title: Transfusion triggers for guiding RBC transfusion for cardiovascular surgery: a systematic review and meta-analysis*.
abstract: OBJECTIVE
  Restrictive red cell transfusion is recommended to minimize risk associated with exposure to allogeneic blood. However, perioperative anemia is an independent risk factor for adverse outcomes after cardiovascular surgery. The purpose of this systematic review and meta-analysis is to determine whether perioperative restrictive transfusion thresholds are associated with inferior clinical outcomes in randomized trials of cardiovascular surgery patients.
  
  
  METHODS
  The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from inception to October 2013; reference lists of published guidelines, reviews, and associated articles, as well as conference proceedings. No language restrictions were applied.
  
  
  METHODS
  We included controlled trials in which adult patients undergoing cardiac or vascular surgery were randomized to different transfusion thresholds, described as a hemoglobin or hematocrit level below which RBCs were transfused.
  
  
  METHODS
  Two authors independently extracted data from included trials. We pooled risk ratios of dichotomous outcomes and mean differences of continuous outcomes across trials using random-effects models.
  
  
  RESULTS
  Seven studies (enrolling 1,262 participants) met inclusion criteria with restrictive and liberal transfusion thresholds most commonly differing by a hemoglobin of 1 g/dL or hematocrit of 6-7%, resulting in decreased transfusions by 0.71 units of RBCs (95% CI, 0.31-1.09, p = 0.0002) without an associated change in adverse events: mortality (risk ratio, 1.12; 95% CI, 0.65-1.95; p = 0.60), myocardial infarction (risk ratio, 0.94; 95% CI, 0.30-2.99; p = 0.92), stroke (risk ratio, 1.15; 95% CI, 0.57-2.32; p = 0.70), acute renal failure (risk ratio, 0.98; 95% CI, 0.64-1.49; p = 0.91), infections (risk ratio, 1.23; 95% CI, 0.85-1.78; p = 0.27), or length of stay. There was no between-trial heterogeneity for any pooled analysis. Including four pediatric trials (456 participants) and 10 trials utilizing only intraoperative acute normovolemic hemodilution (872 participants) did not substantially change the results except that unlike the transfusion threshold trials, the hemodilution trials did not reduce the proportion of patients transfused (interaction p = 0.01).
  
  
  CONCLUSIONS
  Further randomized controlled trials are necessary to determine the optimal transfusion strategy for patients undergoing cardiovascular surgery.
authors.affiliation: 1Departments of Anesthesia and Critical Care, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. 2Departments of Medicine and Laboratory Medicine and Pathobiology (Mount Sinai Hospital), Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. 3Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. 4Departments of Critical Care and Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Gerard F
authors.initials: GF
authors.lastname: Curley
authors.forename: Nadine
authors.initials: N
authors.lastname: Shehata
authors.forename: C David
authors.initials: CD
authors.lastname: Mazer
authors.forename: Gregory M T
authors.initials: GM
authors.lastname: Hare
authors.forename: Jan O
authors.initials: JO
authors.lastname: Friedrich
mesh_terms: D013504:Cardiovascular Surgical Procedures / Q000379:methods* / Q000401:mortality*; D017707:Erythrocyte Transfusion / Q000379:methods*; D006400:Hematocrit; D006438:Hemodilution; D006454:Hemoglobins; D006801:Humans; D007902:Length of Stay; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology* / Q000401:mortality; D016032:Randomized Controlled Trials as Topic
chemical_list: D006454:Hemoglobins