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Efficacy and safety of autotransfusion versus both suction drainage and no drainage in TKA
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November 2016
Efficacy and safety of autotransfusion versus both suction drainage and no drainage in TKA
Study Type:Meta analysis
OE Level Evidence:1
Journal Level of Evidence:N/A
Comparison between autologous blood transfusion drainage and closed-suction drainage/no drainage in total knee arthroplasty: a meta-analysis
BMC Musculoskelet Disord. 2016 Aug 1;17:142Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Fifteen randomized controlled trials were included in this meta-analysis and systematic reviewing comparing the efficacy and safety of autologous blood transfusion systems to both closed suction drainage and no drain use. Results on allogenic blood transfusion rate demonstrated a significantly lower rate with the use of autologous blood transfusion systems compared to closed suction drainage, but not when compared to no drain use. Hemoglobin level, the length of stay, and wound infection rate were not significantly different between either the use of autologous blood transfusion systems and closed suction drainage, or autologous blood transfusion systems and no drainage.
Publication Funding Details
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Funding:
Non-Industry funded
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
4/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
One of the most debated topics in the perioperative management of patients undergoing total knee arthroplasty is blood conservation. More specifically, there is considerable debate about whether autologous blood transfusion drains - a relatively new, expensive technology - offer any significant difference in blood management than standard closed-suction drains or no drain at all. Despite the previous randomized controlled trials conducted on the topic, there is currently a lack of a comprehensive review to base clinical decisions upon.
What was the principal research question?
In total knee arthroplasty, is there any significant difference in efficacy and safety between autologous blood transfusion and either closed-suction drainage or no drainage?
Study Characteristics
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Data Source:
PubMed, EMBASE, and the Cochrane Library were searched for relevant studies published up to March 2015. Reference lists of identified articles were hand searched for any additional studies possibly missed by the electronic search, and clinicaltrials.gov was searched for any in-process trials.
Index Terms:
Search terms included: "total knee arthroplasty", "total knee prosthesis", "unicompartmental", "unicompartmental", "unicondylar", "arthroplasty, replacement, knee", "autologous blood transfusion", "autotransfusion", "blood transfusion, autologous", "intraoperative blood salvage", "intraoperative blood cell salvage", and "operative blood salvage".
Study Selection:
Eligibility criteria included: a randomized controlled trial design; included patients undergoing total knee arthroplasty; allocation of patients to study arms treated with either autologous blood transfusion drainage and standard closed suction drainage or no drainage; and was published in English. the selection was performed independently by two reviewers, with disagreement resolved through discussion with the remaining authors. A total of 15 RCTs, with data sampled from 1721 TKA procedures, were selected for final inclusion.
Data Extraction:
Data extraction was performed independently by two reviewers, with disagreement resolved through discussion with the remaining authors.
Data Synthesis:
Statistical analysis was performed using Review Manager software (RevMan 5.3). Continuous outcomes were expressed as weighted mean differences, and dichotomous outcomes as odds ratios, both with associated 95% confidence intervals. Heterogeneity was assessed using the chi-square test and I-squared (I^2) statistic and considered significant at p<0.10 and >50% for the tests, respectively. A random-effects model was used in cases of significant statistical heterogeneity; otherwise, a fixed-effects model was used. Sensitivity analyses were performed in cases of significant heterogeneity to evaluate a potential source.
What were the important findings?
- There was a significantly lower incidence of allogenic blood transfusions among autologous blood transfusion systems groups compared to closed suction drainage groups (10 studies; OR 0.28 [95%CI 0.14-0.55]; p=0.0002); the difference between autologous blood transfusion systems and no drainage groups was not significant (5 studies; OR 0.73 [95%CI 0.47-1.13]; p=0.16).
- In analyses of hemoglobin levels between 3-5 days postoperatively, no significant differences were observed between autologous blood transfusion systems versus closed suction drainage (3 studies; MD 0.25 [95%CI -0.06, 0.56]; p=0.12), or autologous blood transfusion systems versus no drainage (2 studies; MD 0.41 [95%CI -0.26, 1.09]; p=0.23).
- No significant difference was observed in the length of hospital stay in analyses of autologous blood transfusion systems versus closed suction drainage (3 studies; MD -0.96 [95%CI -2.09, 0.17]; p=0.10), or autologous blood transfusion systems versus no drainage (2 studies; MD 0.07 [95%CI -0.67, 0.81]; p=0.85).
- No significant difference was observed in the incidence of wound infection in analyses of autologous blood transfusion systems versus closed suction drainage (3 studies; OR 0.98 [95%CI 0.40-2.38]; p=0.97), or autologous blood transfusion systems versus no drainage (1 study; OR 1.01 [95%CI 0.06-16.27]; p=1.00).
What should I remember most?
In total knee arthroplasty, autologous blood transfusion systems demonstrated a significantly lower requirement of allogenic transfusion when compared to groups managed with standard closed suction drainage, however, there was no significant difference when compared management without drainage. Postoperative hemoglobin levels, length of hospital stay, and the incidence of wound infection did not significantly differ when compared between autologous blood transfusion systems and closed suction drainage, or autologous blood transfusion systems and no drainage.
How will this affect the care of my patients?
The results of this study suggest that there may be an advantage to using autotransfusion systems over closed suction drains when considering allogenic transfusion rate, though similar efficacy and safety between these two options was observed in all other outcomes studied. Additionally, no significant difference in any outcome measure was observed for autotransfusion compared to no drain use. Therefore, the question becomes whether the autotransfusion systems should be considered for routine use in the absence of a significant advantage over simply not using a drain, given the added expense of using autotransfusion systems.
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