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

Abstract

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.

Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews

“…Of these, we excluded 24 studies [9, for the following reasons: seven were abstracts [16,21,22,24,25,27,31], five presented mortality from one trial [28,29,32,33,38], three did not include a meta-analysis [19,26,34], three pooled non-randomised trials [20,35,37], and six were updated by more recent reviews (Additional file 1: Table S4) [9,17,18,23,30,36]. Nineteen systematic reviews provided 33 meta-analyses that satisfied the eligibility criteria of our overview [8,[39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56]. Table 1 presents the characteristics of the included systematic reviews and meta-analyses.…”

“…The majority of systematic reviews pooled results from mixed medical and surgical settings (six reviews) [8,40,42,43,54,56]. Following this, the most common clinical settings pooled were orthopaedic surgery (five reviews) [39,44,[48][49][50], surgical and critical care (three reviews) [41,45,52], cardiac surgery (two reviews) [46,55], acute upper gastrointestinal bleeding (one review) [51], critical care and acute coronary syndrome (one review) [53], and haematology/oncology (one review) [53]. [8,39,40,[42][43][44][45][46][47][50][51][52][53][54][55][56].…”

“…Following this, the most common clinical settings pooled were orthopaedic surgery (five reviews) [39,44,[48][49][50], surgical and critical care (three reviews) [41,45,52], cardiac surgery (two reviews) [46,55], acute upper gastrointestinal bleeding (one review) [51], critical care and acute coronary syndrome (one review) [53], and haematology/oncology (one review) [53]. [8,39,40,[42][43][44][45][46][47][50][51][52][53][54][55][56]. One review restricted their search to publications in the English language [49], while the language restrictions of the search strategies of two reviews were unclear [41,48].…”

“…One review restricted their search to publications in the English language [49], while the language restrictions of the search strategies of two reviews were unclear [41,48]. Eight reviews did not restrict their search strategy by publication status [8,39,40,43,44,48,54,55], two reviews restricted their search results to trials published as full reports [45,53], while the publication status restriction of the other nine reviews were unclear [41,42,46,47,[49][50][51][52]56]. Figure 2 presents a matrix of unique RCTs pooled by the 19 systematic reviews and meta-analyses.…”

“…Eight of the 19 reviews reported the pooled proportion of patients transfused between restrictive and liberal groups [8, 40, 46, 48-50, 53, 55], with a further three reviews providing enough information for the difference to be calculated [39,43,56]. In the restrictive arm, the proportion of patients transfused ranged from 36% [48,50] to 63% [53], while in the liberal arm the proportion ranged from 74% [48] to 99% [53].…”