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Autologous blood transfusion drainage versus closed suction drainage following TKA
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March 2017
Autologous blood transfusion drainage versus closed suction drainage following TKA
Study Type:Meta analysis
OE Level Evidence:1
Journal Level of Evidence:N/A
The efficacy and safety of autologous blood transfusion drainage in patients undergoing total knee arthroplasty: a meta-analysis of 16 randomized controlled trials
BMC Musculoskelet Disord. 2016 Nov 2;17(1):452Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Sixteen randomized controlled trials were included in this meta-analysis comparing autologous blood transfusion drainage and closed suction drainage following total knee arthroplasty. Results demonstrated a significantly lower incidence of allogeneic transfusion among groups treated with ABTD compared to CSD. No significant differences between drainage types were found in analyses of postoperative blood loss, postoperative hemoglobin levels, and complication rates.
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
3/4
Accessing Data
3/4
Analysing Data
4/4
Results
2/4
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?
Postoperative blood management following total knee arthroplasty procedures is an important consideration for orthopaedic surgeons. Traditional methods of management include the use of closed suction drainage (CSD) to prevent the development of hematoma postoperatively, however, many have expressed concerns that the use of closed suction drains can increase blood loss compared to no drainage and can increase the need for allogeneic transfusion. To address this, autologous blood transfusion drainage (ABTD) has been developed. Despite several randomized controlled trials that have compared results between ABTD and CSD, inconsistent findings have been obtained. A meta-analysis was needed to better assess the comparative efficacy between ABTD and CSD in blood management following total knee arthroplasty.
What was the principal research question?
How does the efficacy and safety compare between autologous blood transfusion drainage and closed suction drainage in total knee arthroplasty?
Study Characteristics
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Data Source:
PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature, the China National Knowledge Infrastructure, Chinese Scientific Journals, and Wanfang were searched for relevant articles published up to February 2016. Reference lists of identified articles were hand searched for any additional studies possibly missed by the electronic search.
Index Terms:
Search terms included: "drainage", "suction", "blood transfusion, autologous", "operative blood salvage", "arthroplasty, replacement, knee", "wound drainage", "closed drainage", "drainage catheter", "drainage tube", "suction drain", "surgical drainage", "drain", "wound drain", "blood autotransfusion", "autotransfusion unit", "blood salvage", "knee arthroplasty".
Study Selection:
Eligibility criteria included: a randomized controlled trial (RCT) design; enrolled patients undergoing total knee arthroplasty; allocated patients to treatment with either autologous blood transfusion drainage or closed suction drainage; and reported outcomes with appropriate data for meta-analysis. A total of sixteen randomized controlled trials, with data sampled from 1534 patients, were selected for final inclusion.
Data Extraction:
Data extraction was performed independently by two reviewers, with disagreements resolved through discussion and consensus.
Data Synthesis:
Statistical analyses were performed using Review Manager software (RevMan 5.3). Continuous outcome was expressed as weight mean differences, and dichotomous outcomes as odds ratios, both with associated 95% confidence intervals. Heterogeneity was assessed using the I-squared (I^2) statistic, and considered significant at values >50%. In the presence of significant heterogeneity, a random-effects model was used; otherwise, a fixed-effects model was used. Funnel plots were used to assess the presence of publication bias.
What were the important findings?
- The incidence of allogeneic blood transfusion was significantly lower among ABTD groups (100/606) compared to CSD groups (242/597) (12 studies; OR 0.25 [95%CI 0.13-0.47]; p=0<0.0001, I-squared 77%). Assessment of funnel plot suggested the presence of publication bias.
- The mean number of transfused units was also significantly lower with ABTD compared to CSD (5 studies; MD -0.68/patient [95%CI -0.98, -0.39]; p<0.00001, I-squared 74%).
- No significant difference between ABTD and CSD groups was observed in the incidence of wound complications (3 studies; OR 0.98 [95%CI 0.40-2.38]; p=0.97, I-squared 0%) or the incidence of deep vein thrombosis (4/257 vs. 6/252; 4 studies; OR 0.69 [95%CI 0.21-2.24]; p=0.54, I-squared 0%).
- No significant difference was observed in the incidence of febrile complications between ABTD groups (50/244) and CSD groups (66/257) (6 studies; OR 0.78 [95%CI 0.25-2.40]; p=0.67, I-squared 56%).
- No significant difference between ABTD and CSD groups was observed in blood drainage volume (7 studies; MD -2.91mL [95%CI -43.50, 37.68]; p=0.89, I-squared 34%) or hemoglobin level between 5-8 days postoperatively (4 studies; MD 0.21g/dL [95%CI -0.07, 0.48]; p=0.14, I-squared 48%).
What should I remember most?
In total knee arthroplasty, the use of autologous blood transfusion drainage led to a significantly lower rate of allogeneic blood transfusion when compared to closed suction drainage, though the presence publication bias could not be rejected. Otherwise, no significant differences between drainage types were observed in the incidences of wound complications, deep vein thrombosis, or febrile complications, nor postoperative blood loss volume.
How will this affect the care of my patients?
The results of this study suggest that autologous blood transfusion drainage systems may reduce the need for allogeneic blood transfusion when compared to closed suction drainage after total knee arthroplasty, while providing similar results regarding postoperative blood loss and complication rate. The result of this study, however, is limited by the suggestion of possible publication bias based on visual inspection of funnel plots. Additionally, many of the included studies featured small sample sizes; future trials should aim to enroll greater sample sizes to improve estimates of effect.
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