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, 6 (2), 23

Interaction Between Peri-Operative Blood Transfusion, Tidal Volume, Airway Pressure and Postoperative ARDS: An Individual Patient Data Meta-Analysis

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Interaction Between Peri-Operative Blood Transfusion, Tidal Volume, Airway Pressure and Postoperative ARDS: An Individual Patient Data Meta-Analysis

Ary Serpa Neto et al. Ann Transl Med.

Abstract

Background: Transfusion of blood products and mechanical ventilation with injurious settings are considered risk factors for postoperative lung injury in surgical Patients.

Methods: A systematic review and individual patient data meta-analysis was done to determine the independent effects of peri-operative transfusion of blood products, intra-operative tidal volume and airway pressure in adult patients undergoing mechanical ventilation for general surgery, as well as their interactions on the occurrence of postoperative acute respiratory distress syndrome (ARDS). Observational studies and randomized trials were identified by a systematic search of MEDLINE, CINAHL, Web of Science, and CENTRAL and screened for inclusion into a meta-analysis. Individual patient data were obtained from the corresponding authors. Patients were stratified according to whether they received transfusion in the peri-operative period [red blood cell concentrates (RBC) and/or fresh frozen plasma (FFP)], tidal volume size [≤7 mL/kg predicted body weight (PBW), 7-10 and >10 mL/kg PBW] and airway pressure level used during surgery (≤15, 15-20 and >20 cmH2O). The primary outcome was development of postoperative ARDS.

Results: Seventeen investigations were included (3,659 patients). Postoperative ARDS occurred in 40 (7.2%) patients who received at least one blood product compared to 40 patients (2.5%) who did not [adjusted hazard ratio (HR), 2.32; 95% confidence interval (CI), 1.25-4.33; P=0.008]. Incidence of postoperative ARDS was highest in patients ventilated with tidal volumes of >10 mL/kg PBW and having airway pressures of >20 cmH2O receiving both RBC and FFP, and lowest in patients ventilated with tidal volume of ≤7 mL/kg PBW and having airway pressures of ≤15 cmH2O with no transfusion. There was a significant interaction between transfusion and airway pressure level (P=0.002) on the risk of postoperative ARDS.

Conclusions: Peri-operative transfusion of blood products is associated with an increased risk of postoperative ARDS, which seems more dependent on airway pressure than tidal volume size.

Keywords: Acute respiratory distress syndrome (ARDS); surgery; tidal volume, ventilator-associated lung injury; transfusion.

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Kaplan-Meier estimates of the probability of the primary outcome. Data for the Kaplan-Meier estimates of the probability of the primary outcome of postoperative ARDS in (A) patients not transfused (black solid line), and patients who received at least one unit of blood product (black dotted line), and (B) patients who received less than three units of RBC (black solid line), and patients who received more than three units of RBC (black dotted line). Data were censored at 30 days after surgery. ARDS, acute respiratory distress syndrome; RBC, red blood cell.
Figure 2
Figure 2
Incidence of postoperative ARDS according to (A) tidal volume size used during general anesthesia, transfusion and type of blood products; and (B) plateau pressure used during general anesthesia and transfusion and type of blood products. ARDS, acute respiratory distress syndrome; RBC, red blood cell; FFP, fresh frozen plasma; PBW, predicted body weight.
Figure 3
Figure 3
Kaplan-Meier estimates of the probability of in-hospital mortality. Data for the Kaplan-Meier estimates of the probability of the secondary outcome of in-hospital mortality in patients not transfused (black solid line), and patients who received at least one unit of blood product (black dotted line). Data were censored at 30 days after surgery.
Figure 4
Figure 4
Hazard ratios for study outcomes according to subgroup. The size of the squares is proportional to the number of patients in the subgroup.
Figure S1
Figure S1
Literature search strategy.
Figure S2
Figure S2
Units of RBC (black bars) and FFP (gray bars) transfused according to the type of surgery (mean ± SD). RBC, red blood cell; FFP, fresh-frozen plasma.
Figure S3
Figure S3
Percentage of patients who received at least one unit of RBC (black bars) or FFP (gray bars) according to the type of surgery. RBC, red blood cell; FFP, fresh-frozen plasma.
Figure S4
Figure S4
Survival-free of ARDS according to the transfusion of RBC or FFP. ARDS, acute respiratory distress syndrome; RBC, red blood cell; FFP, fresh-frozen plasma.
Figure S5
Figure S5
In-hospital mortality according to the transfusion of RBC, ≥03 units of RBC or FFP. RBC, red blood cell; FFP, fresh-frozen plasma.
Figure S6
Figure S6
Patients breathing without assistance according to transfusion or not of blood products.
Figure S7
Figure S7
Units of RBC and FFP transfused in patients who developed (black bars) and do not developed (gray bars) postoperative ARDS (mean ± SD). ARDS, acute respiratory distress syndrome; RBC, red blood cell; FFP, fresh-frozen plasma.
Figure S8
Figure S8
Percentage of patients who developed ARDS according to the number of units of RBC (black bars) and FFP (gray bars) transfused. ARDS, acute respiratory distress syndrome; RBC, red blood cell; FFP, fresh-frozen plasma.

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