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Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery
Dhiman P, Ma J, Gibbs VN, Rampotas A, Kamal H, Arshad SS, Kirtley S, Doree C, Murphy MF, Collins GS, et al
Journal of clinical epidemiology. 2023
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Abstract
BACKGROUND Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice. STUDY DESIGN AND SETTING We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between 01/01/2000 to 30/06/2021. We extracted study characteristics, discrimination performance (c-statistics) of final models and data which we used to perform risk of bias assessment using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). RESULTS We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes. CONCLUSION Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.
PICO Summary
Population
Patients undergoing elective surgery (66 studies).
Intervention
Blood transfusion prediction models used perioperatively.
Comparison
Outcome
This systematic review appraised 120 prediction models developed or validated for predicting blood transfusion in elective surgery (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes.
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Cardiac surgery in Jehovah's Witnesses patients and association with peri-operative outcomes: a systematic review and meta-analysis
Vitolo M, Mei DA, Cimato P, Bonini N, Imberti JF, Cataldo P, Menozzi M, Filippini T, Vinceti M, Boriani G
Current problems in cardiology. 2023;:101789
Abstract
BACKGROUND Strategies for blood conservation, coupled with a careful preoperative assessment, may be applied to Jehovah's Witnesses (JW) patients who are candidates for cardiac surgery interventions. There is a need to assess clinical outcomes and safety of bloodless surgery in JW patients undergoing cardiac surgery. METHODS We performed a systematic review and meta-analysis of studies comparing JW patients with controls undergoing cardiac surgery. The primary endpoint was short-term mortality (in-hospital or 30-day mortality). Peri-procedural myocardial infarction, re-exploration for bleeding, pre-and post-operative Hb levels and cardiopulmonary bypass (CPB) time were also analyzed. RESULTS A total of 10 studies including 2,302 patients were included. The pooled analysis showed no substantial differences in terms of short-term mortality among the two groups (OR 1.13, 95% CI 0.74-1.73, I(2)=0%). There were no differences in peri-operative outcomes among JW patients and controls (OR 0.97, 95% CI 0.39-2.41, I(2)=18% for myocardial infarction; OR 0.80, 95% CI 0.51-1.25, I(2)=0% for re-exploration for bleeding). JW patients had a higher level of pre-operative Hb (Standardized Mean Difference [SMD] 0.32, 95% CI 0.06-0.57) and a trend toward a higher level of post-operative Hb (SMD 0.44, 95% CI -0.01-0.90). A slightly lower CPB time emerged in JWs compared with controls (SMD -0.11, 95% CI -0.30-0.07). CONCLUSIONS JW patients undergoing cardiac surgery, with avoidance of blood transfusions, did not have substantially different peri-operative outcomes compared with controls, with specific reference to mortality, myocardial infarction, and re-exploration for bleeding. Our results support the safety and feasibility of bloodless cardiac surgery, applying patient blood management strategies.
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What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery or portal vein thrombosis? A systematic review of the literature and expert panel recommendations
Kirchner VA, O'Farrell B, Imber C, McCormack L, Northup PG, Song GW, Spiro M, Raptis DA, Durand F
Clinical transplantation. 2022;:e14629
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Abstract
BACKGROUND A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding. (CRD42021244288) RESULTS Of the 2,478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding. CONCLUSIONS Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT. This article is protected by copyright. All rights reserved.
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Point-of-care platelet function testing for guided transfusion in neurosurgical management of intracranial hemorrhage: a systematic review
Xu FWX, Lim NA, Sim MA, Lean LL, Loh NW, Ng KT, Chua VTY, Chew STH, Ti LK
European journal of medical research. 2022;27(1):191
Abstract
Given the rising prevalence of antiplatelet therapy, rapid preoperative identification of patients with bleeding diathesis is necessary for the guidance of blood product administration. This is especially relevant in neurosurgery for intracranial hemorrhage (ICH), where indiscriminate transfusions may lead to further hemorrhagic or thromboembolic injury. Point-of-care (POC) testing of platelet function is a promising solution to this dilemma, as it has been proven effective in cardiac surgery. However, to date, POC platelet function testing in neurosurgery has not been extensively evaluated. This systematic review appraises the use of POC platelet function test (PFT) in emergency neurosurgery in terms of its impact on patient outcomes.A comprehensive search was conducted on four electronic databases (Pubmed, MEDLINE, Embase, and Cochrane) for relevant English language articles from their respective inceptions until 1 June 2022. We included all randomized controlled trials and cohort studies that met the following inclusion criteria: (i) involved adult patients undergoing neurosurgery for ICH; (ii) evaluated platelet function via POC PFT; (iii) reported a change in perioperative blood loss; and/or (iv) reported data on treatment-related adverse events and mortality. Assessment of study quality was conducted using the Newcastle Ottawa Quality Assessment Scale for Cohort Studies and Case-Control Studies, and the JBI Critical Appraisal Checklist for Case Series.The search yielded 2,835 studies, of which seven observational studies comprising 849 patients met the inclusion criteria for this review. Overall, there is evidence that the use of POC PFT to assess bleeding risk reduced bleeding events, thromboembolic adverse outcomes, and the length of hospitalization. However, there is currently insufficient evidence to suggest that using POC PFT improves blood product use, functional outcomes or mortality.
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The Use of Thromboelastography in Percutaneous Coronary Intervention and Acute Coronary Syndrome in East Asia: A Systematic Literature Review
Xu O, Hartmann J, Tang YD, Dias J
Journal of clinical medicine. 2022;11(13)
Abstract
Dual antiplatelet therapy (DAPT), alongside percutaneous coronary intervention (PCI), is central to the prevention of ischemic events following acute coronary syndrome (ACS). However, response to therapy can vary due to several factors including CYP2C19 gene variation, which shows increased prevalence in East Asian populations. DAPT responsiveness can be assessed using techniques such as light transmission aggregometry (LTA), VerifyNow(®) and thromboelastography with the PlateletMapping(®) assay, and there is increasing focus on the utility of platelet function testing to guide individualized treatment. This systematic literature review of one English and three Chinese language databases was conducted to evaluate the evidence for the utility of thromboelastography in ACS/PCI in East Asia. The search identified 42 articles from the English language and 71 articles from the Chinese language databases which fulfilled the pre-determined inclusion criteria, including 38 randomized controlled trials (RCTs). The identified studies explored the use of thromboelastography compared to LTA and VerifyNow in monitoring patient responsiveness to DAPT, as well as predicting ischemic risk, with some studies suggesting that thromboelastography is better able to detect low DAPT response than LTA. Other studies, including one large RCT, described the use of thromboelastography in guiding the escalation of DAPT, with some evidence suggesting that such protocols reduce ischemic events without increasing the risk of bleeding. There was also evidence suggesting that thromboelastography can be used to identify individuals with DAPT hyporesponsiveness genotypes and could potentially guide treatment by adjusting therapy in patients depending on responsiveness.
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Clinical Outcomes of Negative Balloon-Assisted Enteroscopy for Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis
Shao XD, Shao HT, Wang L, Zhang YG, Tian Y
Frontiers in medicine. 2022;9:772954
Abstract
BACKGROUND For patients with obscure gastrointestinal bleeding (OGIB), finding the bleeding site is challenging. Balloon-assisted enteroscopy (BAE) has become the preferred diagnostic modality for OGIB. The long-term outcome of patients with negative BAE remains undefined. The present study aimed to evaluate the long-term outcomes of patients with negative BAE results for OGIB and to clarify the effect of further investigations at the time of rebleeding with a systematic review and meta-analysis of the available cohort studies. METHODS Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following indexes were analyzed: rebleeding rate after negative BAE, rebleeding rate after different follow-up periods, the proportion of patients who underwent further evaluation after rebleeding, the percentage of patients with identified rebleeding sources, and the percentage of patients with rebleeding sources in the small intestine. Heterogeneity was assessed using the I(2) test. RESULTS Twelve studies that involved a total of 407 patients were included in the analysis. The pooled rebleeding rate after negative BAE for OGIB was 29.1% (95% CI: 17.2-42.6%). Heterogeneity was significant among the studies (I(2) = 88%; p < 0.0001). The Chi-squared test did not show a difference in rebleeding rates between the short and long follow-up period groups (p = 0.142). The pooled proportion of patients who underwent further evaluation after rebleeding was 86.1%. Among the patients who underwent further evaluation, rebleeding sources were identified in 73.6% of patients, and 68.8% of the identified rebleeding lesions were in the small intestine. CONCLUSION A negative result of BAE in patients with OGIB indicates a subsequently low risk of rebleeding. Further evaluation should be considered after rebleeding.
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Does Intraoperative Blood Loss Affect the Short-Term Outcomes and Prognosis of Gastric Cancer Patients After Gastrectomy? A Meta-Analysis
Wen ZL, Xiao DC, Zhou X
Frontiers in surgery. 2022;9:924444
Abstract
PURPOSE The purpose of the current meta-analysis was to analyze whether intraoperative blood loss (IBL) influenced the complications and prognosis of gastric cancer patients after gastrectomy. METHODS We systematically searched the PubMed, Embase and Cochrane library databases on November 29, 2021. The Newcastle-Ottawa scale was used to evaluate the quality of included studies. This meta-analysis uses RevMan 5.3 for data analysis. RESULTS A total of nine retrospective studies were included in this meta-analysis, involving 4653 patients. In terms of short-term outcomes, the Larger IBL group has a higher complication rate (OR = 1.94, 95% CI, 1.44 to 2.61, P < 0.0001) and a longer operation time (OR = 77.60, 95% CI, 41.95 to 113.25, P < 0.0001) compared with the smaller IBL group, but the Larger IBL group had higher total retrieved lymph nodes (OR = 3.68, 95% CI, 1.13 to 6.24, P = 0.005). After pooling up all the HRs, the Larger IBL group has worse overall survival (OS) (HR = 1.80, 95% CI, 1.27 to 2.56, P = 0.001) and disease-free survival (DFS) (HR = 1.48, 95% CI, 1.28 to 1.72, P < 0.00001). CONCLUSION Larger IBL increased operation time and postoperative complications, and decreased OS and DFS of gastric cancer patients. Therefore, surgeons should be cautious about IBL during operation.
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Does the intramedullary femoral canal plug reduce blood loss during total knee arthroplasty?
Khanasuk Y, Ngarmukos S, Tanavalee A
Knee surgery & related research. 2022;34(1):31
Abstract
INTRODUCTION The benefit of the femoral canal bone plug during total knee arthroplasty (TKA) in reducing blood loss has never been proven. The aim of this meta-analysis was to determine whether the femoral canal bone plug significantly reduces blood loss in primary TKA. METHOD All studies published before December 2021 were searched. The inclusion criteria were randomized controlled trials comparing blood loss between TKA with plugged and unplugged femoral intramedullary canal, respectively. The primary outcome was postoperative hemoglobin reduction. RESULTS Five studies with a total of 717 patients (361 in the plugged group, 356 in the unplugged group) met the criteria for inclusion in the meta-analysis. The mean difference in hemoglobin level between the two groups was 0.92 g/dL, with significantly less hemoglobin reduction in the plugged group (95% confidence interval [CI] - 1.64 to - 0.21, p = 0.01). The patients in the plugged group also had a significantly lower risk of receiving a blood transfusion (risk ratio 0.58, 95% CI 0.47-0.73, p < 0.00001). CONCLUSIONS This meta-analysis demonstrates that using a femoral canal bone plug can significantly reduce blood loss and lower the risk ratio of blood transfusion in patients undergoing TKA.
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Strategic response to bleeding in laparoscopic hepato-pancreato-biliary surgery: an intraoperative checklist
Vega, EA, Salehi O, Loewenthal JV, Kutlu OC, Vellayappan U, Freeman R, Pomposelli F, Asbun HJ, Gayet B, Conrad C
HPB : the official journal of the International Hepato Pancreato Biliary Association. 2021
Abstract
BACKGROUND The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery. METHODS To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions. RESULTS NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518 ± 852.8 to 151.5 ± 221.7 ml (P = 0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7 ± 2.5 vs 2.3 ± 1.7 units/per patient, P = 0.611) and transfusion rates (22% vs 11%, P = 0.703). CONCLUSION An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.
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A Literature Review to Assess Blood Loss in Minimally Invasive Liver Surgery Versus in Open Liver Resection
Elmahi E, Salama Y, Cadden F
Cureus. 2021;13(6):e16008
Abstract
Aim and objectives The aim of the study was to assess the amount of blood loss in minimally invasive hepatectomy and open liver resection for both benign and neoplastic conditions. Introduction Minimally invasive surgery has progressively developed to a stage where once-novel and highly specialized surgical techniques are now common practice. Colorectal surgery is the key example that has shown minimally invasive surgery as highly beneficial. Successes in the colorectal laparoscopic approach have now been integrated into the speciality of hepatopancreaticobiiary (HPB) surgery. In this review, we will compare the amount of blood loss in minimally invasive liver resection with the more traditional approach of open liver resection. Methods A literature review was conducted which included the length of patient mobilization as a postoperative complication following laparoscopic and open liver resections. Medline, PubMed, and Cochrane were accessed to review previously published studies. Twelve studies were selected, and all of them were in English, ranged from the year 2000 to 2020. Results Eleven out of the 12 included studies indicated that minimally invasive liver resection is associated with reduced blood loss. Conclusion In comparing both minimally invasive liver resection and classic open surgery, minimally invasive liver resection was shown to have reduced blood loss; this was seen in both malignant and benign tumours. Therefore, laparoscopic liver resection could be favoured over the classical open approach to avoid excessive blood loss intra-operatively.