Department of Anesthesiology, Perioperative and Pain Medicine, St. Boniface Hospital, University of Manitoba, CR3008-369 Tache Ave, Winnipeg, MB, R2H 2A6, Canada.
Section of Cardiac Surgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.
Can J Anaesth. 2020 May;67(5):577-587. doi: 10.1007/s12630-020-01592-w. Epub 2020 Feb 28.
Blood transfusions are frequently administered in cardiac surgery. Despite a large number of published studies comparing a "restrictive" strategy with a "liberal" strategy, no clear consensus has emerged to guide blood transfusion practice in cardiac surgery patients. The purpose of this study was to identify, critically appraise, and summarize the evidence on the overall effect of restrictive transfusion strategies compared with liberal transfusion strategies on mortality, other clinical outcomes, and transfusion-related outcomes in adult patients undergoing cardiac surgery.
We searched MEDLINE (OvidSP), EMBASE (OvidSP) and Cochrane CENTRAL (Wiley) from inception to 1 December 2017 and queried clinical trial registries and conference proceedings for randomized-controlled trials of liberal vs restrictive transfusion strategies in cardiac surgery.
From 7,908 citations, we included ten trials (9,101 patients) and eight companion publications. Overall, we found no significant difference in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; 95% confidence interval [CI], 0.76 to 1.54; I = 33%; seven trials; 8,661 patients). The use of a restrictive transfusion strategy did not appear to adversely impact any of the secondary clinical outcomes. As expected, the proportion of patients who received red blood cells (RBCs) in the restrictive group was significantly lower than in the liberal group (RR, 0.68; 95% CI, 0.64 to 0.73; I = 56%; 5 trials; 8,534 patients). Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy.
In adult patients undergoing cardiac surgery, a restrictive transfusion strategy reduces RBC transfusion without impacting mortality rate or the incidence of other perioperative complications. Nevertheless, further large trials in subgroups of patients, potentially of differing age, are needed to establish firm evidence to guide transfusion in cardiac surgery.
PROSPERO (CRD42017071440); registered 20 April, 2018.
心脏手术中经常进行输血。尽管有大量发表的研究比较了“限制性”策略与“宽松性”策略，但仍未达成明确共识来指导心脏手术患者的输血实践。本研究的目的是确定、批判性评价和总结关于限制性输血策略与宽松性输血策略相比对成人心脏手术患者死亡率、其他临床结局和输血相关结局的总体影响的证据。
我们检索了 MEDLINE（OvidSP）、EMBASE（OvidSP）和 Cochrane CENTRAL（Wiley）从建库至 2017 年 12 月 1 日的文献，并查询了临床试验注册库和会议论文集，以获取心脏手术中宽松性与限制性输血策略的随机对照试验。
从 7908 条引文，我们纳入了 10 项试验（9101 例患者）和 8 项伴随出版物。总体而言，我们发现限制性与宽松性输血策略之间的死亡率无显著差异（风险比 [RR]，1.08；95%置信区间 [CI]，0.76 至 1.54；I = 33%；7 项试验；8661 例患者）。使用限制性输血策略似乎不会对任何次要临床结局产生不利影响。正如预期的那样，限制性组接受红细胞（RBC）输注的患者比例明显低于宽松性组（RR，0.68；95%CI，0.64 至 0.73；I = 56%；5 项试验；8534 例患者）。在接受输血的患者中，与宽松性输血策略相比，限制性输血策略每例患者输注的 RBC 单位数更少。
在接受心脏手术的成年患者中，与宽松性输血策略相比，限制性输血策略可减少 RBC 输注，但不影响死亡率或其他围手术期并发症的发生率。然而，仍需要在亚组患者（可能为不同年龄）中进行更大规模的试验，以提供确定的证据来指导心脏手术中的输血。
PROSPERO（CRD42017071440）；注册于 2018 年 4 月 20 日。
