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Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
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Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figuras y tablas -
Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Comparison 1 Intervention versus control, Outcome 1 Mortality.
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Analysis 1.1

Comparison 1 Intervention versus control, Outcome 1 Mortality.

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Comparison 1 Intervention versus control, Outcome 2 Serious adverse events.
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Analysis 1.2

Comparison 1 Intervention versus control, Outcome 2 Serious adverse events.

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Comparison 1 Intervention versus control, Outcome 3 Adverse events (severity unknown).
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Analysis 1.3

Comparison 1 Intervention versus control, Outcome 3 Adverse events (severity unknown).

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Comparison 1 Intervention versus control, Outcome 4 Number requiring allogeneic blood transfusion.
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Analysis 1.4

Comparison 1 Intervention versus control, Outcome 4 Number requiring allogeneic blood transfusion.

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Comparison 1 Intervention versus control, Outcome 5 Red cell transfusion.
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Analysis 1.5

Comparison 1 Intervention versus control, Outcome 5 Red cell transfusion.

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Study

Mean (standard deviation) ml (intervention; 25 patients)

Mean (standard deviation) ml (control; 25 patients)

Mean difference (95% confidence intervals)

P‐value

Low central venous pressure versus control

Wang 2006

437.5 (250.36)

1057.14 (658.33)

‐619.64 ml (‐895.73, ‐343.55)

< 0.001

Figuras y tablas -
Analysis 1.6

Comparison 1 Intervention versus control, Outcome 6 Fresh frozen plasma.

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Comparison 1 Intervention versus control, Outcome 7 Operative blood loss (ml).
Figuras y tablas -
Analysis 1.7

Comparison 1 Intervention versus control, Outcome 7 Operative blood loss (ml).

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Comparison 1 Intervention versus control, Outcome 8 Operating time (minutes).
Figuras y tablas -
Analysis 1.8

Comparison 1 Intervention versus control, Outcome 8 Operating time (minutes).

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Comparison 1 Intervention versus control, Outcome 9 Hospital stay (days).
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Analysis 1.9

Comparison 1 Intervention versus control, Outcome 9 Hospital stay (days).

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Summary of findings for the main comparison. Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection

Cardiopulmonary intervention versus control for liver resection

Patient or population: patients with liver resection.
Settings: secondary or tertiary care.
Intervention: intervention versus control.

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Intervention versus control

Serious adverse events ‐ Haemodilution versus control.

Study population

217 per 1000

219 per 1000
(124 to 391)

Rate ratio 1.01
(0.57 to 1.8)

208
(2 studies)

⊕⊝⊝⊝
very low1,2,3,4,5

Number requiring allogeneic blood transfusion ‐ Low central venous pressure (CVP) versus control.

Study population

RR 0.66
(0.42 to 1.03)

177
(3 studies)

⊕⊝⊝⊝
very low1,3,4,5

303 per 1000

200 per 1000
(127 to 312)

Number requiring allogeneic blood transfusion ‐ Haemodilution versus control.

Study population

RR 0.41
(0.25 to 0.66)

233
(3 studies)

347 per 1000

142 per 1000
(87 to 229)

Red cell transfusion ‐ Low CVP versus control.

The mean red cell transfusion ‐ low CVP versus control in the intervention groups was
0.31 standard deviations lower
(0.65 lower to 0.03 higher)

135
(2 studies)

⊕⊝⊝⊝
very low1,5,6,7

SMD ‐0.31 (‐0.65 to 0.03)

Red cell transfusion ‐ Haemodilution versus control.

The mean red cell transfusion ‐ haemodilution versus control in the intervention groups was
0.33 standard deviations lower
(0.63 to 0.03 lower)

180
(3 studies)

⊕⊝⊝⊝
very low1,5,6

SMD ‐0.33 (‐0.63 to ‐0.03)

*The basis for the assumed risk was the mean control group risk across studies. The corresponding risk (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; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Trials were of high risk of bias.
2 The seriousness of the outcomes was based on the study authors' judgement.
3 The confidence intervals overlap 1 and 0.75 or 1.25, or both.
4 Fewer than 300 events (in both groups).
5 There were few trials to assess whether there was any publication bias.
6 The I‐squared value was high.
7 There were less than 400 patients in both the groups together and the confidence intervals overlap 0 and ‐0.25 and/or +0.25.

Figuras y tablas -
Summary of findings for the main comparison. Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection
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Comparison 1. Intervention versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality Show forest plot

8

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Low CVP versus control

3

177

Risk Ratio (M‐H, Fixed, 95% CI)

0.36 [0.02, 8.43]

1.2 Autologous blood donation versus control

1

79

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 Haemodilution versus control

2

150

Risk Ratio (M‐H, Fixed, 95% CI)

0.35 [0.04, 3.32]

1.4 Haemodilution with controlled hypotension versus control

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.5 Haemodilution with bovine haemoglobin (HBOC‐201) versus haemodilution with hydroxy ethyl starch (HES)

1

12

Risk Ratio (M‐H, Fixed, 95% CI)

3.0 [0.15, 61.74]

1.6 Hypoventilation versus control

1

79

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Serious adverse events Show forest plot

5

Rate Ratio (Fixed, 95% CI)

0.97 [0.57, 1.65]

2.1 Autologous blood donation versus control

1

Rate Ratio (Fixed, 95% CI)

0.49 [0.04, 5.32]

2.2 Haemodilution versus control

2

Rate Ratio (Fixed, 95% CI)

1.01 [0.57, 1.80]

2.3 Haemodilution with bovine haemoglobin (HBOC‐201) versus haemodilution with hydroxy ethyl starch (HES)

1

Rate Ratio (Fixed, 95% CI)

0.50 [0.05, 5.48]

2.4 Hypoventilation versus control

1

Rate Ratio (Fixed, 95% CI)

1.95 [0.18, 21.35]

3 Adverse events (severity unknown) Show forest plot

4

Rate Ratio (Fixed, 95% CI)

1.12 [0.68, 1.85]

3.1 Low CVP versus control

2

Rate Ratio (Fixed, 95% CI)

0.76 [0.28, 2.03]

3.2 Haemodilution versus control

1

Rate Ratio (Fixed, 95% CI)

1.38 [0.56, 3.39]

3.3 Hypoventilation versus control

1

Rate Ratio (Fixed, 95% CI)

1.22 [0.57, 2.62]

4 Number requiring allogeneic blood transfusion Show forest plot

8

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Low CVP versus control

3

177

Risk Ratio (M‐H, Fixed, 95% CI)

0.66 [0.42, 1.03]

4.2 Autologous blood donation versus control

1

79

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.3 Haemodilution versus control

3

233

Risk Ratio (M‐H, Fixed, 95% CI)

0.41 [0.25, 0.66]

4.4 Haemodilution with controlled hypotension versus control

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

0.05 [0.00, 0.72]

4.5 Hypoventilation versus control

1

79

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.17, 3.06]

5 Red cell transfusion Show forest plot

7

Std. Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5.1 Low CVP versus control

2

135

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.31 [‐0.65, 0.03]

5.2 Haemodilution versus control

3

180

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.33 [‐0.63, ‐0.03]

5.3 Haemodilution with controlled hypotension versus control

1

20

Std. Mean Difference (IV, Fixed, 95% CI)

‐3.63 [‐5.16, ‐2.10]

5.4 Haemodilution with bovine haemoglobin (HBOC‐201) versus haemodilution with hydroxy ethyl starch (HES)

1

12

Std. Mean Difference (IV, Fixed, 95% CI)

0.23 [‐0.91, 1.36]

5.5 Hypoventilation versus control

1

80

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.12 [‐0.55, 0.32]

6 Fresh frozen plasma Show forest plot

Other data

No numeric data

6.1 Low central venous pressure versus control

Other data

No numeric data

7 Operative blood loss (ml) Show forest plot

8

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7.1 Low central venous pressure versus control

3

175

Mean Difference (IV, Fixed, 95% CI)

‐419.35 [‐575.06, ‐263.63]

7.2 Autologous blood donation versus control

1

79

Mean Difference (IV, Fixed, 95% CI)

‐37.0 [‐100.51, 26.51]

7.3 Haemodilution versus control

3

128

Mean Difference (IV, Fixed, 95% CI)

‐17.95 [‐67.89, 32.00]

7.4 Haemodilution with controlled hypotension versus control

1

20

Mean Difference (IV, Fixed, 95% CI)

‐245.00 [‐357.80, ‐136.20]

7.5 Haemodilution with bovine haemoglobin (HBOC‐201) versus haemodilution with hydroxy ethyl starch (HES)

1

12

Mean Difference (IV, Fixed, 95% CI)

370.0 [‐1103.59, 1843.59]

8 Operating time (minutes) Show forest plot

5

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8.1 Low CVP versus control

2

90

Mean Difference (IV, Fixed, 95% CI)

‐24.69 [‐44.28, ‐5.09]

8.2 Haemodilution versus control

2

208

Mean Difference (IV, Fixed, 95% CI)

‐28.86 [‐57.37, ‐0.35]

8.3 Haemodilution with bovine haemoglobin (HBOC‐201) versus haemodilution with hydroxy ethyl starch (HES)

1

12

Mean Difference (IV, Fixed, 95% CI)

23.0 [‐83.60, 129.60]

9 Hospital stay (days) Show forest plot

4

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9.1 Low CVP versus control

2

135

Mean Difference (IV, Fixed, 95% CI)

‐4.53 [‐7.38, ‐1.68]

9.2 Haemodilution versus control

1

130

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐2.66, 2.66]

9.3 Haemodilution with bovine haemoglobin (HBOC‐201) versus haemodilution with hydroxy ethyl starch (HES)

1

12

Mean Difference (IV, Fixed, 95% CI)

2.30 [‐7.52, 12.12]
Figuras y tablas -
Comparison 1. Intervention versus control
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