Liberal Transfusion Strategy Research Articles

Adherence to a restrictive red blood cell transfusion strategy in critically ill patients: An observational study.

Randomized controlled trials relatively consistently show that restrictive red blood cell (RBC) transfusion strategies are safe and associated with similar outcomes compared to liberal transfusion strategies in critically ill patients. Based on these data, the general threshold for RBC transfusion was changed to 70 g/L at a 9-bed tertiary level intensive care unit in September 2020. Implementation measures included lectures, webinars and feedback during clinical practice. The aim of this study was to investigate how implementation of a restrictive transfusion strategy influenced RBC usage, haemoglobin trigger levels and adherence to prescribed trigger levels. In this registry-based, observational study, critically ill adult patients without massive bleeding were included and divided into a pre-cohort, with admissions prior to the change of transfusion strategy, and a post-cohort, with admissions following the change of transfusion strategy. These cohorts were compared regarding key RBC transfusion-related variables. In total 5626 admissions were included in the analyses (pre-cohort n = 4373, post-cohort n = 1253). The median volume (interquartile range, IQR) of RBC transfusions per 100 admission days, in the pre-cohort was 6120 (4110-8110) mL versus 3010 (2890-4970) mL in the post-cohort (p < .001). This corresponds to an estimated median saving of 1128 € per 100 admission days after a restrictive RBC transfusion strategy was implemented. In total, 26% of the admissions in the pre-cohort and 19% in the post-cohort (p < .001) received RBC transfusion(s) during days 0-10. Both median (IQR) prescribed trigger levels (determined by intensivist) and actual haemoglobin trigger levels (i.e., levels prior to actual administration of transfusion) were higher in the pre- versus post-cohort (90 [80-100] vs. 80 [72-90] g/L, p < .001 and 89 [82-96] g/L vs. 83 [79-94], p < .001, respectively). Percentage of days without compliance with the prescribed transfusion trigger was higher in the pre-cohort than in the post-cohort (23% vs. 14%, p < .001). Sensitivity analyses, excluding patients with traumatic brain injury, ischemic heart disease and COVID-19 demonstrated similar results. Implementation of a restrictive transfusion trigger in a critical care setting resulted in lasting decreased RBC transfusion use and costs, decreased prescribed and actual haemoglobin trigger levels and improved adherence to prescribed haemoglobin trigger levels.

Efficacy and safety of restrictive versus liberal blood transfusion strategies in acute myocardial infarction and anemia: a systematic review and meta-analysis of randomized controlled trials.

Blood transfusion strategies in patients with acute myocardial infarction (AMI) and anemia are yet to be conclusively identified. Thus, we aim to assess the efficacy and safety of restrictive versus liberal blood transfusion strategies for AMI and anemia. A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, web of science, SCOPUS, EMBASE, and Cochrane Central Register of Controlled Trials were performed through November 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). (PROSPERO): ID: CRD42023490692. We included four RCTs with 4.325 patients. There was no significant difference between both groups regarding MACE whether at 30 days (RR: 0.93 with 95% CI [0.57-1.51], P = 0.76) or ≥ six months (RR: 1.17 with 95% CI [0.95-1.45], P = 0.14), all-cause mortality at 30 days (RR: 1.16 with 95% CI [0.95-1.40], P = 0.14) or ≥ six months (RR: 1.16 with 95% CI [0.88-1.53], P = 0.28). However, the liberal strategy was significantly associated with increased hemoglobin level change (MD: -1.44 with 95% CI [-1.68 to -1.20], P < 0.00001). However, the restrictive strategy was significantly associated with a lower incidence of acute lung injury (RR: 0.11 with 95% CI [0.02-0.60], P = 0.01). There was no significant difference between the restrictive blood transfusion strategy and the liberal blood transfusion strategy regarding the clinical outcomes. However, restrictive blood transfusion strategy was significantly associated with a lower incidence of acute lung injury than liberal blood transfusion strategy.

Restrictive vs Liberal Blood Transfusions for Patients With Acute Myocardial Infarction and Anemia by Heart Failure Status: An RCT Subgroup Analysis

BackgroundRed blood cell transfusion can cause fluid overload. We evaluated the interaction between heart failure (HF) at baseline and transfusion strategy on outcomes in acute myocardial infarction (AMI). MethodsWe used data from the randomized REALITY trial. HF was defined as history of HF or Killip class > 1 at randomization. Primary outcome was major adverse cardiovascular events (MACE): composite of all-cause death, nonrecurrent AMI, stroke, or emergency revascularization prompted by ischemia at 30 days. ResultsAmong 658 randomized patients, 311 (47.3%) had HF. Patients with HF had higher rates of MACE at 30 days and 1 year and higher rates of nonfatal new-onset HF. There was no interaction between HF and effect of randomized assignment on the primary outcome or nonfatal new-onset HF. A liberal transfusion strategy was associated with increased all-cause death at 30 days and at 1 year in patients with HF (Pinteraction = 0.009 and P = 0.049, respectively). The main numerical difference in cause of death between restrictive and liberal strategies was death by HF at 30 days (4 vs 11). ConclusionsHF is frequent in patients with AMI and anemia and is associated with higher risk of MACE (including all-cause death) and nonfatal new-onset HF. Although there was no interaction of HF with effect of transfusion strategy on MACE, a liberal transfusion strategy was associated with higher all-cause death that appears driven by a higher risk of early death caused by HF. Clinical Trial RegistrationNCT02648113.

Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial

BackgroundThe appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels.MethodsWe performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups.ResultsOf the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (β coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (β coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury.ConclusionsOur results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.

Restrictive versus Liberal Transfusion Strategies in Acute Myocardial Infarction and Anemia: A Meta-Analysis and Trial Sequential Analysis.

The optimal transfusion strategy in acute myocardial infarction (AMI)-associated anemia remains uncertain. To compare all-cause mortality between liberal versus restrictive transfusion strategies in patients with AMI-associated anemia, using a meta-analytic approach. Pubmed, Embase, and ClinicalTrials.gov were systematically searched for randomized controlled trials (RCTs) comparing liberal and restrictive transfusion strategies in AMI-associated anemia. Random-effects meta-analysis and trial sequential analysis (TSA) were conducted to compare blood use, efficacy, and safety endpoints. The p-values were 2-sided with an α of 0.05. In a pooled analysis involving 4,217 participants from three RCTs followed-up for 30 days, no statistically significant differences emerged between restrictive and liberal strategies in all-cause mortality (RR 1.03; 95% CI 0.67-1.57; p=0.90) and other efficacy endpoints (recurrent AMI, unscheduled revascularization, acute heart failure, stroke, and acute kidney injury), as well as in safety endpoints including allergic reactions, infection, and acute lung injury. TSA did not reach futility boundaries. In patients assigned to restrictive strategy, substantial differences in transfusion use were observed across RCTs, correlating with mortality rates, and likely accounting for between-study heterogeneity in treatment effects. In patients with AMI-associated anemia, there is no clear superiority between liberal and restrictive transfusion strategies in all-cause mortality or other major outcomes in 30 days. However, the heterogeneity observed in blood use between the restrictive groups likely explains variable findings across RCTs.

Estratégias de Transfusão Restritiva versus Liberal em Infarto Agudo do Miocárdio e Anemia: Metanálise e Análise Sequencial de Ensaios Clínicos

Abstract Background: The optimal transfusion strategy in acute myocardial infarction (AMI)-associated anemia remains uncertain. Objectives: To compare all-cause mortality between liberal versus restrictive transfusion strategies in patients with AMI-associated anemia, using a meta-analytic approach. Methods: Pubmed, Embase, and ClinicalTrials.gov were systematically searched for randomized controlled trials (RCTs) comparing liberal and restrictive transfusion strategies in AMI-associated anemia. Random-effects meta-analysis and trial sequential analysis (TSA) were conducted to compare blood use, efficacy, and safety endpoints. The p-values were 2-sided with an α of 0.05. Results: In a pooled analysis involving 4,217 participants from three RCTs followed-up for 30 days, no statistically significant differences emerged between restrictive and liberal strategies in all-cause mortality (RR 1.03; 95% CI 0.67–1.57; p=0.90) and other efficacy endpoints (recurrent AMI, unscheduled revascularization, acute heart failure, stroke, and acute kidney injury), as well as in safety endpoints including allergic reactions, infection, and acute lung injury. TSA did not reach futility boundaries. In patients assigned to restrictive strategy, substantial differences in transfusion use were observed across RCTs, correlating with mortality rates, and likely accounting for between-study heterogeneity in treatment effects. Conclusions: In patients with AMI-associated anemia, there is no clear superiority between liberal and restrictive transfusion strategies in all-cause mortality or other major outcomes in 30 days. However, the heterogeneity observed in blood use between the restrictive groups likely explains variable findings across RCTs.

Orthopaedic Trauma and Anemia: Conservative versus Liberal Transfusion Strategy: A Prospective Randomized Study

OBJECTIVES: To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period. METHODS: Design: Prospective, randomized, multicenter trial. Setting: Three level 1 trauma centers. Patient Selection Criteria: Patients aged 18–50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL. Outcome Measures and Comparisons: Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds. RESULTS: Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P &lt; 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2). CONCLUSIONS: A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Adherence to balanced transfusion among severely injured patients: A post hoc analysis of the RESTRIC trial.

A balanced transfusion strategy has been a standard resuscitation method for trauma patients, and adherence to a massive transfusion protocol incorporating balanced transfusion is reported to reduce mortality. This study aimed to assess adherence to balanced transfusion among severely injured patients in Japan. This study analyzes RESTRIC (restrictive transfusion strategy for critically injured patients) trial patients who were cluster-randomized based on restrictive or liberal transfusion strategy. We defined two transfusion groups: massive transfusion group 1, which includes RBC transfusions of at least eight units within 6 h; and massive transfusion group 2, which includes RBC transfusions of at least 20 units within 24 h. Adherence to balanced transfusion was assessed as the ratios of fresh frozen plasma (FFP) to red blood cells (RBC) and platelet concentrate (PC) to RBC ratio >0.5. Among 220 eligible patients, 98 (44.5%) were grouped as massive transfusion group 1 and 38 (17.3%) as massive transfusion group 2. The balanced transfusion in terms of the FFP to RBC ratio was nearly 100% for groups 1 and 2 over all periods. However, the balanced transfusion in terms of the PC to RBC ratio within 6 h were 51.0% for group 1 and 68.4% for group 2. This study revealed that while the ratio of FFP to RBC was balanced among patients from the early phase, the ratio of PC to RBC was not fully balanced, particularly in the early phase.

Is restrictive transfusion sufficient in colorectal cancer surgery? A retrospective study before and during the COVID-19 pandemic in Korea.

Blood transfusion is one of the most common procedures used to treat anemia in colorectal surgery. Despite controversy regarding the adverse effects of blood products, surgeons have maintained standards for administering blood transfusions. However, this trend was restrictive during the COVID-19 pandemic because of a shortage of blood products. In this study, we conducted an analysis to investigate whether the restriction of blood transfusions affected postoperative surgical outcomes. Medical records of 318 patients who underwent surgery for colon and rectal cancer at Ewha Womans University Mokdong Hospital between June 2018 and March 2022 were reviewed retrospectively. The surgical outcomes between the liberal and restrictive transfusion strategies in pre- and post-COVID-19 groups were analyzed. In univariate analysis, postoperative transfusion was associated with infectious complications (odds ratio [OR], 1.705; 95% confidence interval [CI], 1.015-2.865; P=0.044). However, postoperative transfusion was not an independent risk factor for the development of infectious complications in multivariate analysis (OR, 1.305; 95% CI, 0.749-2.274; P=0.348). In subgroup analysis, there was no significant association between infectious complications and the hemoglobin threshold level for the administration of a transfusion (OR, 1.249; 95% CI, 0.928-1.682; P=0.142). During colorectal surgery, the decision to perform a blood transfusion is an important step in ensuring favorable surgical outcomes. According to the results of this study, restrictive transfusion is sufficient for favorable surgical outcomes compared with liberal transfusion. Therefore, modification of guidelines is suggested to minimize unnecessary transfusion-related side effects and prevent the overuse of blood products.

MINT trial signals potential benefit of liberal transfusion strategy in MI with anaemia.

MINT trial signals potential benefit of liberal transfusion strategy in MI with anaemia.

Restrictive Versus Liberal Red Blood Cell Transfusion Strategies for Patients with Hematologic Malignancies Receiving Intensive Chemotherapy

Background: It is estimated that one-quarter to one-half of people diagnosed with hematologic malignancies experience anemia and red blood cell (RBC) transfusion plays an essential supportive role in their management. There are different strategies for RBC transfusions to treat anemia. A restrictive transfusion strategy seeks to maintain a lower hemoglobin level (usually between 70 g/L to 90 g/L with a trigger for transfusion when the hemoglobin drops below 70 g/L), whereas a liberal transfusion strategy aims to maintain a higher hemoglobin (usually between 100 g/L to 120 g/L, with a threshold for transfusion when hemoglobin drops below 100 g/L). The most effective and safest strategy is unknown in people with hematological malignancies. Objectives: To determine the efficacy and safety of a restrictive versus liberal RBC transfusion strategies for people diagnosed with hematological malignancies treated with intensive chemotherapy, radiotherapy, or both, with or without a hematopoietic stem cell transplant (HSCT). Methods: Review was completed using Cochrane standard methodological procedures. We included randomized controlled trials RCTs and prospective non-randomized studies NRS that evaluated a liberal compared with a restrictive RBC transfusion strategy in children or adults with malignant hematological disorders receiving intensive chemotherapy/radiotherapy or undergoing HSCT. We searched for RCTs and NRS in MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and eight other databases and three trial registries to 21 March 2023. For dichotomous outcomes such as mortality, results were presented as a risk ratio (RR) with 95% confidence interval (CI) to compare restrictive versus liberal transfusion strategies. For continuous outcomes using the same scale, we assessed the mean difference (MD) with 95% CI. Where outcome measures were heterogenous, a narrative synthesis was used. Review Manager Web was used to meta-analyze the data. GRADE rating methodology was used for the overall certainty of evidence from included studies. Main Results: Nine studies were included: eight RCTs and one NRS. 644 participants were included in analyses from six completed RCTs (n=560) and one completed NRS (n=84). Two ongoing RCTs consisting of 294 participants (260 adult and 34 pediatric) are pending inclusion. One completed RCT included children receiving HSCT (n=6) and five RCTs only included adults (n=239 with acute leukemia receiving chemotherapy and n=315 with a hematological malignancy receiving HSCT). The restrictive strategies varied from 70 g/L to 80 g/L and liberal strategies from 80 g/L to 120 g/L. A restrictive strategy was found to result in a reduction in the number of RBC units per participant compared to a liberal strategy (Four studies; 457 participants; MD: -2.39, 95%CI -3.38 to -1.39, P = &amp;lt;0.00001). No difference was seen in bleeding between strategies although there was high concern for bias in included trials. Effects were reported in the summary of findings tables for RCTs (Table 1) which included results from adults only to reduce indirectness as a result of limited information from the single published pediatric RCT which was terminated early. Overall, a restrictive RBC transfusion strategy may result in little to no difference in the risk of death at 31 to 100 days compared to a liberal transfusion strategy (three studies; 382 participants; RR 0.74, 95% CI 0.13 to 4.09, P= 0.73; I 2=28%; low-certainty evidence). Two outcomes (mortality at 31 to 100 days and clinically significant bleeding) were reported from the one NRS (Table 2). The evidence is very uncertain whether there is a difference in mortality and clinically significant bleeding between the transfusion strategies based on the very low-certainty evidence. Conclusions: A restrictive transfusion strategy demonstrated a reduction in RBC usage, while there may be no impact on mortality. Definite conclusions are challenging given the relatively few studies with low numbers of included participants, concern for bias, heterogeneity of intervention and outcome reporting and overall certainty of evidence. There is a need for larger and methodologically better designed and executed studies. There is insufficient evidence to answer this review's primary outcome. Further RCTs are required overall, particularly trials inclusive of pediatric participants.

Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia

BackgroundA strategy of administering a transfusion only when the hemoglobin level falls below 7 or 8 g per deciliter has been widely adopted. However, patients with acute myocardial infarction may benefit from a higher hemoglobin level.MethodsIn this phase 3, interventional trial, we randomly assigned patients with myocardial infarction and a hemoglobin level of less than 10 g per deciliter to a restrictive transfusion strategy (hemoglobin cutoff for transfusion, 7 or 8 g per deciliter) or a liberal transfusion strategy (hemoglobin cutoff, <10 g per deciliter). The primary outcome was a composite of myocardial infarction or death at 30 days.ResultsA total of 3504 patients were included in the primary analysis. The mean (±SD) number of red-cell units that were transfused was 0.7±1.6 in the restrictive-strategy group and 2.5±2.3 in the liberal-strategy group. The mean hemoglobin level was 1.3 to 1.6 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group on days 1 to 3 after randomization. A primary-outcome event occurred in 295 of 1749 patients (16.9%) in the restrictive-strategy group and in 255 of 1755 patients (14.5%) in the liberal-strategy group (risk ratio modeled with multiple imputation for incomplete follow-up, 1.15; 95% confidence interval [CI], 0.99 to 1.34; P=0.07). Death occurred in 9.9% of the patients with the restrictive strategyand in 8.3% of the patients with the liberal strategy (risk ratio, 1.19; 95% CI, 0.96 to 1.47); myocardial infarction occurred in 8.5% and 7.2% of the patients, respectively (risk ratio, 1.19; 95% CI, 0.94 to 1.49).ConclusionsIn patients with acute myocardial infarction and anemia, a liberal transfusion strategy did not significantly reduce the risk of recurrent myocardial infarction or death at 30 days. However, potential harms of a restrictive transfusion strategy cannot be excluded. (Funded by the National Heart, Lung, and Blood Institute and others; MINT ClinicalTrials.gov number, NCT02981407.)

Effect of a restrictive vs. liberal blood transfusion strategy among patients with acute myocardial infarction and anemia according to heart failure. A subgroup analysis of the REALITY trial

Abstract Background/Introduction The optimal Red Blood Cell (RBC) transfusion strategy in patients with acute myocardial infarction (MI) and anemia remains debated. In REALITY, the largest randomized trial to date in this population (n=666), a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days, but did not achieve non-inferiority at 1 year. One of the main concerns with RBC transfusion is the risk of fluid overload and acute heart failure (HF). Therefore, the balance of benefit and risk of transfusions strategies may differ between patients with and without heart failure. Purpose We aimed to evaluate the potential interaction between HF and RBC transfusion on outcomes in REALITY. Methods HF was defined as either a history of heart failure or Killip class &amp;gt; 1 at randomization (data available for 658 patients). All events until day 30, including HF, were adjudicated by a Critical Event Committee blinded to the transfusion arm and hemoglobin levels. The primary clinical outcome was MACE at 30 days. Secondary endpoints included MACE at one year, individual components of MACE and new onset of heart failure at 30 days and 1 year. Results Among 658 patients, 311 (47.3 %) had HF. HF patients had a higher rate of MACE and a higher rate of new HF than patients without HF at 30 day and at 1 year (Fig 1). There was no interaction between HF and the effect of randomized assignment on the primary outcome or on new HF. In contrast, a liberal strategy was associated with increased all-cause death at 30 days and at 1 year in patients with HF but not in pts without HF (interaction p = 0.0088 and p = 0.049 respectively, Fig 1). Conclusion(s) Heart failure is frequent in MI patients with anemia (nearly half of the patients) and is associated with higher risks of MACE and of HF. While no interaction was observed between HF and transfusion strategies on the primary outcome of MACE, a liberal transfusion strategy was associated with higher all-cause mortality than a restrictive strategy both at 30-days and 1 year. The mechanism of this interaction deserves further investigation.

A Prospective Observational Study of Preoperative Anaemia Management Aided by Bedside Haemoglobin Testers in a Low-Resource Setting

AimPaediatric-preoperative anaemia management is challenging in settings where clinical judgment is used to diagnose anaemia owing to a lack of timely, affordable preoperative haemoglobin testing. We analysed anaemia management in such a setting after the introduction of point-of-care bedside haemoglobin testers. Method1033 children who underwent surgery at a hospital in Bangladesh were included in this study. 569 underwent major surgery, and 464 underwent minor surgery and belonged to predominantly ASA category 1 or 2. Results940/1033 children underwent preoperative anaemia testing. Average haemoglobin was 11.7 g/dL. 103/1033 children were deemed clinically anaemic. However, 285 children were found to have anaemia based on bedside testing. Sensitivity of clinical judgement was 33.68% (95 % CI 28.22%–39.49%), and the specificity was 99.08% (95 % CI 98.02%–99.66%). 63/1033 had preoperative anaemia treatment, of whom 60 underwent transfusion.Subgroup analysis of children with haemoglobin <10 g/dL (n = 124) was done to compare conservative vs liberal transfusion strategy. 43/124 of this subset was transfused. Average length of stay for those transfused was 11.7 days, and those who weren't was 9.9 days (p = 0.087). 4 patients in the transfused subgroup required post-op ICU, and only 1 patient in the conservatively managed arm required ICU (p = 0.048). ConclusionThis study demonstrates the positive impact of bedside haemoglobin testers as they have resulted in a significantly higher proportion of children diagnosed with anaemia at a fraction of the cost and logistics involved in laboratory testing. Further research on haemoglobin thresholds is required to understand the safety and long-term impact of restrictive transfusion in the surgical context. Level of evidence2c (Grading as per the Oxford Centre for Evidence Based Medicine).

Potential benefits of restrictive transfusion in upper gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials

The optimal red blood cell (RBC) transfusion strategy in acute gastrointestinal bleeding (GIB) is debated. We aimed to assess the efficacy and safety of restrictive compared to liberal transfusion strategies in the GIB population. We searched PubMed, CENTRAL, Embase, and Web of Science for randomised controlled trials on 15.01.2022 without restrictions. Studies comparing lower to higher RBC transfusion thresholds after GIB were eligible. We used the random effect model and calculated pooled mean differences (MD), risk ratios (RR) and proportions with 95% confidence intervals (CI) to calculate the overall effect size. The search yielded 3955 hits. All seven eligible studies reported on the upper GIB population. Restrictive transfusion did not increase the in-hospital- (RR: 0.94; CI 0.46, 1.94) and 30-day mortality (RR: 0.71; CI 0.35, 1.45). In-hospital- and 28 to 45-day rebleeding rate was also not higher with the restrictive modality (RR: 0.67; CI 0.30, 1.50; RR:0.75; CI 0.49, 1.16, respectively). Results of individual studies showed a lower rate of transfusion reactions and post-transfusion intervention if the transfusion was started at a lower threshold. A haemoglobin threshold > 80 g/L may result in a higher untoward outcome rate. In summary, restrictive transfusion does not appear to lead to a higher rate of significant clinical endpoints. The optimal restrictive transfusion threshold should be further investigated.

An analysis of quality of life and functional outcomes as reported in randomized trials for red cell transfusions.

Meta-analyses of randomized controlled trials (RCTs) evaluating thresholds for red blood cell (RBC) transfusion typically focus on mortality; however, other outcomes are highly relevant. The aim of this study is to summarize the effects of different transfusion thresholds on the outcomes of quality of life (QoL) and function. We extracted data from RCTs identified in a recently published Cochrane systematic review. Primary analysis was descriptive. A total of 23 RCTs with 13,743 adult participants were included. Fifteen RCTs included patients in the postoperative period, of which 9 RCTs were conducted in hip (n = 3024) and 6 (n = 8672) in cardiac surgeries; 5 RCTs (n = 489) were in patients with hematological malignancies; 2 in the setting of bleeding (gastrointestinal bleed [n = 936] and postpartum [n = 521]); and one RCT (n = 936) included critically ill patients. QoL and function were reported using a variety of questionnaires and tools. The timing of assessments varied between trials. No clear clinical differences in QoL outcomes were identified in comparisons between restrictive and liberal transfusion thresholds. There is no evidence that a liberal transfusion strategy improves QoL and functional outcomes. However, the substantial limitations of many included studies indicate the need for further well-designed and adequately powered trials.

The Restrictive Red Blood Cell Transfusion Strategy for Critically Injured Patients (RESTRIC) trial: a cluster-randomized, crossover, non-inferiority multicenter trial of restrictive transfusion in trauma.

The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7-9 or 10-12g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49-2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.

Restrictive vs liberal blood transfusion strategy for patients with burn trauma: a systematic review and meta-analysis

British Journal of Hospital MedicineVol. 84, No. 5 PosterRestrictive vs liberal blood transfusion strategy for patients with burn trauma: a systematic review and meta-analysisValerie J Dirjayanto, Jasmine V Anjani, Tazkiya P Ariviani, Febriyan N Satria, Raisa ZM Abubakar, Cut A Rhania, Muhammad A ArsyafValerie J DirjayantoCorrespondence to: Valerie J Dirjayanto; E-mail Address: [email protected]Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Jasmine V AnjaniFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Tazkiya P ArivianiFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Febriyan N SatriaFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Raisa ZM AbubakarFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Cut A RhaniaFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this author, Muhammad A ArsyafFaculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UKFaculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaSearch for more papers by this authorValerie J Dirjayanto; Jasmine V Anjani; Tazkiya P Ariviani; Febriyan N Satria; Raisa ZM Abubakar; Cut A Rhania; Muhammad A ArsyafPublished Online:4 May 2023https://doi.org/10.12968/hmed.2023.0144AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Docherty AB, O’Donnell R, Brunskill S et al. 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Transfusion thresholds: the need for a patient-centered approach in hematologic disorders that require chronic transfusion therapy.

Transfusion is an essential life-sustaining treatment for many patients. However, unnecessary transfusion has been reported to be related to worse patient outcomes. Further, owing to the recent pandemic, blood supply has been more challenging to maintain. Many studies have been conducted to elucidate the optimal transfusion threshold for many clinical conditions, and most suggested that a restrictive transfusion strategy has advantages over a liberal transfusion strategy. Hematologic disorders, which require chronic transfusion in many cases, have not been the main subjects of such studies, and only little evidence is available regarding the optimal transfusion threshold in these patients. According to several recent studies, a liberal transfusion strategy is preferable for patients with hematologic disorders due to their quality of life. A patient-centered approach is needed for proper management of hematologic disorders.

Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial

BackgroundThere is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events. MethodsA two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year. ResultsThe primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups. ConclusionsThe TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms.TRIAL REGISTRATION: http://clinicaltrials.gov identifier: NCT03229941