Postoperative Transfusion Guidelines in Aneurysmal Cerebral Subarachnoid Hemorrhage: A Systematic Review and Critical Summary of Available Evidence

Paula Mofor; Emmanuella Oduguwa; Jonathan Tao; Umaru Barrie; Yves J Kenfack; Eric Montgomery; Derrek Edukugho; Benjamin Rail; William H Hicks; Mark N Pernik; Emmanuel Adeyemo; James Caruso; Tarek Y El Ahmadieh; Carlos A Bagley; Rafael De Oliveira Sillero; Salah G Aoun

doi:10.1016/j.wneu.2021.12.007

Postoperative Transfusion Guidelines in Aneurysmal Cerebral Subarachnoid Hemorrhage: A Systematic Review and Critical Summary of Available Evidence

World Neurosurg. 2022 Feb:158:234-243.e5. doi: 10.1016/j.wneu.2021.12.007. Epub 2021 Dec 7.

Authors

Paula Mofor¹, Emmanuella Oduguwa¹, Jonathan Tao¹, Umaru Barrie², Yves J Kenfack¹, Eric Montgomery¹, Derrek Edukugho³, Benjamin Rail¹, William H Hicks¹, Mark N Pernik¹, Emmanuel Adeyemo¹, James Caruso¹, Tarek Y El Ahmadieh⁴, Carlos A Bagley¹, Rafael De Oliveira Sillero¹, Salah G Aoun¹

Affiliations

¹ Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
² Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA. Electronic address: Umaru.Barrie@UTSouthwestern.edu.
³ Department of Neurological Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA.
⁴ Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.

PMID: 34890850
DOI: 10.1016/j.wneu.2021.12.007

Abstract

Objective: Surgical management of aneurysmal subarachnoid hemorrhage (SAH) often involves red blood cell (RBC) transfusion, which increases the risk of postoperative complications. RBC transfusion guidelines report on chronically critically ill patients and may not apply to patients with SAH. Our study aims to synthesize the evidence to recommend RBC transfusion thresholds among adult patients with SAH undergoing surgery.

Methods: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to critically assess primary articles discussing RBC transfusion thresholds and describe complications secondary to RBC transfusion in adult patients with SAH in the perioperative period.

Results: Sixteen articles meeting our search strategy were reviewed. Patients with SAH who received blood transfusion were older, female, had World Federation of Neurosurgical Societies grade IV-V and modified Fisher grade 3-4 scores, and presented with more comorbidities such as hypertension, diabetes, and cardiovascular and pulmonary diseases. In addition, transfusion was associated with multiple postoperative complications, including higher rates of vasospasms, surgical site infections, cardiovascular and respiratory complications, increased postoperative length of stay, and 30-day mortality. Analysis of transfused patients showed that a higher hemoglobin (>10 g/dL) goal after SAH was safe and that patients may benefit from a higher whole hospital stay hemoglobin nadir, as shown by a reduction in risk of cerebral vasospasm and improvement in clinical outcomes (level B class II).

Conclusions: Among patients with SAH, the benefits of reducing cerebral ischemia and anemia are shown to outweigh the risks of transfusion-related complications.

Keywords: Anemia; Aneurysmal subarachnoid hemorrhage; Blood loss; Cerebral ischemia; SAH; Systematic review; Transfusion thresholds.

Publication types

Review
Systematic Review

MeSH terms

Adult
Anemia* / complications
Anemia* / therapy
Erythrocyte Transfusion / adverse effects
Female
Hemoglobins
Humans
Subarachnoid Hemorrhage* / complications
Subarachnoid Hemorrhage* / surgery
Transfusion Reaction*
Vasospasm, Intracranial* / complications

Substances

Hemoglobins