Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial

Fischer, Marc-Olivier; Guinot, Pierre‐Grégoire; Debroczi, Stéphane; Huette, Pierre; Beyls, Christophe; Babatasi, Gérard; Bafi, Kevin; Guilbart, Mathieu; Caus, Thierry; Lorne, Emmanuel; Dupont, Hervé; Hanouz, Jean‐Luc; Abou-Arab, Osama

doi:10.1016/j.bja.2021.09.037

Cited by 24 publications

(14 citation statements)

References 15 publications

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“…In a recent RCT, an individualised strategy based on a central venous oxygen saturation threshold of 70% allowed for a more restrictive RBC transfusion strategy with no incidence on postoperative morbidity or 6-month mortality. 981 Furthermore, a retrospective study in critically ill patients found that when A-V O 2diff is greater than 3.7 ml, it could provide a more personalised approach in identifying patients who might benefit from transfusion, as indicated by lower mortality compared with those who received transfusion when A-V O 2diff was lower. 982 Monitoring tissue perfusion A before-and-after study in 204 patients undergoing gastrointestinal surgery received treatment by an algorithm combining mean arterial pressure greater than 65 mmHg, SpO 2 greater than 95%, PCO 2 gap less than 6 mmHg, and pulse pressure variation less than 13% and compared with patients previously operated on by the same team who were receiving conventional management.…”

Section: Evidence Summary Transfusion Triggersmentioning

confidence: 99%

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Kietaibl

Ahmed

Afshari

et al. 2023

European Journal of Anaesthesiology

108

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BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

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Section: Evidence Summary Transfusion Triggersmentioning

confidence: 99%

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Kietaibl

Ahmed

Afshari

et al. 2023

European Journal of Anaesthesiology

108

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“…21,22 Individualizing restrictive transfusion according to a metabolic trigger may help to adjust RBC transfusion to adequate oxygen delivery. 23,24 In 2 randomized controlled studies, RBC transfusion was conditioned to central venous oxygen saturation. 23,24 When RBC transfusion was administered only when central venous oxygen saturation was <65% to 70% in complement to hemoglobin concentration <9 g/dL, transfusion was reduced by 20% to 30% in comparison to a standard strategy.…”

Section: Discussionmentioning

confidence: 99%

“…The absence of benefit of restrictive transfusion over liberal transfusion suggests that avoiding RBC transfusion may be not sufficient to improve outcomes,17 possibly because restrictive transfusion delays anemia correction and exposes patients to anemia-related complications 21,22. Individualizing restrictive transfusion according to a metabolic trigger may help to adjust RBC transfusion to adequate oxygen delivery 23,24. In 2 randomized controlled studies, RBC transfusion was conditioned to central venous oxygen saturation 23,24.…”

Section: Discussionmentioning

confidence: 99%

Impact of Red Blood Cell Transfusion on In-hospital Mortality of Isolated Coronary Artery Bypass Graft Surgery

Colson

Gaudard

Meunier³

et al. 2022

Annals of Surgery

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Objective: To assess the relationship between red blood cell (RBC) transfusion exposure and in-hospital mortality after isolated coronary artery bypass graft (CABG) surgery. Background: RBC transfusion was commonly used to treat anemia in isolated CABG surgery, but transfusion was found an independent risk factor of postoperative mortality; recent guidelines on patient blood management strategy issued in the last decade may have changed transfusion incidence and related mortality. Methods: A retrospective cohort study was conducted from the National database on patients’ hospital discharge reports. Consecutive adult patients who underwent isolated CABG surgery in France from January 1, 2016, to December 31, 2018, were included. The primary outcome was the in-hospital mortality rate. RBC transfusion during the hospital stay was identified by specific codes and ordered as categorical variables (no, moderate, or massive transfusion). Results: A total of 37,498 participants were studied [mean (SD) age, 66.5 (9.6) years, 31,587 (84.2%) were men]. In-hospital mortality rate was 1.45% (n=541) and RBC transfusion rate was 9.4% (n=3521). In-hospital deaths were more frequent among transfused patients [1.06% (361) if no transfusion up to 10.2% (n=113) if massive transfusion]. After adjustment for confounding variables, RBC transfusion remained a significant independent factor of in-hospital mortality: odds ratio=1.66 (95% confidence interval: 1.27–2.19, P<0.001) for moderate transfusion, 6.40 (95% confidence interval: 5.07–8.09, P<0.001) if massive. Conclusions and Relevance: Despite a modest patients’ exposure to transfusion, this study suggests that RBC administration is an independent factor of in-hospital mortality in isolated CABG surgery.

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“…43,54 In a recent randomized controlled trial, patients with postoperative hemoglobin <9.0 g/dL admitted to cardiac care units after cardiac surgery were randomized to receive either a transfusion with 1 RBC unit (control group) or a transfusion only if the central venous oxygen saturation was <70% (study group). 55 The study group received fewer RBC transfusions without increasing in-hospital morbidity or mortality. 55 This study did show that RBC transfusion triggers using physiologic parameters, in combination with hemoglobin values, reduced overall transfusions.…”

Section: Updates On Transfusion Studies In Cardiac Surgerymentioning

confidence: 97%

“…55 The study group received fewer RBC transfusions without increasing in-hospital morbidity or mortality. 55 This study did show that RBC transfusion triggers using physiologic parameters, in combination with hemoglobin values, reduced overall transfusions. One key limitation of this study, however, was that the transfusion trigger of 9.0 g/dL was higher than the recommended thresholds in the recent clinical guidelines.…”

Section: Updates On Transfusion Studies In Cardiac Surgerymentioning

confidence: 97%

Coagulation and Transfusion Updates From 2021

Fabbro

Patel

Henderson

et al. 2022

Journal of Cardiothoracic and Vascular Anesthesia

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Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial

Cited by 24 publications

References 15 publications

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Impact of Red Blood Cell Transfusion on In-hospital Mortality of Isolated Coronary Artery Bypass Graft Surgery

Coagulation and Transfusion Updates From 2021

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