Clinicians can use lower hemoglobin threshold for transfusion after hip fracture

acpnews.org

A lower hemoglobin threshold for blood transfusion after hip fracture surgery yielded similar outcomes as a more liberal threshold in older patients at high risk of cardiac disease, a new study found.
Researchers randomly assigned 2,016 patients age 50 years and older to a "liberal" transfusion strategy (to maintain a hemoglobin level of at least 10 g/dL) or a "restrictive" strategy (at physician discretion when hemoglobin level fell below 8 g/dL, or symptoms of anemia appeared). All patients had a history of, or risk factors for, cardiovascular disease and a hemoglobin level less than 10 g/dL within three days after hip fracture surgery. Patients were enrolled from mid-2004 to early 2009 and came from 47 clinical sites in the U.S. and Canada. The main outcome was death or inability to walk 10 feet or across a room without human assistance at 60-day follow-up. Results were published online Dec. 14 by The New England Journal of Medicine.
The mean patient age was 81.6 years, with cardiovascular disease present in 62.9%. In the liberal-strategy group, a median of two units of packed red cells was transfused, compared to none in the restrictive-strategy group. Primary outcome rates didn't differ between groups (35.2% in the liberal-strategy group vs. 34.7% in the restrictive-strategy group). Secondary outcomes also didn't differ significantly, with rates of in-hospital acute coronary syndrome or death at 4.3% in the liberal-strategy group versus 5.2% in the restrictive, and mortality rates of 7.6% and 6.6%, respectively, at 60-day follow-up. Other complication rates were also similar in both groups. There was an interaction between transfusion strategy and sex in the liberal-strategy group that suggested higher mortality or inability to walk without human help at 60 days in men but not women.
Noting that patients in the restrictive-strategy group received 65% fewer units of blood than the other group, and more than half received none, the authors wrote that "widespread implementation of this restrictive approach to transfusion in similar patients would greatly reduce blood use." It's reasonable to withhold transfusion in post-surgery patients who lack anemia symptoms or who haven't seen a decline in hemoglobin below 8 g/dL, even elderly patients with cardiac disease or risks, they concluded. Editorialists agreed, but warned clinicians to be alert for the risks of undertransfusion, adding that the decision to transfuse should be based on assessment of an individual's signs, symptoms and lab measures, not just the hemoglobin level.

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