Indications for red blood cell transfusion in cardiac surgery: A systematic review and meta-analysis

Nishith Patel; Vassilios Avlontis; Hayley Jones; Barnaby Reeves; Jonathan Sterne; Gavin Murphy

doi:10.1016/S2352-3026(15)00198-2

Indications for red blood cell transfusion in cardiac surgery: A systematic review and meta-analysis

Nishith Patel, Vassilios Avlontis, Hayley Jones, Barnaby Reeves, Jonathan Sterne, Gavin Murphy

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Abstract

Background: Good blood management is an important determinant of outcome incardiac surgery. Current guidelines recommend restrictive red blood cell (RBC)transfusion practice. Our objective was to systematically review the evidence fromrandomised controlled trials (RCTs) and observational studies that are used to informtransfusion decisions in adult cardiac surgery.

Methods: We searched electronic databases (PUBMED, EMBASE, Cochrane Library,DARE) from inception to May 2015, databases from specialist societies, andbibliographies of included studies and recent relevant review articles. RCTs thatevaluated the effect of liberal versus restrictive RBC transfusion threshold in cardiac andnon-cardiac surgery patients, and observational studies that evaluated the effect of RBCtransfusion compared with no transfusion on postoperative outcomes in adult cardiacsurgery patients were included. Adjusted odds ratios were pooled using fixed- andrandom-effects meta-analyses.

Findings: Data from 6 cardiac surgical RCTs (3352 patients), 19 non-cardiac surgicalRCTs (8361 patients), and 39 observational studies (232 806 patients) were included.The pooled mortality odds ratios comparing liberal versus restrictive transfusionthresholds were 0·70 (95% CI 0.49–1·02, p=0.06) and 1·10 (95% CI 0·96-1·27, p=0.16)for cardiac surgical RCTs and RCTs in settings other than cardiac surgery, respectively.By contrast, observational cohort studies in cardiac surgery found that RBC transfusioncompared with no transfusion was associated with substantially higher mortality (OR2·72; 95% CI 2·11–3·49, p<0.001) and other morbidity, although with substantialheterogeneity and small study effects.

Interpretation: Evidence from RCTs in cardiac surgery refutes findings fromobservational studies that RBC transfusion is associated with a substantially increasedrisk of mortality and morbidity. Such studies, and RCTs in non-cardiac surgery, shouldnot be used to inform treatment decisions or guidelines for cardiac surgery patients.

Original language	English
Pages (from-to)	e543-e553
Number of pages	11
Journal	Lancet Haematology
Volume	2
Issue number	12
Early online date	16 Nov 2015
DOIs	https://doi.org/10.1016/S2352-3026(15)00198-2
Publication status	Published - 1 Dec 2015

Research Groups and Themes

BTC (Bristol Trials Centre)
Centre for Surgical Research

Keywords

Erythrocyte transfusion
Systematic review
Meta-Analysis
Cardiac Surgery
Randomised Controlled Trials
Observational Studies

Access to Document

10.1016/S2352-3026(15)00198-2

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This is the author accepted manuscript (AAM). The final published version (version of record) is available online via Elsevier at http://dx.doi.org/10.1016/S2352-3026(15)00198-2. Please refer to any applicable terms of use of the publisher.
Accepted author manuscript, 613 KBLicence: CC BY-NC-ND

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Persistent link

Evidence synthesis of diagnostic test performance from a decision-making perspective
Jones, H. E. (Principal Investigator)
12/08/15 → 11/08/19
Project: Research
ConDuCT-II
Blazeby, J. (Principal Investigator)
1/04/14 → 31/03/19
Project: Research

Dr Hayley E Jones
- Hayley.Jonesbristol.acuk
- Bristol Medical School (PHS) - Associate Professor in Medical Statistics
- Bristol Population Health Science Institute
Person: Academic , Member
Professor Jonathan A C Sterne
- Jonathan.Sternebristol.acuk
- Bristol Medical School (PHS) - Professor of Medical Statistics and Epidemiology
- Bristol Population Health Science Institute
- Infection and Immunity
Person: Academic , Member

Cite this

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title = "Indications for red blood cell transfusion in cardiac surgery: A systematic review and meta-analysis",

abstract = "Background: Good blood management is an important determinant of outcome incardiac surgery. Current guidelines recommend restrictive red blood cell (RBC)transfusion practice. Our objective was to systematically review the evidence fromrandomised controlled trials (RCTs) and observational studies that are used to informtransfusion decisions in adult cardiac surgery. Methods: We searched electronic databases (PUBMED, EMBASE, Cochrane Library,DARE) from inception to May 2015, databases from specialist societies, andbibliographies of included studies and recent relevant review articles. RCTs thatevaluated the effect of liberal versus restrictive RBC transfusion threshold in cardiac andnon-cardiac surgery patients, and observational studies that evaluated the effect of RBCtransfusion compared with no transfusion on postoperative outcomes in adult cardiacsurgery patients were included. Adjusted odds ratios were pooled using fixed- andrandom-effects meta-analyses. Findings: Data from 6 cardiac surgical RCTs (3352 patients), 19 non-cardiac surgicalRCTs (8361 patients), and 39 observational studies (232 806 patients) were included.The pooled mortality odds ratios comparing liberal versus restrictive transfusionthresholds were 0·70 (95% CI 0.49–1·02, p=0.06) and 1·10 (95% CI 0·96-1·27, p=0.16)for cardiac surgical RCTs and RCTs in settings other than cardiac surgery, respectively.By contrast, observational cohort studies in cardiac surgery found that RBC transfusioncompared with no transfusion was associated with substantially higher mortality (OR2·72; 95% CI 2·11–3·49, p<0.001) and other morbidity, although with substantialheterogeneity and small study effects. Interpretation: Evidence from RCTs in cardiac surgery refutes findings fromobservational studies that RBC transfusion is associated with a substantially increasedrisk of mortality and morbidity. Such studies, and RCTs in non-cardiac surgery, shouldnot be used to inform treatment decisions or guidelines for cardiac surgery patients.",

keywords = "Erythrocyte transfusion, Systematic review, Meta-Analysis, Cardiac Surgery, Randomised Controlled Trials, Observational Studies",

author = "Nishith Patel and Vassilios Avlontis and Hayley Jones and Barnaby Reeves and Jonathan Sterne and Gavin Murphy",

year = "2015",

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doi = "10.1016/S2352-3026(15)00198-2",

language = "English",

volume = "2",

pages = "e543--e553",

journal = "Lancet Haematology",

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publisher = "Lancet Publishing Group",

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TY - JOUR

T1 - Indications for red blood cell transfusion in cardiac surgery

T2 - A systematic review and meta-analysis

AU - Patel, Nishith

AU - Avlontis, Vassilios

AU - Jones, Hayley

AU - Reeves, Barnaby

AU - Sterne, Jonathan

AU - Murphy, Gavin

PY - 2015/12/1

Y1 - 2015/12/1

N2 - Background: Good blood management is an important determinant of outcome incardiac surgery. Current guidelines recommend restrictive red blood cell (RBC)transfusion practice. Our objective was to systematically review the evidence fromrandomised controlled trials (RCTs) and observational studies that are used to informtransfusion decisions in adult cardiac surgery. Methods: We searched electronic databases (PUBMED, EMBASE, Cochrane Library,DARE) from inception to May 2015, databases from specialist societies, andbibliographies of included studies and recent relevant review articles. RCTs thatevaluated the effect of liberal versus restrictive RBC transfusion threshold in cardiac andnon-cardiac surgery patients, and observational studies that evaluated the effect of RBCtransfusion compared with no transfusion on postoperative outcomes in adult cardiacsurgery patients were included. Adjusted odds ratios were pooled using fixed- andrandom-effects meta-analyses. Findings: Data from 6 cardiac surgical RCTs (3352 patients), 19 non-cardiac surgicalRCTs (8361 patients), and 39 observational studies (232 806 patients) were included.The pooled mortality odds ratios comparing liberal versus restrictive transfusionthresholds were 0·70 (95% CI 0.49–1·02, p=0.06) and 1·10 (95% CI 0·96-1·27, p=0.16)for cardiac surgical RCTs and RCTs in settings other than cardiac surgery, respectively.By contrast, observational cohort studies in cardiac surgery found that RBC transfusioncompared with no transfusion was associated with substantially higher mortality (OR2·72; 95% CI 2·11–3·49, p<0.001) and other morbidity, although with substantialheterogeneity and small study effects. Interpretation: Evidence from RCTs in cardiac surgery refutes findings fromobservational studies that RBC transfusion is associated with a substantially increasedrisk of mortality and morbidity. Such studies, and RCTs in non-cardiac surgery, shouldnot be used to inform treatment decisions or guidelines for cardiac surgery patients.

AB - Background: Good blood management is an important determinant of outcome incardiac surgery. Current guidelines recommend restrictive red blood cell (RBC)transfusion practice. Our objective was to systematically review the evidence fromrandomised controlled trials (RCTs) and observational studies that are used to informtransfusion decisions in adult cardiac surgery. Methods: We searched electronic databases (PUBMED, EMBASE, Cochrane Library,DARE) from inception to May 2015, databases from specialist societies, andbibliographies of included studies and recent relevant review articles. RCTs thatevaluated the effect of liberal versus restrictive RBC transfusion threshold in cardiac andnon-cardiac surgery patients, and observational studies that evaluated the effect of RBCtransfusion compared with no transfusion on postoperative outcomes in adult cardiacsurgery patients were included. Adjusted odds ratios were pooled using fixed- andrandom-effects meta-analyses. Findings: Data from 6 cardiac surgical RCTs (3352 patients), 19 non-cardiac surgicalRCTs (8361 patients), and 39 observational studies (232 806 patients) were included.The pooled mortality odds ratios comparing liberal versus restrictive transfusionthresholds were 0·70 (95% CI 0.49–1·02, p=0.06) and 1·10 (95% CI 0·96-1·27, p=0.16)for cardiac surgical RCTs and RCTs in settings other than cardiac surgery, respectively.By contrast, observational cohort studies in cardiac surgery found that RBC transfusioncompared with no transfusion was associated with substantially higher mortality (OR2·72; 95% CI 2·11–3·49, p<0.001) and other morbidity, although with substantialheterogeneity and small study effects. Interpretation: Evidence from RCTs in cardiac surgery refutes findings fromobservational studies that RBC transfusion is associated with a substantially increasedrisk of mortality and morbidity. Such studies, and RCTs in non-cardiac surgery, shouldnot be used to inform treatment decisions or guidelines for cardiac surgery patients.

KW - Erythrocyte transfusion

KW - Systematic review

KW - Meta-Analysis

KW - Cardiac Surgery

KW - Randomised Controlled Trials

KW - Observational Studies

U2 - 10.1016/S2352-3026(15)00198-2

DO - 10.1016/S2352-3026(15)00198-2

M3 - Article (Academic Journal)

SN - 2352-3026

VL - 2

SP - e543-e553

JO - Lancet Haematology

JF - Lancet Haematology

IS - 12

ER -

Indications for red blood cell transfusion in cardiac surgery: A systematic review and meta-analysis

Abstract

Research Groups and Themes

Keywords

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Projects

Evidence synthesis of diagnostic test performance from a decision-making perspective

ConDuCT-II

Profiles

Dr Hayley E Jones

Professor Jonathan A C Sterne

Cite this