Ary Serpa Neto1,2,3, Nicole P Juffermans1, Sabrine N T Hemmes1, Carmen S V Barbas3, Martin Beiderlinden4,5, Michelle Biehl6, Ana Fernandez-Bustamante7, Emmanuel Futier8, Ognjen Gajic6, Samir Jaber9, Alf Kozian10, Marc Licker11, Wen-Qian Lin12, Stavros G Memtsoudis13, Dinis Reis Miranda14, Pierre Moine7, Domenico Paparella15, Marco Ranieri16, Federica Scavonetto17, Thomas Schilling10, Gabriele Selmo18, Paolo Severgnini18, Juraj Sprung17, Sugantha Sundar19, Daniel Talmor19, Tanja Treschan4, Carmen Unzueta20, Toby N Weingarten17, Esther K Wolthuis1, Hermann Wrigge21, Marcelo Gama de Abreu22, Paolo Pelosi23, Marcus J Schultz1,24. 1. Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 2. Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, São Paulo, Brazil. 3. Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. 4. Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany. 5. Department of Anaesthesiology, Marienhospital Osnabrück, Osnabrück, Germany. 6. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA. 7. Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA. 8. Department of Anesthesiology and Critical Care Medicine, Estaing University Hospital, Clermont-Ferrand, France. 9. Department of Critical Care Medicine and Anesthesiology (SAR B), Saint Eloi University Hospital, Montpellier, France. 10. Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany. 11. Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland. 12. State Key Laboratory of Oncology of South China, Sun Yat-sen University Cancer Center, Guangzhou 510060, China. 13. Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, USA. 14. Department of Intensive Care, Erasmus MC, Rotterdam, The Netherlands. 15. Division of Cardiac Surgery, Department of Emergency and Organ Transplant (D.E.T.O.), University of Bari Aldo Moro, Bari, Italy. 16. Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy. 17. Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA. 18. Department of Environment, Health and Safety, University of Insubria, Varese, Italy. 19. Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA. 20. Department of Anaesthesiology and Intensive Care, Hospital de Sant Pau, Barcelona, Spain. 21. Department Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany. 22. Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. 23. Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST University of Genoa, Genoa, Italy. 24. Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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.
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.
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