Abstract
Purpose
To determine if deliberate hypotension decreases blood loss and transfusion requirements in patients undergoing orthopedic surgery, a systematic review of all randomized trials addressing this issue was undertaken.
Methods
Electronic databases, citations lists and review articles were searched for potential articles. Relevant articles met the following inclusion criteria: English language, humans undergoing orthopedic surgery, deliberate hypotension used by any method, intraoperative blood loss measured as an outcome, and the trial methodology being randomized and controlled. Four outcomes were analyzed, including estimated blood loss, blood transfused, surgery duration, and quality of the surgical field. For all analyses, the random-effects model was used.
Results
Seventeen articles met the inclusion criteria. The surgeries studied included total hip arthroplasty (seven), orthog-nathic surgery (eight), total knee arthroplasty (one) and spinal fusion (one). A total of 636 patients were randomized across all studies. For blood loss, the overall weighted mean difference favoured treatment, with a savings of about 287 mL of blood [95% confidence interval (CI): -447, -127]. The mean differences also showed a statistically significant benefit for deliberate hypotension in reducing transfusion requirements (-667 mL of blood transfused; 95% CI: -963, -370). Deliberate hypotension was not shown to reduce the duration of surgery (-1.9 min of surgery; 95% CI: -7.2, 3.5) or improve surgical conditions (surgical field quality rating -0.5; 95% CI: -1.1, 0.2).
Conclusion
This review provides some support for the use of deliberate hypotension in reducing blood loss and transfusion requirements in orthopedic surgery, but these results are tempered by the small sample sizes and poor methodological quality of published studies.
Résumé
Objectif
Afin de déterminer si l’hypotension délibérée réduit les pertes sanguines et l’incidence transfusionnelle chez les patients subissant une chirurgie orthopédique, un compte-rendu systéma-tique de toutes les études randomisées traitant de cette question a été entrepris.
Méthode
Les bases de données électroniques, listes de citations et articles de compte-rendu ont été consultés afin de trouver des articles potentiellement pertinents. Les articles pertinents ont répondu aux critères suivants: langue anglaise, êtres humains subissant une chirurgie orthopédique, utilisation d’une méthode d’hypotension délibérée, quelle qu’elle soit, pertes sanguines pero-pératoires mesurées en tant que résultat, et méthodologie d’étude randomisée et contrôlée. Quatre évolutions ont été analysées, notamment les pertes sanguines estimées, le sang transfusé, la durée de la chirurgie et la qualité de l’hémostase chirurgicale. Un modèle à effets aléatoires a été utilisé pour toutes les analyses.
Résultats
Dix-sept articles ont répondu aux critères d’inclusion. Les chirurgies évaluées comprenaient: arthroplasties totales de la hanche (sept), chirurgies orthognathes (huit), arthroplastie totale du genou (une) et spondylodèse (une). Un total de 636 patients ont été randomisés dans ces études. En ce qui a trait à la perte sanguine, la différence moyenne pondérée totale a montré un résultat en faveur du traitement, avec une diminution des pertes sanguines d’environ 287 mL [95 % intervalle de confiance (IC) : 447, -127]. Les différences moyennes ont également montré que l’hypotension délibérée présente des bienfaits statistiquement si-gnificatifs dans la réduction de l’incidence transfusionnelle (-667 mL de sang transfusé; 95 % IC: -963, -370). L’hypotension délibérée n’a pas eu d’influence sur la durée de chirurgie (-1,9 min de chirurgie; 95 % IC: -7,2, 3,5) ou sur l’ amélioration des conditions chirurgicales (évaluation de la qualité de l’hémostase chirurgicale -0,5 ;95%IC:-1,1, 0,2).
Conclusion
Ce compte-rendu soutient dans une certaine mesure l’utilisation de l’hypotension délibérée pour réduire les pertes sanguines et l’incidence transfusionnelle lors de chirurgie ortho-pédique; toutefois, ces résultats sont mitigés par les petites tailles d’échantillons et la pauvreté méthodologique des études publiées.
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Financial support: Hamilton Health Sciences, Department of Anesthesia Academic Fund.
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Paul, J.E., Ling, E., Lalonde, C. et al. Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: A meta-analysis of randomized controlled trials. Can J Anesth 54, 799–810 (2007). https://doi.org/10.1007/BF03021707
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DOI: https://doi.org/10.1007/BF03021707