A restrictive transfusion strategy in adult cardiac surgery does not alter mortality or complications.

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• Hessam H Kashani, Carly Lodewyks, Morvarid S Kavosh, Maya M Jeyaraman, Christine Neilson, George Okoli, Rasheda Rabbani, Ahmed M Abou-Setta, Ryan Zarychanski, and Hilary P Grocott.
• Department of Anesthesiology, Perioperative and Pain Medicine, St. Boniface Hospital, University of Manitoba, CR3008-369 Tache Ave, Winnipeg, MB, R2H 2A6, Canada.
• Can J Anaesth. 2020 May 1; 67 (5): 577-587.

PurposeBlood transfusions are frequently administered in cardiac surgery. Despite a large number of published studies comparing a "restrictive" strategy with a "liberal" strategy, no clear consensus has emerged to guide blood transfusion practice in cardiac surgery patients. The purpose of this study was to identify, critically appraise, and summarize the evidence on the overall effect of restrictive transfusion strategies compared with liberal transfusion strategies on mortality, other clinical outcomes, and transfusion-related outcomes in adult patients undergoing cardiac surgery.SourceWe searched MEDLINE (OvidSP), EMBASE (OvidSP) and Cochrane CENTRAL (Wiley) from inception to 1 December 2017 and queried clinical trial registries and conference proceedings for randomized-controlled trials of liberal vs restrictive transfusion strategies in cardiac surgery.Principal FindingsFrom 7,908 citations, we included ten trials (9,101 patients) and eight companion publications. Overall, we found no significant difference in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; 95% confidence interval [CI], 0.76 to 1.54; I2 = 33%; seven trials; 8,661 patients). The use of a restrictive transfusion strategy did not appear to adversely impact any of the secondary clinical outcomes. As expected, the proportion of patients who received red blood cells (RBCs) in the restrictive group was significantly lower than in the liberal group (RR, 0.68; 95% CI, 0.64 to 0.73; I2 = 56%; 5 trials; 8,534 patients). Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy.ConclusionsIn adult patients undergoing cardiac surgery, a restrictive transfusion strategy reduces RBC transfusion without impacting mortality rate or the incidence of other perioperative complications. Nevertheless, further large trials in subgroups of patients, potentially of differing age, are needed to establish firm evidence to guide transfusion in cardiac surgery.Trial RegistrationPROSPERO (CRD42017071440); registered 20 April, 2018.

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