Modified ultrafiltration reduces postoperative blood loss and transfusions in adult cardiac surgery: a meta-analysis of randomized controlled trials

 Open in a separate windowOBJECTIVESCardiopulmonary bypass in cardiac surgery has been associated with several deleterious effects including haemodilution and systemic inflammation. Modified ultrafiltration (MUF) has been well established in paediatric cardiac surgery in counteracting postperfusion syndrome. However, MUF is less commonly used in adult cardiac surgery. In this meta-analysis, we compared clinical outcomes in adult patients who underwent cardiopulmonary bypass with and without MUF.METHODSElectronic searches were performed using Pubmed, Ovid Medline, EMBASE and the Cochrane Library until April 2020. Selection criteria were randomized studies of adult cardiac surgery patients comparing MUF versus no MUF. Primary outcomes were postoperative mortality, haematocrit, blood transfusion, chest tube drainage, duration of intensive care unit (ICU) stay and duration of mechanical ventilation.RESULTSThirteen randomized controlled trials were included, comprising 626 patients in the MUF group, and 610 patients in the control (no-MUF) group. There was a significantly improved postoperative haematocrit [mean difference 2.70, 95% confidence interval (CI) 0.68–4.73, P = 0.009], lower chest tube drainage (mean difference −105 ml, 95% CI −202 to −7 ml, P = 0.032), lower postoperative blood transfusion rate (mean difference −0.73 units, 95% CI −0.98 to −0.47 units, P < 0.0001) and shorter duration of ICU stay (mean difference −0.13 days, 95% CI −0.27 to −0.00 days, P = 0.048) in the MUF group. There was no difference in ventilation time (mean difference −0.47 h, 95% CI −2.05 to 1.12 h, P = 0.56) or mortality rates (odds ratio 0.62, 95% CI 0.28–1.33, P = 0.22). There were no reported complications associated with MUF.CONCLUSIONSMUF is a safe and feasible option in adult cardiac patients, with significant benefits including improved postoperative haematocrit, as well as reduced postoperative chest tube bleeding, transfusion requirements and duration of ICU stay.     

负压封闭引流技术与常规换药方法治疗四肢创面疗效比较的Meta分析

目的 对负压封闭引流(VSD)技术与常规换药方法治疗四肢创面的疗效比较进行Meta分析,为四肢创面的修复提供参考依据. 方法 搜索Pubmed、Cochrane图书馆、EMBASE、CNKI、万方数据库等,检索从建库至2012年4月比较VSD技术与常规换药方法治疗四肢创面的中、英文随机对照研究和临床对照研究,纳入满足要求的文献,选择创面愈合时间、换药次数和住院时间作为Meta分析的评价指标,采用RevMan5.1进行分析.结果 共纳入8项研究529例患者,其中随机对照研究5篇,临床对照研究3篇.Meta分析结果显示:与常规换药方法相比,VSD技术治疗四肢创面可缩短创面愈合时间[MD=-6.80,95％ CI(-9.17,-4.43),P＜0.05]、减少换药次数[MD=-12.08,95％ CI( - 15.91,-8.25),P＜0.05]、缩短住院时间[MD=- 8.57,95％CI( - 12.08,-5.06),P＜0.05],两种方法比较差异均有统计学意义. 结论 VSD技术治疗四肢创面的创面愈合时间、换药次数和住院时间等指标均优于常规换药方法.     

The role of prophylactic fresh frozen plasma in decreasing blood loss and correcting coagulopathy in cardiac surgery. A systematic review

Summary Fresh frozen plasma is commonly used in cardiac surgery in an attempt to replace clotting factors and to decrease bleeding. Despite this, there has been no previous review of the available literature to support this practice. The aim of this review was to study the effect of prophylactic peri-operative transfusion of fresh frozen plasma on bleeding and coagulopathy in patients undergoing cardiac surgery. A comprehensive literature search was performed and all randomised controlled trials of the use of fresh frozen plasma in cardiac surgery were included. Six small trials were found that included a total of 363 participants with six different dose regimens of fresh frozen plasma. The overall quality of the studies was poor due to small patient numbers and lack of allocation concealment. There was no evidence that the prophylactic use of fresh frozen plasma affected peri-operative blood loss in cardiac surgery. There was some evidence that it may improve platelet count and fibrinogen concentration.     

Laparoscopic vs conventional appendectomy – a meta-analysis of randomised controlled trials

Aim: To compare the effectiveness and safety of laparoscopic and conventional “open” appendectomy in the treatment of acute appendicitis. Methods: Meta-analysis of randomised controlled trials available by May 1998 that compared both techniques. Within each trial and for each outcome an effect size was calculated; the effect sizes were then pooled by a random-effects model. Results: We summarised outcome data of 2877 patients included in 28 trials. Operating time was +16 min (95% confidence interval +12–20 min) longer for laparoscopic appendectomy. Overall complication rates were comparable, but wound infections were definitely reduced after laparoscopy [rate difference –4.2%, (–2.3% to –6.1%)]. Intra-abdominal abscesses, however, occurred slightly more frequently [+0.9%, (–0.4% to +2.3%)]. Hospital stay after laparoscopic appendectomy was 15 h (8–23 h) shorter, and patients returned to full fitness or work 7 days (5–9 days) earlier. Pain intensity on day 1 was slightly less. Heterogeneity was present for some outcome measures due to methodological differences among the primary studies. Conclusion: Laparoscopic appendectomy reduces wound infections and eases postoperative recovery. Nevertheless, the various differences among the primary studies and their partly flawed methodology make it difficult to generalise from these findings. Received: 25 May 1998     

赛洛多辛治疗良性前列腺增生安全性和有效性的Meta分析

目的 采用Meta分析方法评价赛洛多辛治疗BPH的安全性和有效性.方法 制定原始文献的纳入标准、排除标准及检索策略,检索MEDIINE(1966-2012年)、EMBASE(1988-2012年)、Cochrane图书馆、中国生物医学期刊文献数据库(1979-2012年),CNK1数字图书馆(1979-2012年)有关赛洛多辛治疗BPH的随机对照研究(RCT),利用RevMan软件进行固定效应模型和随机效应模型的Meta分析.计算合并效应尺度以标准均数差(standard mean difference,SMD)及其95％可信区间(95％ CI)表示.结果 共纳入4篇文献,包括2543例患者,包含3个赛洛多辛与安慰剂比较的RCT和3个赛洛多辛与坦索罗辛比较的RCT.患者使用赛洛多辛后,总IPSS(SMD=2.92,95％ CI =2.19 ～3.65)、排尿期IPSS(SMD=1.92,95％ CI=1.44 ～ 2.39)、储尿期IPSS(SMD=0.92,95％ CI=0.60 ～ 1.24)和Qmax(SMD=1.56,95％ CI=1.38 ～ 1.75)与安慰剂组比较差异均有统计学意义(P＜0.05);主要不良反应是异常射精.与0.2 mg坦索罗辛相比,8 mg赛洛多辛可以更有效地改善IPSS和Qmax(P＜0.05);以异常射精为主的不良反应也较明显(SMD=1.37,95％ CI=1.18～1.58,P＜0.05).与0.4 mg坦索罗辛相比,8 mg赛洛多辛治疗BPH的有效性和总体不良反应的发生率差异无统计学意义(SMD =1.21,95％ CI =0.98 ～ 1.49,P＞0.05).结论 赛洛多辛治疗BPH引起的下尿路症状较安慰剂和0.2 mg坦索罗辛更有效,与0.4 mg坦索罗辛作用相当.赛洛多辛的主要不良反应为异常射精.     

Aprotinin reduces postoperative bleeding and the need for blood products in thoracic surgery: results of a randomized double-blind study

Objective: Bleeding complications have been a major concern in certain thoracic surgery operations, especially decortication and pulmonary resection for inflammatory pulmonary infection. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood consumption. Methods: Use of blood products (packed red cells, whole blood), chest tube drainage, analgesic requirement, chest tube duration for the patients undergoing major thoracic operations were recorded. In a double blind randomized fashion, patients were assigned to two groups receiving aprotinin (n=51) at a loading dose of 10⁶ kallikrein inhibitory units (KIU) followed by an infusion of the same dose during chest closure or receiving placebo (n=52). On a daily basis, red-cell percentages of total fluid from drainage bottles were recorded and using the blood hematocrit level of the patient of the day before, the corrected value for the patient's blood volume equivalent of daily drainage was calculated. Results: There was a significant reduction in perioperative use of donor blood (0.98±0.92 vs. 0.45±0.32 unit; P=0.0026), and total chest tube drainage (corrected value for the corresponding blood volume) (28.2±36.9 vs. 76.9±53.3 ml, P=0.0004) (mean±standard deviation) in the aprotinin group. However, aprotinin did not reduce postoperative transfusion or decrease in hematocrit level due to thoracic operations. In high transfusion-risk thoracic surgery patients (patients who underwent decortication, pulmonary resection for inflammatory lung disease and chest wall resection), the perioperative transfusion was only 0.50±1.08 units in aprotinin group, compared with 1.94±0.52 units in control group (P=0.003). Postoperative transfusion was also reduced in aprotinin administrated group (0.53±0.56 vs. 1.38±0.97 units; P=0.02). The mean total blood loss was decreased to nearly one third of the blood loss of the control group (41±28 ml vs. 121±68 ml; P=0.001). Conclusion: Aprotinin significantly reduced perioperative transfusion requirement and postoperative bleeding during major thoracic operations. Aprotinin decreased perioperative transfusion needs. Moreover, patients who were at risk of greater blood loss during and after certain thoracic operations had a greater potential to benefit from prophylactic perioperative aprotinin treatment.     

单纯减压与减压融合术治疗老年退行性腰椎管狭窄症的Meta分析

目的对单纯减压术与减压融合术治疗老年退行性腰椎管狭窄症进行Meta分析。方法计算机检索Pub Med、Embase、Cochrane图书馆、万方数据库和中国期刊全文数据库中2016年2月以前的相关文献。根据纳入与排除标准,由2名研究者分别独立筛选文献,按照Cochrane偏倚风险评估工具严格进行质量评估,并利用Rev Man 5.2软件对相关结局指标(总体疗效、手术时间、术中出血量、并发症发生率、二次手术率)进行Meta分析。结果纳入9篇符合纳入标准的随机对照试验,共964例,单纯减压组580例,减压融合组384例。Meta分析结果显示,与减压融合组比较,单纯减压组手术时间和术中出血量明显更少,差异有统计学意义(P0.05);而2组在术后总体疗效、并发症发生率和二次手术率方面差异无统计学意义(P0.05)。结论单纯减压和减压融合术治疗老年退行性腰椎管狭窄症的疗效相当,但单纯减压术具有手术创伤小、出血量少、手术时间短、术后康复快的优点。     

昂丹司琼预防妇科腹腔镜手术恶心呕吐的Meta分析

目的 系统评价昂丹司琼预防妇科腹腔镜全麻术后恶心呕吐(postoperative nausea and vomiting,PONV)的有效性和安全性. 方法 电子检索中国学术期刊全文数据库(CNKI)、中国生物医学文献数据库(CBM)、重庆维普中文科技期刊全文数据库、万方数据库、Pubmed、Springer、Embase、Web of knowledge数据库,并查阅所获文献的参考文献,收集1995～2012年发表的有关昂丹斯琼预防妇科腹腔镜全麻PONV的随机对照试验(randomized controlled trials,RCTs).按Cochrane Handbook5.0.1对纳入文献进行质量评价和资料提取,统计学分析采用Stata11.0软件. 结果共纳入18个RCT,包括1 597例患者.Meta分析结果显示:①有效性:昂丹司琼单次静脉注射能降低妇科腹腔镜全麻PONV的发生率[(RR=0.210,95％CI=0.164～0.268)];昂丹司琼4 mg与8 mg单次静脉注射对预防妇科腹腔镜全麻术后患者24 h PONV效果相当[(RR=0.948,95％CI=0.433～2.075)];手术前期应用昂丹司琼较术毕应用患者PONV发生率更低[(RR=0.450,95％CI=0.290～0.698)];昂丹斯琼4 mg或氟哌利多1.25 mg～2 mg静脉注射患者术后24 h PONV发生率相同[(RR=1.36,95％CI=0.74～2.51)];昂丹司琼联合氟哌利多静脉注射预防术后PONV发生较单独使用昂丹司琼效果更好[(RR=3.56,95％CI=1.74～7.29)].②安全性:昂丹司琼静脉注射不增加头痛、低热的发生率. 结论 昂丹司琼4 mg术前静脉注射能明显降低妇科腹腔镜全麻PONV的发生率,但并不能降低头痛、低热等副作用的发生率.昂丹司琼联合小剂量氟哌利多静脉注射较单独使用昂丹司琼对预防妇科腹腔镜全麻PONV的发生效果更好.     

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

ObjectiveEarly excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.MethodsPatients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.ResultsTwenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).DiscussionThis study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.     

Risks of perioperative blood transfusions

It has been estimated that up to 40% of blood transfusions are given to surgical patients. Despite transfusion being safer than it ever has been, it still poses significant risk. These can be heightened in the perioperative period when identifying complications can also be more challenging. This article outlines the risks associated with perioperative transfusions and discusses the current recommendations for transfusion and use of alternatives to blood transfusion.     

Risks of perioperative blood transfusions

It has been estimated that up to 40% of blood transfusions are given to surgical patients. Despite transfusion being safer than it ever has been, it still poses significant risks. These can be enhanced in the perioperative period where identifying complications can also be more challenging. This article outlines the risks associated with perioperative transfusions and discusses the current recommendations for transfusion and use of alternatives to blood transfusion.     

Autotransfusion of washed shed mediastinal fluid decreases the requirement for autologous blood transfusion following cardiac surgery: a prospective randomized trial

Objectives: The National Blood Service issues 2.2 million units of blood per year, 10% of these (220 000) are utilized in cardiac procedures. Transfusion reactions, infection risk and cost should stimulate us to decrease this transfusion rate. We test the efficacy of autotransfusion following surgery in a prospective randomized trial. Methods: One hundred and twelve patients undergoing CABG, valve or CABG+valve procedures were randomized into two groups. Group A received washed postoperative drainage fluid and group C were controls. The indication for transfusion was a postoperative haemoglobin (Hb) <10 g/l or a PCV<30. There was no significant difference in preoperative and operative variables between the groups. Results: Twenty-eight patients in group A and 46 in group C required homologous transfusion (P=0.0008). Group A patients required 298±49 ml of banked blood per patient, group C 508±49 ml (P=0.003). There was no difference in total blood required (volume autotransfused+volume banked blood transfused) between the groups (group A 404±50 ml, group C 508±50 ml) or in mean total mediastinal fluid drainage (group A 652±51 ml, group C 686±50ml). The mean Hb concentration was significantly higher in group A on day 1 (11.2 g/dl±51 vs.10.6 g/dl±13 (P=0.002)). No morbidity was associated with autotransfusion. Conclusion: Autotransfusion can decrease the amount of homologous blood transfused following cardiac surgery. This represents a benefit to the patient and a decrease in cost to the health service.     

Tranexamic acid reduces postoperative blood loss of degenerative lumbar instability with stenosis in posterior approach lumbar surgery: a randomized controlled trial

Study design

This study is randomized controlled trial.

Purpose

To evaluate the effect of tranexamic acid (TXA) on reducing postoperative blood loss in posterior approach lumbar surgery for degenerative lumbar instability with stenosis.

Methods

Sixty patients with degenerative lumbar instability with stenosis were randomized into TXA and control groups, receiving 15 mg/kg body weight of TXA or placebo (0.9 % Sodium chloride solution) intravenously, respectively, before the skin incision was made. The operation of pedicle screw system fixation was performed for all patients, and then selective laminectomy and posterior lumbar interbody fusion (PLIF) were carried out. Intraoperative and postoperative blood loss were compared between the two groups. And the complication of TXA was also investigated.

Results

There were no statistically significant differences between the TXA and control groups in terms of age, sex, body mass index, and operation time. There was no significantly difference in intraoperative blood loss between the two groups. However, in the TXA group, postoperative blood loss was significantly lower than that in the control group (13.0 %). Especially, postoperative blood loss during the first 12 h was reduced by 29.9 % as compared to the control group. There were no thromboembolic events or other complications occurred in either group.

Conclusions

Preoperative single-dose TXA can significantly reduce postoperative blood loss in posterior approach lumbar surgery, and there were no significant side effects.     

血红蛋白靶目标值对慢性肾脏病患者生存影响的荟萃分析

目的 探讨血红蛋白(Hb)水平对慢性肾脏病(CKD)患者生存时间的影响,为明确CKD患者最佳Hb靶目标值提供参考依据.方法 采用荟萃分析的方法,利用Medline、Embase和Cochrane数据库检索国内外公开发表的有关Hb水平对CKD患者生存影响的临床试验,通过Cochrane协作网提供的Revman软件对检索结果进行荟萃分析.结果 纳入本次荟萃分析的文献共23篇,随访样本总量10 204例.综合分析后发现,与低Hb(Hb＜100 g/L)水平组患者相比,维持高Hb(Hb＞127 g/L)水平可增加患者死亡及发生高血压、中风及住院治疗的风险,相对危险度(RR)值分别为1.10、1.40、1.73和1.07,两组比较差异均有统计学意义(P＜ 0.05).但两组非致命性心肌梗死(RR=1.13,95％CI 0.79～1.62)及肾脏替代治疗(RR=1.00,95％CI 0.85～1.18)的发生率差异均无统计学意义.结论 在纠正CKD患者贫血过程中,维持低Hb水平可以降低患者发生高血压、中风、入院治疗和死亡的风险,但不能改善心肌梗死发生及肾脏替代治疗的风险.     

Amniotic membrane for treating skin graft donor sites: A systematic review and meta-analysis

ObjectiveTo evaluate the efficacy and safety of amniotic membrane (AM) for the healing of split-thickness skin graft donor sites (STSGDS).MethodElectronic search of PubMed, Cochrane library and EMBASE for randomized controlled trials (RCTs) or non-randomized clinical trials (NRCTs) of AM therapy in STSGDS. Review Manager5.3 was utilized to analyze and present the data.ResultsSeven studies with 219 patients were included. Compared with other treatments, the mean difference (MD) in healing time was −3.87 days (95% CI −4.39, −3.35; P < 0.00001); Relative risk for the healing rate was 1.61 (95% CI 0.0.47–5.47; P = 0.44); There was no statistical difference in the sensation of pain (P > 0.05); The relative risk for infection rate was 0.66 (95% CI 0.29, 2.18; I² = 0%; P = 0.65).ConclusionThis systematic review and meta-analysis indicate that it is effective and safe to use AM for treating STSGDS.     

Electrolyte and acid-base disturbances caused by blood transfusions

The effect of blood transfusions on the electrolyte, metabolic and hemodynamic status of 31 patients undergoing major laparotomies was studied. Two groups were compared: Group I, 11 patients receiving continuous intraoperative blood transfusions exceeding 5 units at a rate over 0.3 ml/kg/min, and Group II, 20 patients receiving transfusions of 1-5 units at a rate below the limit. Transiently increased potassium values (5.2 +/- 0.3 mmol/l) were found in Group I during the rapid transfusion phase. The difference was statistically significant (P less than 0.05) when compared to Group II (4.3 +/- 0.2 mmol/l). There was also a significant correlation (r = 0.64; P less than 0.05) between the increase in serum potassium concentrations and the respective potassium load caused by the blood transfused. Most of the hyperpotassemic patients had surgery of the abdominal aorta. During the rapid transfusion, the patients in Group I had significantly lower concentrations of serum ionized calcium (P less than 0.05) and higher central venous pressures (P less than 0.05), but more periods of hypotension when compared to Group II. After the transfusion the massively transfused patients had slight metabolic alcalosis, the BE and pH differing significantly (P less than 0.05) from the values of Group II. It is concluded that hyperpotassemia may occur during rapid transfusions (over 0.4 ml/kg/min) of stored blood, especially in patients undergoing surgery of the abdominal aorta, even without simultaneous shock, acidosis or hypothermia. Calcium administration may be of benefit especially in situations where combined hyperpotassemia and hypocalcemia reduce the myocardial performance.     

单切口微创与传统全髋置换术疗效比较的Meta分析

目的应用Meta分析系统总结评价单切口微创与传统全髋关节置换术的临床疗效。方法计算机检索2000年1月至2011年5月间PubMed、Embase、Cochrane图书馆、Elsevier、Springer、CNKI、万方、维普数据库,并手工补充检索相关领域的杂志,纳入单切口微创与传统全髋关节置换术的临床随机对照试验。根据改良Jadad评分量表评价纳入研究质量,并采用RevMan4.2软件进行Meta分析。结果共纳入16项随机对照研究,共计1415位患者,1490侧关节。其中,微创组为742侧,传统组为748侧。结果显示：单切口微创全髋关节置换术手术切口较传统全髋关节置换术短约6.61cm（WMD=-6.61,95%CI：-8.05～-5.16,P〈0.01）,而手术时间（WMD=-0.74,95%CI：-7.76～6.27,P=0.84）、术后3年内Harris评分（WMD=1.26,95%CI：-2.34～4.85,P〉0.05）、术后6周时WOMAC评分（WMD=-0.55,95%CI：-3.54～2.44,P〉0.05）及术后3年内并发症发生率（WMD=1.00,95%CI：0.70～1.44,P〉0.05）两组间差异均无统计学意义。结论单切口微创全髋关节置换术短期临床疗效与传统全髋关节置换术相似,其远期疗效是否优于后者仍有待观察、总结。