Comparison of restrictive and liberal transfusion strategy on postoperative delirium in aged patients following total hip replacement: A preliminary study

Fan, Yunxia; Liu, Fangfang; Jia, Min; Yang, Jiaojiao; Shen, Jin-Chun; Zhu, Guangming; Zhu, Shirley; Li, Weiyan; Yang, Jian-Guang; Ji, Mu‐Huo

doi:10.1016/j.archger.2014.03.009

Cited by 47 publications

(67 citation statements)

References 21 publications

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“…Only a few moderate ratings occurred: for confounding [19,20], selection [19], information [15,20,21], missing data [22,23], and departure from interventions [19,20,21]. Overall, the RCTs performed by Parker [19] and Fan et al [20] received 3 moderate ratings each.…”

Section: Resultsmentioning

confidence: 99%

“…In another study, patients received not only RBCs but also fresh frozen plasma (FFP) [20]. In these studies, a risk for information bias cannot be excluded.…”

Section: Discussionmentioning

confidence: 99%

“…In 2 studies [19,20], relevant confounders were not measured or not appropriately analysed, thus a moderate risk for confounding bias cannot be excluded.…”

Section: Discussionmentioning

confidence: 99%

“…Duration of follow-up varied across the RCTs, was sometimes unclear [15,20] or was not reported [23]; thus the risk of bias from missing data was rated as moderate.…”

Section: Discussionmentioning

confidence: 99%

“…With respect to the trial of Carson et al [14], the risk of selection bias was assessed as moderate due to the exclusive inclusion of patients with cardiovascular co-morbidity. For the trial of Fan et al [20], the risks of confounding bias and bias due to departure from intervention were both rated as moderate, since patients in the restrictive treatment arm received more hydroxyethyl starch and Ringer lactate to achieve hemodynamic stability, whereas patients in the liberal arm more often received FFP. Moderate risks for confounding bias, selection bias and bias due to departure from intervention were detected in the trial of Parker [19].…”

Section: Discussionmentioning

confidence: 99%

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Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review

Müller

Oberle

Drechsel-Bäuerle

et al. 2018

Transfus Med Hemother

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Background: Benefits and risks of liberal and restrictive transfusion regimens are under on-going controversial discussion. This systematic review aimed at assessing both regimens in terms of pre-defined outcomes with special focus on patients undergoing major orthopaedic surgery. Methods: We performed a literature search for mortality, morbidity and related outcomes following peri-operative blood transfusion in patients with major orthopaedic surgery in electronic databases. Combined outcome measure estimates were calculated within the scope of meta-analyses including randomised clinical trials comparing restrictive versus liberal blood transfusion regimens (e.g. MH risk ratio, Peto odds ratio). Results: A total of 880 publications were identified 15 of which were finally included (8 randomised clinical trials (RCTs) with 3,693 patients and 6 observational studies with 4,244,112 patients). Regarding RCTs, no significant differences were detected between the transfusion regimes for all primary outcomes (30-day mortality, thromboembolic events, stroke/transitory ischaemic attack, myocardial infarction, wound infection and pneumonia) and a secondary outcome (length of hospital stay), whereas there was a significantly reduced risk of receiving at least one red blood concentrate under a restrictive regimen. Conclusion: The results of this systematic review do not suggest an increased risk associated with either a restrictive or a liberal transfusion regimen in patients undergoing major orthopaedic surgery.

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Section: Resultsmentioning

confidence: 99%

“…In another study, patients received not only RBCs but also fresh frozen plasma (FFP) [20]. In these studies, a risk for information bias cannot be excluded.…”

Section: Discussionmentioning

confidence: 99%

“…In 2 studies [19,20], relevant confounders were not measured or not appropriately analysed, thus a moderate risk for confounding bias cannot be excluded.…”

Section: Discussionmentioning

confidence: 99%

“…Duration of follow-up varied across the RCTs, was sometimes unclear [15,20] or was not reported [23]; thus the risk of bias from missing data was rated as moderate.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review

Müller

Oberle

Drechsel-Bäuerle

et al. 2018

Transfus Med Hemother

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Clinical Practice Guidelines From the AABB

Carson

Guyatt

Heddle

et al. 2016

JAMA

865

254

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IMPORTANCE More than 100 million units of blood are collected worldwide each year, yet the indication for red blood cell (RBC) transfusion and the optimal length of RBC storage prior to transfusion are uncertain.OBJECTIVE To provide recommendations for the target hemoglobin level for RBC transfusion among hospitalized adult patients who are hemodynamically stable and the length of time RBCs should be stored prior to transfusion.EVIDENCE REVIEW Reference librarians conducted a literature search for randomized clinical trials (RCTs) evaluating hemoglobin thresholds for RBC transfusion (1950( -May 2016 and RBC storage duration (1948( -May 2016 without language restrictions. The results were summarized using the Grading of Recommendations Assessment, Development and Evaluation method. For RBC transfusion thresholds, 31 RCTs included 12 587 participants and compared restrictive thresholds (transfusion not indicated until the hemoglobin level is 7-8 g/dL) with liberal thresholds (transfusion not indicated until the hemoglobin level is 9-10 g/dL). The summary estimates across trials demonstrated that restrictive RBC transfusion thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or thromboembolism. For RBC storage duration, 13 RCTs included 5515 participants randomly allocated to receive fresher blood or standard-issue blood. These RCTs demonstrated that fresher blood did not improve clinical outcomes.FINDINGS It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient. Recommendation 1: a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence). A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence). Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence). CONCLUSIONS AND R...

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Patient Blood Management

Mueller

Remoortel

Meybohm

et al. 2019

JAMA

423

121

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IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEWThe scientific committee developed 17 Population/Intervention/ Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018.FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCEThe 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.

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Comparison of restrictive and liberal transfusion strategy on postoperative delirium in aged patients following total hip replacement: A preliminary study

Cited by 47 publications

References 21 publications

Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review

Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review

Clinical Practice Guidelines From the AABB

Patient Blood Management

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