Department of Anesthesia and Perioperative Medicine and Centre for Medical Evidence, Decision Integrity, Clinical Impact (MEDICI), Western University, London, ON, Canada.
Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
Crit Care Med. 2018 Feb;46(2):252-263. doi: 10.1097/CCM.0000000000002873.
To address the significant uncertainty as to whether transfusion thresholds for critical care versus surgical patients should differ.
Meta-analysis of randomized controlled trials.
Medline, EMBASE, and Cochrane Library searches were performed up to 15 June 2016.
Trials had to enroll adult surgical or critically ill patients for inclusion.
Studies had to compare a liberal versus restrictive threshold for the transfusion of allogeneic packed RBCs.
The primary outcome was 30-day all-cause mortality, sub-grouped by surgical and critical care patients. Secondary outcomes included myocardial infarction, stroke, renal failure, allogeneic blood exposure, and length of stay. Odds ratios and weighted mean differences were calculated using random effects meta-analysis. To assess whether subgroups were significantly different, tests for subgroup interaction were used. Subgroup analysis by trials enrolling critically ill versus surgical patients was performed. Twenty-seven randomized controlled trials (10,797 patients) were included. In critical care patients, restrictive transfusion resulted in significantly reduced 30-day mortality compared with liberal transfusion (odds ratio, 0.82; 95% CI, 0.70-0.97). In surgical patients, a restrictive transfusion strategy led to the opposite direction of effect for mortality (odds ratio, 1.31; 95% CI, 0.94-1.82). The subgroup interaction test was significant (p = 0.04), suggesting that the effect of restrictive transfusion on mortality is statistically different for critical care (decreased risk) versus surgical patients (potentially increased risk or no difference). Regarding secondary outcomes, for critically ill patients, a restrictive strategy resulted in reduced risk of stroke/transient ischemic attack, packed RBC exposure, transfusion reactions, and hospital length of stay. In surgical patients, restrictive transfusion resulted in reduced packed RBC exposure.
The safety of restrictive transfusion strategies likely differs for critically ill patients versus perioperative patients. Further trials investigating transfusion strategies in the perioperative setting are necessary.
解决关键护理与外科患者的输血阈值是否应有所不同的重大不确定性。
随机对照试验的荟萃分析。
对截至 2016 年 6 月 15 日的 Medline、EMBASE 和 Cochrane 图书馆进行了检索。
必须纳入成年外科或重症患者的试验。
必须比较所有同种异体浓缩红细胞输血的宽松与严格阈值。
主要结果为 30 天全因死亡率，按外科和重症监护患者进行亚组分析。次要结局包括心肌梗死、中风、肾功能衰竭、异体血液暴露和住院时间。使用随机效应荟萃分析计算比值比和加权均数差。为了评估亚组是否存在显著差异，使用亚组交互检验进行检验。对纳入重症监护与外科患者的试验进行亚组分析。纳入 27 项随机对照试验（10797 例患者）。在重症监护患者中，与宽松输血相比，限制性输血可显著降低 30 天死亡率（比值比，0.82；95%置信区间，0.70-0.97）。在外科患者中，限制性输血策略导致死亡率的效果相反（比值比，1.31；95%置信区间，0.94-1.82）。亚组交互检验有统计学意义（p=0.04），表明限制性输血对死亡率的影响在重症监护（降低风险）与外科患者（潜在增加风险或无差异）之间存在统计学差异。关于次要结局，对于重症监护患者，限制性策略可降低中风/短暂性脑缺血发作、浓缩红细胞暴露、输血反应和住院时间的风险。在外科患者中，限制性输血可减少浓缩红细胞的暴露。
对于重症患者与围手术期患者，限制性输血策略的安全性可能有所不同。需要进一步研究围手术期输血策略。
