcomes after the surgery. OBJECTIVE To examine the association between perioperative blood transfusion and postoperative adverse outcomes in patients undergoing coronary artery bypass grafting. METHODS A systematic review of the literature, via the matrix method of quality evaluation, was conducted. PubMed, CINAHL, and Science Direct databases for 2000 through 2016 were searched. Inclusion criteria were articles published in English and original research related to clinical outcomes of blood transfusion after coronary artery bypass grafting. Seventeen articles were included in the review. RESULTS Mortality, both short- and long-term, was significantly higher in transfusion patients than in nontransfusion patients. Patients with transfusion of red blood cells had higher resource utilization and more complications, including infection, pneumonia, renal failure, graft occlusion, and atrial fibrillation, than did nontransfusion patients. CONCLUSION An association exists between red blood cell transfusions and adverse clinical outcomes for patients undergoing coronary artery bypass grafting. Transfusion of red blood cells is sometimes unnecessary, may be injurious, and should be used cautiously. Even a single-unit increase in perioperative red blood cell transfusions can have a significant adverse impact on outcomes. Individual benefits and risks should be weighed before transfusion to avoid adverse outcomes. Transfusion guidelines should be reviewed to include the latest evidence to guarantee the most appropriate use of blood products.
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Impact of Perioperative Levosimendan Administration on Risk of Bleeding After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials
Yan SB, Wang XY, Shang GK, Wang ZH, Deng QM, Song JW, Sai WW, Song M, Zhong M, Zhang W
American journal of cardiovascular drugs : drugs, devices, and other interventions. 2019
Abstract
BACKGROUND Levosimendan, a calcium sensitizer and potassium channel opener, has been demonstrated to improve myocardial function without increasing oxygen consumption and to show protective effects in other organs. Recently, a prospective, randomized controlled trial (RCT) revealed an association between levosimendan use and a possible increased risk of bleeding postoperatively. Levosimendan's anti-platelet effects have been shown in in vitro studies. Current studies do not provide sufficient data to support a relation between perioperative levosimendan administration and increased bleeding risk. PURPOSE Our goal was to investigate the relation between perioperative levosimendan administration and increased bleeding risk using a meta-analysis study design. METHODS The PubMed, Ovid, EMBASE and Cochrane Library databases were searched for relevant RCTs before July 1, 2019. The outcome parameters included reoperation secondary to increased bleeding in the postoperative period, the amount of postoperative recorded blood loss, and the need for transfusion of packed red blood cells (RBCs) and other blood products. RESULTS A total of 1160 patients in nine RCTs (576 in the levosimendan group and 584 in the control group) were included according to our inclusion criteria. Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation secondary to bleeding nor increased the amount of postoperative chest tube drainage when compared with the control group. In terms of blood product transfusion, levosimendan did not influence the requirement for RBC transfusion, platelet transfusion nor fresh frozen plasma (FFP) transfusion. Levosimendan also did not shorten or prolong the aortic cross-clamp time or the cardiopulmonary bypass time. CONCLUSION The analyzed parameters, including reoperations due to bleeding, postoperative chest drainage and the requirement for blood products, revealed that levosimendan did not increase postoperative bleeding risk. More studies with a larger sample size are needed to address a more reliable conclusion due to study limitations.
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Red blood cell transfusion threshold after pediatric cardiac surgery: A systematic review and meta-analysis
Deng X, Wang Y, Huang P, Luo J, Xiao Y, Qiu J, Yang G
Medicine. 2019;98(11):e14884
Abstract
BACKGROUND Restrictive red blood cell transfusion strategy is implemented to minimize risk following allogeneic blood transfusion in adult cardiac surgery. However, it is still unclear if it can be applied to pediatric cardiac patients. The purpose of this systematic review and meta-analysis was to determine the effect of postoperative restrictive transfusion thresholds on clinical outcomes based on up-to-date results of randomized controlled trials (RCTs) and observational studies in pediatric cardiac surgery. METHOD We searched for RCTs and observational studies in the following databases: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ClinicalTrials.gov from their inception to October 26, 2017. We also searched reference lists of published guidelines, reviews, and relevant articles, as well as conference proceedings. No language restrictions were applied and no observational study met the inclusion criteria. RESULTS Four RCTs on cardiac surgery involving 454 patients were included. There were no differences in the pooled fixed effects of intensive care unit (ICU) stay between the liberal and restrictive transfusion thresholds (standardized mean difference SMD, 0.007; 95% confidence interval CI, -0.18-0.19; P = .94). There were also no differences in the length of hospital stay (SMD, -0.062; 95% CI, -0.28-0.15; P = .57), ventilation duration (SMD, -0.015; 95% CI, -0.25-0.22; P = .90), mean arterial lactate level (SMD, 0.071; 95% CI, -0.22-0.36; P = .63), and mortality (risk ratio, 0.49; 95% CI, 0.13-1.94; P = .31). There was no inter-trial heterogeneity for any pooled analysis. Publication bias was tested using Egger, Begg, or the trim-and-fill test, and the results indicated no significant publication bias. CONCLUSION Evidence from RCTs in pediatric cardiac surgery, though limited, showed non-inferiority of restrictive thresholds over liberal thresholds in length of ICU stay and other outcomes following red blood cell transfusion. Further high-quality RCTs are necessary to confirm the findings.
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Thromboelastography or rotational thromboelastometry for bleeding management in adults undergoing cardiac surgery: a systematic review with meta-analysis and trial sequential analysis
Li C, Zhao Q, Yang K, Jiang L, Yu J
Journal of thoracic disease. 2019;11(4):1170-1181
Abstract
Background: Severe bleeding and massive transfusion of blood products may be associated with increased morbidity and mortality of cardiac surgery. A transfusion algorithm incorporating thromboelastography (TEG) or rotational thromboelastometry (ROTEM) can help to determine the appropriate time and target for the use of hemostatic blood products, which may thus reduce the quantity of blood loss as well as blood products transfused. Methods: We conducted meta-analysis and trial sequential analysis to evaluate the effects of TEG or ROTEM-guided transfusion algorithms vs. standard treatments for patients undergoing cardiac surgery with cardiac pulmonary bypass. Results: Nineteen studies with a total of 15,320 participants, including 13 randomized controlled trials (RCTs), were included. All-cause mortality was not reduced either in overall studies or in RCTs. Blood loss volume was reduced by 132 mL in overall studies [mean difference (MD): -132.46, 95% CI: -207.49, -57.43; I(2) =53%, P<0.01], and by 103 mL in RCTs (MD: -103.50, 95% CI: -156.52, -50.48; I(2) =0%, P<0.01). The relative risks (RRs) in RCTs were 0.89 (95% CI: 0.80-0.98; I(2) =0%, P=0.02) for red blood cells transfusion, 0.59 (95% CI: 0.42-0.82; I(2) =55%, P<0.01) for fresh frozen plasma transfusion, and 0.81 (95% CI: 0.74-0.90; I(2) =0%, P<0.01) for platelet transfusion, respectively. Trial sequential analysis of continuous data on blood loss and dichotomous outcomes on transfusion of blood products suggested the benefits of a TEG/ROTEM-guided algorithm. Conclusions: TEG or ROTEM-guided transfusion strategies may reduce blood loss volume and the transfusion rates in adult patients undergoing cardiac surgery.
