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Point-of-care viscoelastic hemostatic testing in cardiac surgery patients: a systematic review and meta-analysis

  • Carly Lodewyks
  • Jeffrey Heinrichs
  • Hilary P. Grocott
  • Keyvan Karkouti
  • Grace Romund
  • Rakesh C. Arora
  • Navdeep Tangri
  • Rasheda Rabbani
  • Ahmed Abou-Setta
  • Ryan Zarychanski
Review Article/Brief Review

Abstract

Purpose

Thromboelastography and rotational thromboelastometry are point-of-care (POC) viscoelastic tests used to help guide blood product administration. It is unclear whether these tests improve clinical or transfusion-related outcomes. The objective of this study was to appraise data from randomized trials evaluating the benefit of POC testing in cardiac surgery patients. Primary outcomes were the proportion of patients transfused with blood products and all-cause mortality.

Source

Medline (Ovid), EMBASE (Ovid), CENTRAL (the Cochrane Library-Wiley), Web of Science, Biosis, Scopus, and CINAHL databases, as well as clinical trial registries and conference proceedings were queried from inception to February 2018.

Principal findings

We identified 1,917 records, 11 of which were included in our analysis (8,294 patients). Point-of-care testing was not associated with a difference in the proportion of patients transfused with any blood product (risk ratio [RR], 0.90; 95% confidence interval [CI], 0.79 to 1.02; I2 = 51%; four trials, 7,623 patients), or all-cause mortality (RR, 0.73; 95% CI, 0.47 to 1.13; I2 = 5%; six trials, 7,931 patients). Nevertheless, POC testing was weakly associated with a decrease in the proportion of patients receiving red blood cells (RBC) (RR, 0.91; 95% CI, 0.85 to 0.96; I2 = 0%; seven trials, 8,029 patients), and heterogeneous reductions in frozen plasma (FP) (RR, 0.58; 95% CI, 0.34 to 0.99; I2 = 87%; six trials, 7,989 patients) and platelets (RR, 0.66; 95% CI, 0.49 to 0.90; I2 = 65%; seven trials, 8,029 patients). Meta-analysis of the number of units of RBCs and FP was not possible due to heterogeneity in reporting, however POC testing significantly reduced the units of platelets transfused (standard mean difference, -0.09; 95% CI, -0.18 to 0.00; four trials, 7,643 patients).

Conclusion

Our review indicates that in cardiac surgery patients, POC viscoelastic hemostatic testing is not associated with a reduction in the proportion of patients receiving any blood product or all-cause mortality. However, viscoelastic testing is weakly associated with a reduction in proportion of patients transfused with specific blood products. Presently, the benefits associated with viscoelastic testing in cardiac surgery patients are insufficiently robust to recommend routine implementation of this technology.

Trial registration

PROSPERO (CRD4201706577). Registered 11 May 2017.

Tests hémostatiques viscoélastiques au point de service des patients subissant une chirurgie cardiaque : revue systématique de la littérature et méta-analyse

Résumé

Objectif

La thromboélastographie et la thromboélastométrie rotative sont des tests de la viscosité sanguine au point de service du patient et qui peuvent servir de guide à l’administration de produits sanguins. On ne sait pas avec certitude si ces tests améliorent l’évolution clinique ou les résultats liés à la transfusion. L’objectif de cette étude était d’évaluer les données provenant d’essais randomisés ayant étudié les bénéfices des tests de viscosité sanguine au point de service des patients subissant une chirurgie cardiaque. Les critères d’évaluation principaux ont été le pourcentage de patients recevant des transfusions de produits sanguins et la mortalité toutes causes confondues.

Sources

les bases de données MEDLINE (Ovid), EMBASE (Ovid), CENTRAL (la Cochrane Library-Wiley), Web of Science, Biosis, Scopus et CINAHL, ainsi que les registres d’essais cliniques et les comptes rendus de congrès ont été passés au crible depuis leur création jusqu’en février 2018.

Constatations principales

Nous avons identifié 1 917 rapports, dont 11 qui ont été inclus dans notre analyse (8 294 patients). Les tests de viscosité au point de service n’ont été associés à aucune différence en termes de pourcentages de patients recevant des transfusions de différents produits sanguins (rapport de risque [RR], 0,90; intervalle de confiance [IC] à 95 % : 0,79 à 1,02; I2 = 51 %; quatre essais, 7 623 patients) ou la mortalité toutes causes (RR, 0,73; IC à 95 % : 0,47 à 1,13; I2 = 5 %; six essais, 7 931 patients). Néanmoins, les tests de viscosité au point de service du patient ont été faiblement associés à une diminution du pourcentage de patients recevant des globules rouges (RR, 0,91; IC à 95 % : 0,85 à 0,96; I2 = 0 %; sept essais, 8 029 patients) et à des réductions hétérogènes de plasma congelé (RR, 0,58; IC à 95 % : 0,34 à 0,99; I2 = 87 %; six essais, 7 989 patients) et de plaquettes (RR, 0,66; IC à 95 % : 0,49 à 0,90; I2 = 65 %; sept essais, 8 029 patients). Une méta-analyse du nombre d’unités de globules rouges et de plasma congelé n’a pas été possible en raison de l’hétérogénéité des rapports; cependant, les tests de viscosité au point de service du patient ont significativement réduit le nombre d’unités de plaquettes transfusées (différence des moyennes standard, -0,09; IC à 95 % : -0,18 à 0,00; quatre essais, 7 643 patients).

Conclusion

Notre analyse indique que chez les patients subissant une chirurgie cardiaque, les tests de viscosité sanguine au point de service du patient ne sont pas associés à une réduction du pourcentage de patients recevant un produit sanguin ou à une réduction de la mortalité toutes causes confondues. Cependant, les tests de viscosité sont faiblement associés à une réduction du pourcentage de patients transfusés avec des produits sanguins spécifiques. Actuellement, les avantages associés aux tests de la viscosité sanguine chez les patients de chirurgie cardiaque ne sont pas suffisamment robustes pour recommander la mise en œuvre systématique de cette technologie.

Enregistrement de l’essai clinique

PROSPERO (CRD4201706577). Enregistré le 11 mai 2017.

Notes

Disclosures

Rakesh C. Arora has received an unrestricted educational grant from Pfizer Canada Inc. and an honorarium from Mallickrodt Pharmaceuticals. Keyvan Karkouti has received research support from TEM International Gmbh. Ryan Zarychanski receives salary and operating support from the Canadian Institutes of Health Research.

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Steven Backman, Associate Editor, Canadian Journal of Anesthesia.

Author contributions

Carly Lodewyks coordinated all aspects of the review, assisted with the literature search, screened relevant material, extracted and analyzed data, and prepared the final manuscript; Jeffrey Heinrichs assisted with screening relevant material, and extracting data in duplicate; two cardiac anesthesiologists (Hilary P. Grocott and Keyvan Karkouti) and one hematologist/critical care physician (Ryan Zarychanski) provided content expertise and methodological advice; one librarian with expertise in systematic review search methodology designed and executed the literature search strategies (Grace Romund); one clinician/researcher with expertise in conducting systematic reviews provided technical and methodological advice (Ahmed Abou-Setta); one senior biostatistician (Rasheda Rabbani) provided methodological expertise on statistical analysis; two clinician/researchers assisted with project planning and manuscript preparation (Rakesh C. Arora and Navdeep Tangri).

Sources of support

We did not obtain any specific funding for this systematic review.

Supplementary material

12630_2018_1217_MOESM1_ESM.pdf (57 kb)
Supplementary material 1 (PDF 56 kb)

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Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  • Carly Lodewyks
    • 1
    • 2
    • 8
  • Jeffrey Heinrichs
    • 3
  • Hilary P. Grocott
    • 3
  • Keyvan Karkouti
    • 4
  • Grace Romund
    • 5
  • Rakesh C. Arora
    • 1
    • 7
  • Navdeep Tangri
    • 2
    • 7
  • Rasheda Rabbani
    • 2
    • 6
  • Ahmed Abou-Setta
    • 2
    • 6
  • Ryan Zarychanski
    • 2
    • 6
    • 7
  1. 1.Department of Surgery, Section of Cardiac Surgery, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  2. 2.Department of Community Health Sciences, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  3. 3.Department of Anesthesia and Perioperative Medicine, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  4. 4.Department of Anesthesia, Institute of Health Policy, Management, and Evaluation, and Peter Munk Cardiac CentreUniversity of TorontoTorontoCanada
  5. 5.Neil John Maclean Library, University of ManitobaWinnipegCanada
  6. 6.George & Fay Yee Center for Healthcare InnovationUniversity of Manitoba/Winnipeg Regional Health AuthorityWinnipegCanada
  7. 7.Department of Internal Medicine, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  8. 8.WinnipegCanada

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