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Restrictive Versus Liberal Strategy for Red Blood-Cell Transfusion: A Systematic Review and Meta-Analysis in Orthopaedic Patients.
J Bone Joint Surg Am. 2018 Apr 18; 100(8):686-695.JB

Abstract

BACKGROUND

Current guidelines recommend restrictive criteria for red blood-cell transfusion in most clinical settings. However, patients undergoing orthopaedic surgery may require distinct transfusion criteria since benefits and potential harm often vary considerably based on patient characteristics and surgical procedures. We aimed to assess the efficacy and safety of restrictive transfusion in patients undergoing orthopaedic surgery, especially in important subgroups.

METHODS

Electronic databases were searched to identify randomized controlled trials investigating restrictive (mostly a hemoglobin level of 8.0 g/dL or symptomatic anemia) versus liberal (mostly a hemoglobin level of 10.0 g/dL) transfusion in patients undergoing orthopaedic surgery. For the primary outcome of cardiovascular events, we performed random-effects meta-analyses to synthesize the evidence and to assess the effects in different subgroups according to patient characteristics (with versus without preexisting cardiovascular disease) and surgical procedures (hip fracture surgery versus elective arthroplasty).

RESULTS

Ten trials involving 3,968 participants who underwent hip or knee surgery were included. Mean participant age ranged from 68.7 to 86.9 years. Compared with liberal transfusion, restrictive transfusion increased the risk of cardiovascular events (8 trials; 3,618 participants; relative risk [RR], 1.51; 95% confidence interval [CI], 1.16 to 1.98; p = 0.003; with no heterogeneity across all trials), irrespective of preexisting cardiovascular disease (pinteraction = 0.63). In a subgroup analysis, the increase was observed in patients undergoing hip fracture surgery (RR, 1.51; 95% CI, 1.08 to 2.10; p = 0.02), but did not reach significance in those undergoing elective arthroplasty (RR, 1.53; 95% CI, 0.96 to 2.44; p = 0.07). To minimize the bias caused by variations in transfusion threshold, we conducted an analysis that only included trials using 8.0 g/dL hemoglobin or symptomatic anemia as the threshold for restrictive transfusion and obtained identical results (6 trials; 2,872 participants; RR, 1.51; 95% CI, 1.09 to 2.08; p = 0.01; I = 0%). The 2 arms did not differ with respect to the rates of all infections, 30-day mortality, thromboembolic events, wound infection, pulmonary infection (mainly pneumonia), and cerebrovascular accidents (mainly stroke).

CONCLUSIONS

In patients undergoing orthopaedic surgery, when compared with liberal transfusion, restrictive transfusion increases the risk of cardiovascular events irrespective of preexisting cardiovascular disease. Importantly, the increased risk was observed in patients undergoing hip fracture surgery but did not reach significance in those undergoing elective arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Authors+Show Affiliations

Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing, People's Republic of China.Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing, People's Republic of China.Department of Orthopaedic Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.The Second Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, People's Republic of China.Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing, People's Republic of China.Department of Medical Information, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing, People's Republic of China.

Pub Type(s)

Journal Article
Meta-Analysis
Systematic Review

Language

eng

PubMed ID

29664857

Citation

Gu, Wan-Jie, et al. "Restrictive Versus Liberal Strategy for Red Blood-Cell Transfusion: a Systematic Review and Meta-Analysis in Orthopaedic Patients." The Journal of Bone and Joint Surgery. American Volume, vol. 100, no. 8, 2018, pp. 686-695.
Gu WJ, Gu XP, Wu XD, et al. Restrictive Versus Liberal Strategy for Red Blood-Cell Transfusion: A Systematic Review and Meta-Analysis in Orthopaedic Patients. J Bone Joint Surg Am. 2018;100(8):686-695.
Gu, W. J., Gu, X. P., Wu, X. D., Chen, H., Kwong, J. S. W., Zhou, L. Y., Chen, S., & Ma, Z. L. (2018). Restrictive Versus Liberal Strategy for Red Blood-Cell Transfusion: A Systematic Review and Meta-Analysis in Orthopaedic Patients. The Journal of Bone and Joint Surgery. American Volume, 100(8), 686-695. https://doi.org/10.2106/JBJS.17.00375
Gu WJ, et al. Restrictive Versus Liberal Strategy for Red Blood-Cell Transfusion: a Systematic Review and Meta-Analysis in Orthopaedic Patients. J Bone Joint Surg Am. 2018 Apr 18;100(8):686-695. PubMed PMID: 29664857.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Restrictive Versus Liberal Strategy for Red Blood-Cell Transfusion: A Systematic Review and Meta-Analysis in Orthopaedic Patients. AU - Gu,Wan-Jie, AU - Gu,Xiao-Ping, AU - Wu,Xiang-Dong, AU - Chen,Hao, AU - Kwong,Joey S W, AU - Zhou,Lu-Yang, AU - Chen,Shuo, AU - Ma,Zheng-Liang, PY - 2018/4/18/entrez PY - 2018/4/18/pubmed PY - 2019/6/18/medline SP - 686 EP - 695 JF - The Journal of bone and joint surgery. American volume JO - J Bone Joint Surg Am VL - 100 IS - 8 N2 - BACKGROUND: Current guidelines recommend restrictive criteria for red blood-cell transfusion in most clinical settings. However, patients undergoing orthopaedic surgery may require distinct transfusion criteria since benefits and potential harm often vary considerably based on patient characteristics and surgical procedures. We aimed to assess the efficacy and safety of restrictive transfusion in patients undergoing orthopaedic surgery, especially in important subgroups. METHODS: Electronic databases were searched to identify randomized controlled trials investigating restrictive (mostly a hemoglobin level of 8.0 g/dL or symptomatic anemia) versus liberal (mostly a hemoglobin level of 10.0 g/dL) transfusion in patients undergoing orthopaedic surgery. For the primary outcome of cardiovascular events, we performed random-effects meta-analyses to synthesize the evidence and to assess the effects in different subgroups according to patient characteristics (with versus without preexisting cardiovascular disease) and surgical procedures (hip fracture surgery versus elective arthroplasty). RESULTS: Ten trials involving 3,968 participants who underwent hip or knee surgery were included. Mean participant age ranged from 68.7 to 86.9 years. Compared with liberal transfusion, restrictive transfusion increased the risk of cardiovascular events (8 trials; 3,618 participants; relative risk [RR], 1.51; 95% confidence interval [CI], 1.16 to 1.98; p = 0.003; with no heterogeneity across all trials), irrespective of preexisting cardiovascular disease (pinteraction = 0.63). In a subgroup analysis, the increase was observed in patients undergoing hip fracture surgery (RR, 1.51; 95% CI, 1.08 to 2.10; p = 0.02), but did not reach significance in those undergoing elective arthroplasty (RR, 1.53; 95% CI, 0.96 to 2.44; p = 0.07). To minimize the bias caused by variations in transfusion threshold, we conducted an analysis that only included trials using 8.0 g/dL hemoglobin or symptomatic anemia as the threshold for restrictive transfusion and obtained identical results (6 trials; 2,872 participants; RR, 1.51; 95% CI, 1.09 to 2.08; p = 0.01; I = 0%). The 2 arms did not differ with respect to the rates of all infections, 30-day mortality, thromboembolic events, wound infection, pulmonary infection (mainly pneumonia), and cerebrovascular accidents (mainly stroke). CONCLUSIONS: In patients undergoing orthopaedic surgery, when compared with liberal transfusion, restrictive transfusion increases the risk of cardiovascular events irrespective of preexisting cardiovascular disease. Importantly, the increased risk was observed in patients undergoing hip fracture surgery but did not reach significance in those undergoing elective arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. SN - 1535-1386 UR - https://www.unboundmedicine.com/medline/citation/29664857/Restrictive_Versus_Liberal_Strategy_for_Red_Blood_Cell_Transfusion:_A_Systematic_Review_and_Meta_Analysis_in_Orthopaedic_Patients_ L2 - http://dx.doi.org/10.2106/JBJS.17.00375 DB - PRIME DP - Unbound Medicine ER -