Postoperative blood transfusion strategy in frail, anemic elderly patients with hip fracture

Abstract

Background and purpose — Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery.

Patients and methods — We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days.

Results — No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1–5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1–3.6; p = 0.01).

Interpretation — According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.

MG (project manager) and EMD recruited the study participants. LCB ensured protocol compliance in the orthopedic ward, with MG and EMD doing likewise in the geriatric ward. MG registered data collected from the assessors, performed the statistical analyses, and prepared the manuscript. All the authors took part in structuring and writing of the manuscript.

We gratefully acknowledge the kind participation of patients, their relatives, and general practitioners. We also thank the staff of the orthopedic and geriatric wards. The Helga and Peter Korning Foundation provided a grant for medical equipment (HemoCue portable photometer). The costs of data collection, analysis, and preparation of the manuscript were borne by the Department of Geriatrics, Aarhus University Hospital.

No competing interests declared.