Restrictive versus liberal transfusion strategy for red blood cell transfusion: systematic review of randomised trials with meta-analysis and trial sequential analysis

Abstract

ObjeCtive To compare the benefit and harm of restrictive versus liberal transfusion strategies to guide red blood cell transfusions. DesignSystematic review with meta-analyses and trial sequential analyses of randomised clinical trials. Data sOurCesCochrane central register of controlled trials, SilverPlatter Medline (1950 to date), SilverPlatter Embase (1980 to date), and Science Citation Index Expanded (1900 to present). Reference lists of identified trials and other systematic reviews were assessed, and authors and experts in transfusion were contacted to identify additional trials.trial seleCtiOn Published and unpublished randomised clinical trials that evaluated a restrictive compared with a liberal transfusion strategy in adults or children, irrespective of language, blinding procedure, publication status, or sample size. Data extraCtiOnTwo authors independently screened titles and abstracts of trials identified, and relevant trials were evaluated in full text for eligibility. Two reviewers then independently extracted data on methods, interventions, outcomes, and risk of bias from included trials. random effects models were used to estimate risk ratios and mean differences with 95% confidence intervals. results 31 trials totalling 9813 randomised patients were included. The proportion of patients receiving red blood cells (relative risk 0.54, 95% confidence interval 0.47 to 0.63, 8923 patients, 24 trials) and the number of red blood cell units transfused (mean difference −1.43, 95% confidence interval −2.01 to −0.86) were lower with the restrictive compared with liberal transfusion strategies. Restrictive compared with liberal transfusion strategies were not associated with risk of death (0.86, 0.74 to 1.01, 5707 patients, nine lower risk of bias trials), overall morbidity (0.98, 0.85 to 1.12, 4517 patients, six lower risk of bias trials), or fatal or non-fatal myocardial infarction (1.28, 0.66 to 2.49, 4730 patients, seven lower risk of bias trials). Results were not affected by the inclusion of trials with unclear or high risk of bias. Using trial sequential analyses on mortality and myocardial infarction, the required information size was not reached, but a 15% relative risk reduction or increase in overall morbidity with restrictive transfusion strategies could be excluded. COnClusiOnsCompared with liberal strategies, restrictive transfusion strategies were associated with a reduction in the number of red blood cell units transfused and number of patients being transfused, but mortality, overall morbidity, and myocardial infarction seemed to be unaltered. Restrictive transfusion strategies are safe in most clinical settings. Liberal transfusion strategies have not been shown to convey any benefit to patients. trial registratiOn PROSPERO CRD42013004272.

2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

“…U pacjentów z hematokrytem > 30% obserwowano istotny wzrost śmiertelności po wykonaniu transfuzji [300]. Metaanaliza 31, w większości nieprzeprowadzonych metodą ślepej próby, RCT obejmujących łącznie 9813 chorych (jedynie niewielka grupa z NSTE-ACS) nie wykazała istotnych różnic w zakresie pierwotnego punktu końcowego w przypadku liberalnej strategii przetoczeń krwi w porównaniu z restrykcyjną [301]. Najbardziej aktualne RCT przeprowadzono u 2007 chorych, w większości przypadków u pacjentów w stanie stabilnym, po operacji kardiochirurgicznej [302].…”

Is there a “magic” hemoglobin number? Clinical decision support promoting restrictive blood transfusion practices

“…Additional RBC units should be prescribed only after reassessment of the patient between transfusion events. This best practices framework is supported by the recent metanalysis by Holst et al, which concluded that liberal transfusion strategies have not been shown to convey any benefit to patients [59].…”

A Review on Artificial Blood: A Source We Need

“…Thus, in proceeding the artificial blood products on to the blood stream, the blood transfusion method is analyzed. Many trials were conducted with different blood samples, to find the common effect of treatment effect using metaanalysis [19,23]. To considered different average percentage of donors which would not support the motivator goodness of fit test were used [24].…”