1.
Optimal dose, timing and ratio of blood products in massive transfusion: results from a systematic review
McQuilten ZK, Crighton G, Brunskill S, Morison JK, Richter TH, Waters N, Murphy MF, Wood EM
Transfusion Medicine Reviews. 2017;32((1):):6-15
Abstract
Optimal dose, timing and ratio to red blood cells (RBC) of blood component therapy (fresh frozen plasma [FFP], platelets, cryoprecipitate or fibrinogen concentrate) to reduce morbidity and mortality in critically bleeding patients requiring massive transfusion is unknown. We performed a systematic review for randomized controlled trials (RCT) in MEDLINE, The Cochrane Library, Embase, CINAHL, PubMed the Transfusion Evidence Library and using multiple clinical trials registries to 21 February 2017. Sixteen RCTs were identified: six completed (five in adult trauma patients, one pediatric burn patients) and ten ongoing trials. Of the completed trials: three were feasibility trials, comparing a FFP, platelets and RBC ratio of 1:1:1 to laboratory-guided transfusion practice [n=69], early cryoprecipitate compared to standard practice [n=41], and early fibrinogen concentrate compared to placebo [n=45]; one trial compared the effect of FFP, platelets and RBC ratio of 1:1:1 with 1:1:2 on 24-hour and 30-day mortality [n=680]; one compared whole blood to blood component therapy on 24-hour blood use [n=107]; one compared a FFP to RBC ratio of 1:1 with 1:4 [n=16]. Data from two trials were pooled in a meta-analysis for 28-day mortality because the transfusion ratios achieved were similar. Results from these two trials suggest higher transfusion ratios were associated with transfusion of more FFP and platelets without evidence of significant difference with respect to mortality or morbidity. On the limited evidence available, there is insufficient basis to recommend a 1:1:1 over a 1:1:2 ratio or standard care for adult patients with critical bleeding requiring massive transfusion.
2.
Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis
Docherty AB, O'Donnell R, Brunskill S, Trivella M, Doree C, Holst L, Parker M, Gregersen M, Pinheiro de Almeida J, Walsh TS, et al
Bmj.. 2016;352:i1351.
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Abstract
OBJECTIVE To compare patient outcomes of restrictive versus liberal blood transfusion strategies in patients with cardiovascular disease not undergoing cardiac surgery. DESIGN Systematic review and meta-analysis. DATA SOURCES Randomised controlled trials involving a threshold for red blood cell transfusion in hospital. We searched (to 2 November 2015) CENTRAL, Medline, Embase, CINAHL, PubMed, LILACS, NHSBT Transfusion Evidence Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, ISRCTN Register, and EU Clinical Trials Register. Authors were contacted for data whenever possible. TRIAL SELECTION Published and unpublished randomised controlled trials comparing a restrictive with liberal transfusion threshold and that included patients with cardiovascular disease. DATA EXTRACTION AND SYNTHESIS Data extraction was completed in duplicate. Risk of bias was assessed using Cochrane methods. Relative risk ratios with 95% confidence intervals were presented in all meta-analyses. Mantel-Haenszel random effects models were used to pool risk ratios. MAIN OUTCOME MEASURES 30 day mortality, and cardiovascular events. RESULTS 41 trials were identified; of these, seven included data on patients with cardiovascular disease. Data from a further four trials enrolling patients with cardiovascular disease were obtained from the authors. In total, 11 trials enrolling patients with cardiovascular disease (n=3033) were included for meta-analysis (restrictive transfusion, n=1514 patients; liberal transfusion, n=1519). The pooled risk ratio for the association between transfusion thresholds and 30 day mortality was 1.15 (95% confidence interval 0.88 to 1.50, P=0.50), with little heterogeneity (I(2)=14%). The risk of acute coronary syndrome in patients managed with restrictive compared with liberal transfusion was increased (nine trials; risk ratio 1.78, 95% confidence interval 1.18 to 2.70, P=0.01, I(2)=0%). CONCLUSIONS The results show that it may not be safe to use a restrictive transfusion threshold of less than 80 g/L in patients with ongoing acute coronary syndrome or chronic cardiovascular disease. Effects on mortality and other outcomes are uncertain. These data support the use of a more liberal transfusion threshold (>80 g/L) for patients with both acute and chronic cardiovascular disease until adequately powered high quality randomised trials have been undertaken in patients with cardiovascular disease. REGISTRATION PROSPERO CRD42014014251.Copyright Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PICO Summary
Population
Patients with cardiovascular disease not undergoing cardiac surgery (11 randomised controlled trials, n= 3,033).
Intervention
Restrictive transfusion strategy (n= 1,514).
Comparison
Liberal transfusion strategy (n= 1,519).
Outcome
The pooled risk ratio for the association between transfusion thresholds and 30-day mortality was 1.15 (95% confidence interval (CI): 0.88 to 1.50), with little heterogeneity (I2= 14%). The risk of acute coronary syndrome in patients managed with restrictive compared with liberal transfusion was increased (nine trials; risk ratio: 1.78, 95% CI: 1.18 to 2.70, I2= 0%).
3.
What is the maximum time that a unit of red blood cells can be safely left out of controlled temperature storage?
Brunskill S, Thomas S, Whitmore E, McDonald CP, Doree C, Hopewell S, Staves J, Cardigan R, Murphy MF
Transfusion Medicine Reviews. 2012;26((3):):209-223.e3.
Abstract
The objective of this systematic review was to identify and analyze the evidence base supporting the 30-minuteand 4-hourrules in transfusion medicine. The 30-minute rule states that red blood cell (RBC) units left out of controlled temperature storage for more than 30 minutes should not be returned to storage for reissue; the 4-hour rule states that transfusion of RBC units should be completed within 4 hours of their removal from controlled temperature storage. Eligible studies were identified from searches (to October 2010) of a range of electronic databases (including The Cochrane Library, MEDLINE, EMBASE, and the National Health Service Blood and Transplant's Transfusion Evidence Library) and contact with transfusion medicine and blood bank experts. Twenty-three studies were identified that measured the quality of the RBC unit (n = 19), bacterial contamination in the RBC unit (n = 4), or both (n = 2) after exposure to greater than 4degreesC +/- 2degreesC from between 20 minutes to 42 days. The overall finding was that temperature exposure did not adversely affect the quality of the RBC units or result in significant bacterial contamination. However, the variation in the temperature of exposure, its duration, the amount of data reported by the individual studies, and the age of the studies (and thus their comparability to current clinical practice) make it difficult to draw significant conclusions. To reliably determine whether these time rulescould be extended without an adverse risk to the RBC unit requires robust, modern studies using multiple combinations of blood, anticoagulant, and additive solutions with defined temperatures and times of exposure. Crown Copyright Copyright 2012. Published by Elsevier Inc. All rights reserved.
4.
Quality of life and use of red cell transfusion in patients with myelodysplastic syndromes. A systematic review
Pinchon DJ, Stanworth SJ, Doree C, Brunskill S, Norfolk DR
American Journal of Hematology. 2009;84((10):):671-77.
Abstract
The main treatment for many patients with Myelodysplastic Syndromes (MDS) remains red cell transfusion to attenuate the symptoms of chronic anemia. Fatigue can reduce a patient's health related quality of life (HRQoL), but there is little understanding of the optimal use of transfusions to improve this. A systematic review was performed to identify and appraise publications reporting the use of HRQoL instruments in patients with MDS. A total of 17 separate studies were identified that used 14 HRQoL instruments, but only one MDS disease specific HRQoL instrument (QOL-E) was reported. Two well established HRQoL instruments were most often used in MDS research (variants of the Functional Assessment of Cancer Therapy (FACT) and the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30)). Several common problems were identified in the published literature including a lack of power calculations to detect clinically relevant changes, small sample sizes and significant attrition rates for completion of HRQoL assessments, all of which limit the strength of any conclusions. There is no consensus on the optimal transfusion regimen to improve HRQoL in transfusion-dependent MDS. Future research into HRQoL within MDS is a pressing requirement. Studies should focus on the domains that are of most clinical importance to the patient as well as traditional quantitative changes of hemoglobin concentration.