Liberal versus restrictive red blood cell transfusion strategy in sepsis or septic shock: a systematic review and meta-analysis of randomized trials

Hiroshi Tanaka,Yohei Hirano,Ken Okamoto,Yukari Miyoshi,Yutaka Kondo

doi:10.1186/s13054-019-2543-1

Hiroshi Tanaka, Yohei Hirano + Show 3 more

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https://doi.org/10.1186/s13054-019-2543-1

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Journal: Critical Care	Publication Date: Jul 25, 2019
Citations: 25	License type: open-access

Affiliation: Juntendo University Urayasu Hospital

Abstract

BackgroundWe assessed the effect of liberal versus restrictive red blood cell transfusion strategy on survival outcome in sepsis or septic shock by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs).MethodsWe searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases. We included RCTs that compared mortality between a liberal transfusion strategy with a hemoglobin threshold of 9 or 10 g/dL and a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL in adults with sepsis or septic shock. Two investigators independently screened citations and conducted data extraction. The primary outcome was 28- or 30-day mortality. Secondary outcomes were 60- and 90-day mortality, use of life support at 28 days of admission, and number of patients transfused during their intensive care unit stay. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs).ResultsA total of 1516 patients from three RCTs were included; 749 were randomly assigned to the liberal transfusion group and 767 to the restrictive strategy group. Within 28–30 days, 273 patients (36.4%) died in the liberal transfusion group, while 278 (36.2%) died in the restrictive transfusion group (pooled OR, 0.99; 95% confidence interval [CI], 0.67–1.46). For the primary outcome, heterogeneity was observed among the studies (I2 = 61.0%, χ2 = 5.13, p = 0.08). For secondary outcomes, only two RCTs were included. There were no significant differences in secondary outcomes between the two groups.ConclusionsWe could not show any difference in 28- or 30-day mortality between the liberal and restrictive transfusion strategies in sepsis or septic shock patients by meta-analysis of RCTs. Our results should be interpreted with caution due to the existence of heterogeneity. As sepsis complicates a potentially wide range of underlying diseases, further trials in carefully selected populations are anticipated.Trial registrationThis present study was registered in the PROSPERO database (CRD42018108578).

Highlights

We assessed the effect of liberal versus restrictive red blood cell transfusion strategy on survival outcome in sepsis or septic shock by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs)
We identified the studies to be included by following a research question formulated according to the participants, interventions, comparisons, and outcomes (PICO) model, as follows: P, adult (≥ 18 year old) patients admitted to the intensive care unit (ICU) with a diagnosis of sepsis or septic shock; I, liberal red blood cell (RBC) transfusion strategy; C, restrictive RBC transfusion strategy
To our knowledge, this study is the first systematic review and meta-analysis of RCTs investigating the effect of liberal versus restrictive RBC transfusion strategies on mortality in sepsis or septic shock patients. This meta-analysis included only three RCTs, the results suggested that the liberal strategy of RBC transfusion failed to show any improvement in short-term (28- or 30-day) mortality in sepsis or septic shock patients, compared to the restrictive strategy

Summary

Introduction

We assessed the effect of liberal versus restrictive red blood cell transfusion strategy on survival outcome in sepsis or septic shock by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). After the introduction of the systematic review process, the newest international guidelines for the management of sepsis and septic shock (Surviving Sepsis Campaign, 2016) recommended restrictive RBC transfusions only when the hemoglobin level decreases to < 7.0 g/dL in adult sepsis in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, or acute hemorrhage [7]. This recommendation is based on limited data from only two clinical trials, including one less-direct assessment of blood transfusion therapy [8, 9]

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