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Rivista di Anestesia, Rianimazione, Terapia Antalgica e Terapia Intensiva
Minerva Anestesiologica 2016 Maggio;82(5):582-98
Restrictive versus liberal transfusion strategy for red blood cell transfusion in critically ill patients and in patients with acute coronary syndrome: a systematic review, meta-analysis and trial sequential analysis
Javier RIPOLLÉS MELCHOR 1, Rubén CASANS FRANCÉS 2, Ángel ESPINOSA 3, Eugenio MARTÍNEZ HURTADO 1, Rosalía NAVARRO PÉREZ 1, Alfredo ABAD GURUMETA 4, Misericordia BASORA 5, José M. CALVO VECINO 1, on behalf of EAR Group Anesthesia Evidence Review Group ✉
1 Department of Anesthesia, Complutense University of Madrid, Hospital Universitario Infanta Leonor, Madrid, Spain; 2 Department of Anesthesia, University of Zaragoza, Hospital Universitario Lozano Blesa, Avenida San Juan Bosco, Zaragoza, Spain; 3 Department of Anesthesia, Thorax Intensive Care Centre, Örebro University, Örebro County Council Hospital, Örebro, Sweden; 4 Department of Anesthesia, Hospital Universitario la Paz, Paseo de la Castellana, Madrid, Spain; 5 Department of Anesthesia, Hospital Clínic i Provincial, Barcelona, Spain
INTRODUCTION: The risks and benefits of transfusing critically ill patients continue to evoke controversy. Specifically, the critically ill patients with active ischemic cardiac disease continue to represent a “gray area” in the literature.
EVIDENCE ACQUISITION: Meta-analysis of the effects of lower versus higher hemoglobin thresholds on mortality in critically ill patients was carried out using PRISMA methodology. A systematic research was performed in PubMed, Embase, and the Cochrane Library (last update, December 2014). Inclusion criteria: Anemic critically ill adult patients admitted to intensive care units and/or anemic patients with acute coronary syndrome in which a restrictive vs. liberal transfusion therapy was compared. Primary Endpoint: mortality. Included studies were subjected to quantifiable analysis, predefined subgroup analysis, trial sequential analysis and predefined sensitivity analysis.
EVIDENCE SYNTHESIS: Thirty RCT’s were initially identified; 6 fulfilled the inclusion criteria, including 2156. There were no differences in mortality between the restrictive and liberal groups (RR: 0.86, 95% CI 0.70-1.05 P=0.14), neither in patients with chronic cardiovascular disease subgroup (RR: 1.13, 95% IC 0.88-1.46 P=0.34). However, there is a trend towards decreased mortality in the subgroup critically ill (RR: 0.86, 95% CI 0.73-1.01 P=0.06); while in the subgroup of patients with acute myocardial infarct seems like it might be a non-significant trend towards increased mortality (RR: 3.85, 95% CI 0.82-18.0 P=0.09).
CONCLUSIONS: Restrictive strategy is at least as effective to liberal strategy in critically ill patients. Nevertheless, there is insufficient evidence to recommend a restrictive strategy for patients with acute coronary syndrome.