Research in context
Evidence before this study
Much effort has been directed towards development of patient blood management strategies and guidelines. There is now increased focus on assessment of individual risk and benefit during transfusion decision making. Paediatric guidelines have been published, recognising the special physiological needs of young patients. However, we did not identify any specific patient blood management guidelines for older patients.
We did a literature review and examined evidence from randomised controlled trials (RCTs) regarding transfusion outcomes for older patients. We searched PubMed, Scopus, and the Cochrane Library databases from their inception to May 5, 2017. The search was not limited by clinical setting, date, language, or study type. Articles not in English were excluded if translations of the abstracts were not available, and if studies did not specify age. Observational studies and duplicate patient and outcome data from studies that generated multiple publications were also excluded. Medical Subject Headings and free-text terms relating to the concepts of geriatric and transfusion were used. 13 papers relating to nine recent RCTs with a geriatric focus were identified. The studies examined orthopaedic, cardiac, and oncology surgery settings. Outcome data for 5780 patients from these RCTs were included in our meta-analysis and assessment of bias, following Cochrane and PRISMA methods.
Added value of this study
To our knowledge, this study is the first published meta-analysis of RCTs focused on geriatric-specific transfusion outcomes. Pooled RCT outcome data analysed in our study identify that liberal transfusion strategies had better geriatric patient outcomes with respect to 30-day and 90-day mortality and cardiovascular complications than restrictive transfusion strategies. Risk of myocardial infarction showed no difference; and risks of infections and length of hospital stay were equivalent between the transfusion groups. These findings bring into question the appropriateness of restrictive transfusion strategies for older patients. It highlights the need for geriatric-specific consideration in the development and revision of patient blood management guidelines, to bookend the paediatric guidelines that have been developed.
Implications of all the available evidence
There is a growing body of evidence from RCTs to address several conflicts in transfusion medicine. RCT evidence was identified that is specific to transfusion in older adults. Meta-analysis of these RCTs indicates that liberal transfusion strategies might provide better outcomes for the geriatric patient groups included in the studies than restrictive transfusion strategies. Further geriatric-specific studies are needed to guide the development and revision of patient blood management and transfusion guidelines for older adults.