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Meta-Analysis
. 2019 Apr 1;40(13):1081-1088.
doi: 10.1093/eurheartj/ehy435.

Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis

Nadine Shehata  1 , Nikhil Mistry  2 , Bruno R da Costa  3   4 , Tiago V Pereira  3 , Richard Whitlock  5 , Gerard F Curley  6 , David A Scott  7 , Gregory M T Hare  8 , Peter Jüni  9 , C David Mazer  8
Affiliations
Meta-Analysis

Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis

Nadine Shehata et al. Eur Heart J. .

Abstract

Aims: To determine whether a restrictive strategy of red blood cell (RBC) transfusion at lower haemoglobin concentrations is inferior to a liberal strategy of RBC transfusion at higher haemoglobin concentrations in patients undergoing cardiac surgery.

Methods and results: We conducted a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials of the effect of restrictive and liberal RBC transfusion strategies on mortality within 30 days of surgery as the primary outcome. Secondary outcomes were those potentially resulting from anaemia-induced tissue hypoxia and transfusion outcomes. We searched the electronic databases MEDLINE, EMBASE, and the Cochrane Library until 17 November 2017. Thirteen trials were included. The risk ratio (RR) of mortality derived from 4545 patients assigned to a restrictive strategy when compared with 4547 transfused according to a liberal strategy was 0.96 [95% confidence interval (CI) 0.76-1.21, I2 = 0]. A restrictive strategy did not have a statistically significant effect on the risk of myocardial infarction (RR 1.01, 95% CI 0.81-1.26; I2=0), stroke (RR 0.93, 95% CI 0.68-1.27, I2 = 0), renal failure (RR 0.96, 95% CI 0.76-1.20, I2 = 0), or infection (RR 1.12, 95% CI 0.98-1.29, I2 = 0). Subgroup analysis of adult and paediatric trials did not show a significant interaction. At approximately 70% of the critical information size, the meta-analysis of mortality crossed the futility boundary for inferiority of the restrictive strategy.

Conclusion: The current evidence does not support the notion that restrictive RBC transfusion strategies are inferior to liberal RBC strategies in patients undergoing cardiac surgery.

Keywords: Blood transfusion; Cardiac surgery; Thresholds.

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Figures

Figure 1
Figure 1
Study selection.
Figure 2
Figure 2
Risk of bias summary.
Figure 3
Figure 3
Risk of bias for each study.
Figure 4
Figure 4
Mortality within 30 days of surgery in randomized controlled trials of adult and paediatric cardiac surgery patients. Fixed-effects meta-analysis.
Figure 5
Figure 5
Sensitivity analysis for mortality according to intra-operative or post-operative randomization. Fixed-effects meta-analysis.
Figure 6
Figure 6
Trial sequential analysis for mortality within 30 days of surgery for adult and paediatric patients undergoing cardiac surgery using a fixed-effects model. Trials are added in chronological order and the most recent studies were the largest studies published. The information size (9019 patients) was adequate to demonstrate that the restrictive strategy was not inferior to the liberal strategy (and that the liberal strategy was not superior to restrictive) as the futility boundary was crossed (upper panel).
Figure 7
Figure 7
Trial sequential analysis for mortality within 30 days of surgery for adult patients undergoing cardiac surgery using a fixed effects model. Trials are added in chronological order and the most recent studies were the largest studies published. The information size (8565 patients) was adequate to demonstrate that the restrictive strategy was not inferior to the liberal strategy (and that the liberal strategy was not superior to restrictive) as the futility boundary was crossed (upper panel).
Take home figure
Take home figure
The current evidence suggests restrictive transfusion strategies are not inferior to liberal transfusion strategies in adult and pediatric patients undergoing cardiac surgery. RBC indicates red blood cell; ICU indicates intensive care unit. ICU stay and hospital stay are reported as days.
None
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References

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