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Editor's Choice
  • Nuñez JH
  • Colomina J
  • Angles F
  • Pallisó F
  • Acosta HF
  • et al.
Arch Orthop Trauma Surg. 2024 Apr;144(4):1585-1595 doi: 10.1007/s00402-024-05243-3.
POPULATION:

Patients undergoing primary total hip or knee arthroplasty (5 studies, n= 17,667).

INTERVENTION:

Systematic review and meta-analysis to assess the necessity of routine pretransfusion tests before primary total hip or knee arthroplasty.

COMPARISON:

OUTCOME:

Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI [0.92, 1.00]) among patients undergoing primary total hip or knee arthroplasty. The pooled prevalence of hospital transfusion rate was 3.6%. There were statistically significant differences in preoperative haemoglobin (Hb) levels between patients not requiring transfusion (Hb= 13.9 g/dl; 95% CI [12.59, 15.20]) and those needing transfusion (Hb= 11.9 g/dl; 95% CI [10.69, 13.01]).

BACKGROUND:

The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes.

STUDY METHODS:

A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed.

RESULTS:

The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars.

DISCUSSION:

Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Editor's Choice
  • Schoenfeld DW
  • Rosen CL
  • Harris T
  • Thomas SH
Acad Emerg Med. 2024 Mar 22; doi: 10.1111/acem.14882.
POPULATION:

Patients in the civilian emergency medical services setting (3 randomised controlled trials).

INTERVENTION:

Blood products.

COMPARISON:

No blood products.

OUTCOME:

In assessing a single patient-centered endpoint-1-month mortality- the authors calculated an overall risk ratio (RR) estimate. Analysis of the included studies yielded a model with acceptable heterogeneity (I(2) 48%). Pooled estimate revealed civilian prehospital transfusion results in a statistically non-significant relative mortality reduction of 13% (RR 0.87; 95% CI [0.63, 1.19]).

BACKGROUND:

Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products.

METHOD:

The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified.

RESULTS:

In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19).

CONCLUSIONS:

Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

Editor's Choice
  • Meyer CH
  • Bailey NM
  • Leslie SL
  • Thrasher K
  • Grady Z
  • et al.
Am J Surg. 2024 Feb;228:192-198 doi: 10.1016/j.amjsurg.2023.09.024.
POPULATION:

Trauma patients in haemorrhagic shock (8 studies).

INTERVENTION:

Systematic review to determine a consensus definition for ultra-massive transfusion.

COMPARISON:

OUTCOME:

Only two studies demonstrated a consensus definition of ultra-massive transfusion, which used ≥20 units of red blood cell product within 24hrs. Parameters associated with increased mortality included lower blood pressure, lower pulse and lower Glasgow Coma Score at the time of presentation and a higher injury severity score and undergoing a resuscitative thoracotomy.

BACKGROUND:

Despite the widespread use of ultra-massive transfusion (UMT) as an intervention for trauma patients in hemorrhagic shock, no standard definition exists. We performed a systematic review to determine a consensus definition for UMT.

METHODS:

A search was performed from 1979-2022. The authors screened studies defining UMT and associated outcomes as defined by our prespecified PICO questions. The PRISMA guidelines were used.

RESULTS:

1662 articles met criteria for eligibility assessment, 17 for full-text review and eight for data extraction. Only two studies demonstrated a consensus definition of UMT, which used ≥20 units of red blood cell product within 24hrs. Parameters associated with increased mortality included lower blood pressure, lower pulse and lower Glasgow Coma Score at the time of presentation and a higher injury severity score and undergoing a resuscitative thoracotomy.

CONCLUSIONS:

The absence of a consensus definition for UMT raises challenges from clinical, research and ethical perspectives. Based on our findings, the authors advocate for the feasibility of standardizing the definition of UMT as ≥20 units of red blood cell product within 24hrs.