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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 1 All‐cause mortality within 30 days of surgery.
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Analysis 1.1

Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 1 All‐cause mortality within 30 days of surgery.

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Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 2 Number of participants with major procedure‐related bleeding within 7 days of surgery.
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Analysis 1.2

Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 2 Number of participants with major procedure‐related bleeding within 7 days of surgery.

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Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 3 Number of participants with minor procedure‐related bleeding within 7 days of surgery.
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Analysis 1.3

Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 3 Number of participants with minor procedure‐related bleeding within 7 days of surgery.

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Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 4 Proportion of participants requiring additional interventions to stop bleeding within 7 days of surgery.
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Analysis 1.4

Comparison 1 Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery, Outcome 4 Proportion of participants requiring additional interventions to stop bleeding within 7 days of surgery.

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Comparison 2 Prophylactic platelet transfusion prior to surgery versus alternative treatments, Outcome 1 Number of participants with minor procedure‐related bleeding within 7 days of surgery.
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Analysis 2.1

Comparison 2 Prophylactic platelet transfusion prior to surgery versus alternative treatments, Outcome 1 Number of participants with minor procedure‐related bleeding within 7 days of surgery.

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Comparison 2 Prophylactic platelet transfusion prior to surgery versus alternative treatments, Outcome 2 Proportion of participants requiring additional interventions to stop bleeding within 7 days of surgery.
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Analysis 2.2

Comparison 2 Prophylactic platelet transfusion prior to surgery versus alternative treatments, Outcome 2 Proportion of participants requiring additional interventions to stop bleeding within 7 days of surgery.

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Comparison 2 Prophylactic platelet transfusion prior to surgery versus alternative treatments, Outcome 3 Serious adverse events (transfusion related adverse effects within 24 hours of the transfusion).
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Analysis 2.3

Comparison 2 Prophylactic platelet transfusion prior to surgery versus alternative treatments, Outcome 3 Serious adverse events (transfusion related adverse effects within 24 hours of the transfusion).

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Summary of findings for the main comparison. Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery

Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery

Patient or population: people with a low platelet count

Setting: surgery

Intervention: platelet transfusion

Comparison: no platelet transfusion

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with no platelet transfusion

Risk with platelet transfusion

All‐cause mortality within 30 days of surgery

Study population

RR 0.78
(0.41 to 1.45)

72
(1 RCT)

⊕⊝⊝⊝
Very lowa,b

—

405 per 1000

316 per 1000
(166 to 588)

Mortality secondary to bleeding within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to thromboembolism within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to infection within 30 days of surgery – not reported

—

—

—

—

—

—

Number of participants with major bleeding within 7 days of surgery (surgical site bleeding requiring a second intervention or reoperation or surgical site bleeding that causes a haematoma or haemarthrosis of sufficient size to delay mobilisation or wound healing)

Study population

RR 1.60
(0.29 to 8.92)

64
(1 RCT)

⊕⊝⊝⊝
Very lowb,c

—

61 per 1000

97 per 1000
(18 to 541)

The number of participants with minor procedure‐related bleeding within 7 days of surgery

Study population

RR 1.29
(0.90 to 1.85)

64
(1 RCT)

⊕⊝⊝⊝
Very lowa,c,d

—

576 per 1000

743 per 1000
(518 to 1000)

Serious adverse events (surgery‐related adverse effects within 30 days)

No events occurred in either study arm

64
(1 RCT)

⊕⊝⊝⊝
Very lowa,c,d

—

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aOnly adults in the intensive care unit were included in this trial (downgraded one level for indirectness).

bThe confidence intervals included a serious risk of harm or benefit (downgraded two levels for imprecision).

cThis is a subjective outcome and the trial was unblinded (downgraded one level for risk of bias).

dThe confidence intervals included a risk of harm or benefit (downgraded one level for imprecision).

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Summary of findings for the main comparison. Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery
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Summary of findings 2. Prophylactic platelet transfusion prior to surgery versus alternative treatments

Prophylactic platelet transfusion prior to surgery versus alternative treatments

Patient or population: people with a low platelet count

Setting: surgery

Intervention: platelet transfusion

Comparison: desmopressin

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with desmopressin

Risk with platelet transfusion

All‐cause mortality within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to bleeding within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to thromboembolism within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to infection within 30 days of surgery – not reported

—

—

—

—

—

—

Number of participants with major bleeding within 7 days of surgery (bleeding that required ≥ 2 units of whole blood/red blood cells within 24 hours of the bleeding)

No events in either study arm

36
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

—

Number of participants with minor procedure‐related bleeding within 7 days of surgery

Study population

RR 0.89
(0.06 to 13.23)

36
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

—

59 per 1000

52 per 1000
(4 to 778)

Serious adverse events (transfusion‐related adverse effects within 24 hours of the transfusion)

Study population

RR 2.70
(0.12 to 62.17)

36
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

—

0 per 1000

0 per 1000
(0 to 0)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aOpen‐label trial (downgraded one level for risk of bias).

bStudy only included adults with chronic liver disease (downgraded one level for indirectness).

cConfidence intervals included a serious risk or benefit or treatment (downgraded one level for imprecision, as already downgraded one level for indirectness and risk of bias).

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Summary of findings 2. Prophylactic platelet transfusion prior to surgery versus alternative treatments
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Summary of findings 3. Different platelet count thresholds for administering a prophylactic platelet transfusion prior to surgery

Different platelet count thresholds for administering a prophylactic platelet transfusion prior to surgery

Patient or population: people with a low platelet count

Setting: surgery

Intervention: platelet transfusion

Comparison: TPO mimetic

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with TPO mimetic

Risk with platelet transfusion

All‐cause mortality within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to bleeding within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to thromboembolism within 30 days of surgery – not reported

—

—

—

—

—

—

Mortality secondary to infection within 30 days of surgery – not reported

—

—

—

—

—

—

Number of participants with major bleeding within 7 days of surgery

No bleeding in any of the study arms

65
(1 RCT)

⊕⊝⊝⊝
Very lowa,b

—

Number of participants with minor procedure‐related bleeding within 7 days of surgery

No bleeding occurred in any of the study arms

65
(1 RCT)

⊕⊝⊝⊝
Very lowa,b

—

Serious adverse events – not reported

—

—

—

—

—

—

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio; TPO: thrombopoietin.

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aStudy only included adults with chronic liver disease (downgraded one level for indirectness).

bNo events occurred (downgraded two levels for imprecision).

Figures and Tables -
Summary of findings 3. Different platelet count thresholds for administering a prophylactic platelet transfusion prior to surgery
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Comparison 1. Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 All‐cause mortality within 30 days of surgery Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Number of participants with major procedure‐related bleeding within 7 days of surgery Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

3 Number of participants with minor procedure‐related bleeding within 7 days of surgery Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

4 Proportion of participants requiring additional interventions to stop bleeding within 7 days of surgery Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected
Figures and Tables -
Comparison 1. Prophylactic platelet transfusion prior to surgery versus no prophylactic platelet transfusion prior to surgery
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Comparison 2. Prophylactic platelet transfusion prior to surgery versus alternative treatments

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Number of participants with minor procedure‐related bleeding within 7 days of surgery Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

1.1 Desmopressin vs platelet transfusion

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

1.2 Thrombopoietin mimetics vs platelet transfusion

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

2 Proportion of participants requiring additional interventions to stop bleeding within 7 days of surgery Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2.1 Desmopressin vs platelet transfusion

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

3 Serious adverse events (transfusion related adverse effects within 24 hours of the transfusion) Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

3.1 Desmopressin vs platelet transfusion

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]
Figures and Tables -
Comparison 2. Prophylactic platelet transfusion prior to surgery versus alternative treatments
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