Factors affecting transfusion requirement after hip fracture: can we reduce the need for blood?

Early surgery within 48 h was associated with reduced perioperative blood loss and red blood cell transfusion requirements in older patients with hip fracture: a retrospective study

PURPOSE

The aim of this study was to analyze the relationship between the timing of surgery and perioperative blood loss, red blood cell (RBC) transfusion rate, and RBC transfusion volume in older patients with hip fracture.

METHODS

From January 2020 to August 2022, this retrospective study enrolled older patients with hip fracture who underwent surgery in our hospital. The demographics, fracture type, type of surgery, time from injury to hospital, timing of surgery, medical history (hypertension, diabetes), duration of surgery, intraoperative blood loss, laboratory tests, and preoperative, postoperative and perioperative RBC transfusion requirements were recorded and analyzed. According to the surgical treatment within 48 h or after 48 h after admission, the patients were divided into early surgery group (ES) and delayed surgery group (DS).

RESULTS

A total of 243 older patients with hip fracture were finally included in the study. Among these, 96 patients (39.51%) underwent surgery within 48 h of admission and 147 (60.49%) underwent surgery after this time. Total blood loss (TBL) in the ES group was lower than that in the DS group (576.03 ± 265.57 ml vs 699.26 ± 380.58 ml, P = 0.003). Preoperative RBC transfusion rate, and preoperative and perioperative RBC transfusion volume in the ES group were significantly lower than those in the DS group (15.63% vs 26.53%, P = 0.046; 50.00 ± 128.15 ml vs 117.01 ± 225.85 ml, P = 0.004; 80.21 ± 196.63 ml vs 144.90 ± 253.52 ml, P = 0.027).

CONCLUSION

Timing of surgery within 48 h of admission for older patients with hip fracture was associated with reduced the total blood loss and RBC transfusion requirements during the perioperative period.

Transfusion Thresholds Can Be Safely Lowered in the Hip Fracture Patient: A Consecutive Series of 1,496 Patients

INTRODUCTION

The purpose of this study is to identify optimal threshold hemoglobin (Hgb) and hematocrit (Hct) laboratory values to transfuse hip fracture patients.

METHODS

A consecutive series of hip fracture patients were reviewed for demographic, clinical, and cost data. Patients receiving an allogeneic transfusion of packed red blood cells (pRBCs) were grouped based on last Hct or Hgb (H&H) value before first transfusion. Multivariate logistic regressions of H&H quantile were performed to predict "good outcomes," a composite binary variable defined as admissions satisfying (1) no major complications, (2) length of stay below top tertile, (3) cost below median, (4) no mortality within 30 days, and (5) no readmission within 30 days. Odds ratios (OR) for "good outcomes" were calculated for each H&H quantile.

RESULTS

One thousand four hundred ninety-six hip fracture patients were identified, of which 598 (40.0%) were transfused with pRBCs. Patients first transfused at Hgb values from 7.55 to 7.85 g/dL ( P = 0.043, OR = 2.70) or Hct values from 22.7 to 23.8% ( P = 0.048, OR = 2.63) were most likely to achieve "good outcomes."

DISCUSSION

The decision to transfuse patients should be motivated by Hgb and Hct laboratory test results, given that transfusion timing relative to surgery has been shown to not affect outcomes among patients matched by trauma risk score. Surgeons should aim to transfuse hip fracture patients at Hgb levels between 7.55 g/dL and 7.85 g/dL or Hct levels between 22.7% and 23.8%. These transfusion thresholds have the potential to lower healthcare costs without compromising quality, ultimately resulting in less costly, efficacious care for the patient.

LEVEL OF EVIDENCE

Level III.

Blood-Transfusion Risk Factors after Intramedullary Nailing for Extracapsular Femoral Neck Fracture in Elderly Patients

BACKGROUND

Extracapsular femoral neck fractures (eFNF) are the third most common type of fracture in traumatology. Intramedullary nailing (IMN) is one of the most frequently used ortho-pedic treatments for eFNF. Blood loss is one of the main complications of this treatment. This study aimed to identify and evaluate the perioperative risk factors that lead to blood transfusion in frail patients with eFNF who undergo IMN.

METHODS

From July 2020 to December 2020, 170 eFNF-affected patients who were treated with IMN were enrolled and divided into two groups according to blood transfusion: NBT (71 patients who did not need a blood transfusion), and BT (72 patients who needed blood transfusion). Gender, age, BMI, pre-operative hemoglobin levels, in-ternational normalized ratio (INR) level, number of blood units transfused, length of hospital stay, surgery duration, type of anesthesia, pre-operative ASA score, Charlson Comorbidity Index, and mortality rate were assessed.

RESULTS

Cohorts differed only for pre-operatively Hb and surgery time (p < 0.05).

CONCLUSION

Patients who have a lower preoperative Hb level and longer surgery time have a high blood-transfusion risk and should be closely followed peri-operatively.

Comparison of complication profiles for femoral neck, intertrochanteric, and subtrochanteric geriatric hip fractures

INTRODUCTION

Most geriatric hip fractures occur in the femoral neck (FN) and intertrochanteric (IT) regions of the femur, while a minority occur in the subtrochanteric (ST) region. Relative outcomes based on the anatomical subtype of fracture are not well studied. This study characterizes postoperative complications and outcomes of hip fractures distinguished by anatomic region.

MATERIALS AND METHODS

The targeted hip fracture series of the American College of Surgeons National Surgical Quality Improvement Program database was queried to identify geriatric (≥ 65 years) patients who sustained operative FN, IT, and ST hip fractures. Primary patient demographic and perioperative data were collected and correlated with 30-day postoperative complications and outcomes. Multivariate regression was used to calculate relative risks of adverse events (AEs) between groups.

RESULTS

In total, 8220 geriatric hip fracture patients were identified. Risk-adjusted 30-day mortality was not significantly different between patients with ST (5.8%, p = 0.735) and IT (7.3%, p = 0.169) femur fractures relative to those with FN fractures (6.6%). The overall risk-adjusted rate of minor and major medical AEs within 30 days and risk-adjusted rate of wound complications was not significantly different between FN, IT, and ST fractures. Patients with IT [34.4%, OR 2.35 (2.35-3.08), p < 0.001] and ST fractures [49.8%, OR 5.94 (4.58-7.70), p < 0.00] had higher risk-adjusted incidence of postoperative blood transfusion relative to FN fractures (18.5%). Furthermore, patients with IT fractures had a slightly lower risk-adjusted incidence of unplanned reoperation [2.1 vs. 2.7%, OR 0.69 (0.47-0.99), p = 0.046] and hospital readmission (7.8 vs. 9.2%, OR 0.76 [0.63-0.91], p = 0.003) than patients with FN fractures.

CONCLUSIONS

With respect to anatomic region, geriatric hip fractures have similar short-term mortality and medical AE profiles with differences in transfusion, reoperation, and readmission rates. Knowledge of these short-term outcomes may guide surgeons in counseling hip fracture patients peri-operatively.

Tranexamic acid usage in hip fracture surgery: a meta-analysis and meta-regression analysis of current practice

INTRODUCTION

The use of tranexamic acid (TXA) in hip fracture surgery remains inconclusive. The aim of the present meta-analysis was to assess the role of TXA use in hip fracture surgery, and attempt to disclose possible factors which might influence TXA efficacy and safety.

MATERIALS AND METHODS

A systematic computerized literature search was conducted to retrieve all randomized controlled trials (RCTs) and cohort studies regarding TXA use in hip fracture surgery. Overall efficacy and safety were evaluated. Then, subgroup and meta-regression analyses were conducted to disclose the influence of geographic area, fracture type, administration route, frequency and dosage of TXA, blood transfusion threshold, and follow-up duration on the overall effect.

RESULTS

Thirty-four RCTs and 11 cohort studies were included. Patients receiving TXA had a significant decrease in the need for blood transfusion, reduced total, intra-operative and post-operative blood loss, a decrease in pre- and postoperative hemoglobin difference, without increasing thromboembolic events risk. Subgroup analysis showed that topical TXA had a lower transfusion rate compared with controls, yet the result did not reach statistical significance. Also, TXA had similar efficacy and safety profiles in patients with different frequency and dosage of TXA.

CONCLUSION

Current evidence indicated that intravenous administration of TXA could significantly reduce blood transfusion and blood loss without increasing risk of thromboembolic events. The frequency and dosage of TXA might not alter the beneficial effect. The application of topical TXA should be cautious.

Factors affecting the need of postoperative blood transfusion in elderly patients with intertrochanteric hip fracture

INTRODUCTION

We investigated the risk factors that increased the frequency of blood transfusions in elderly patients with intertrochanteric hip fractures to determine blood transfusion risk before surgery and to take selective precautionary measures in the group at high risk for transfusion to ensure safe surgery.

MATERIALS AND METHODS

We retrospectively reviewed the electronic medical records of 203 patients who underwent surgical fixation of intertrochanteric hip fractures from January 2015 to December 2020. We hypothesized that patient sex, age, body mass index, preoperative hemoglobin, preoperative platelet count, glomerular filtration rate (GFR), preoperative albumin level, American Society of Anesthesiologist score, intraoperative blood loss, duration of surgery, method of anesthesia, and time from injury to surgery would affect the need for blood transfusion. Student's t-test, Chi-squared test, and the one-way analysis of variance test were used to determine whether differences between variables in the transfusion and non-transfusion groups were significant.

RESULTS

Unstable fractures (P = 0.002), general anesthesia (P = 0.028), lower preoperative hemoglobin levels (P < 0.001), and lower GFRs (P < 0.001) were identified as related to blood transfusions in univariate analysis. In multivariate logistic analysis, the need for allogeneic blood transfusion in unstable fractures was approximately 2.949 times higher than in stable fractures (P = 0.009). The risk in general anesthesia patients was about 2.953 times higher than in spinal anesthesia patients (P = 0.007). In addition, the need for allogeneic blood transfusion increased by about 1.293 times as preoperative hemoglobin levels decreased by 1 g/dL (P = 0.017) and increased by about 1.017 times as the GFR decreased by 1 mL/min/1.7m2 (P = 0.006).

CONCLUSION

Low preoperative hemoglobin levels, low GFRs, general anesthesia, and unstable fractures in elderly patients with intertrochanteric hip fractures increased the risk of blood transfusion.

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial

INTRODUCTION

Topical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.

METHODS

A total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.

RESULTS

There was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760-1.795) in the TXA group and 1.078 L (IQR: 0.797-1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40-140) in the TXA group and 70 mL (IQR: 30-168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).

CONCLUSION

A 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.

Red Blood Cell Transfusion and Postoperative Delirium in Hip Fracture Surgery Patients: A Retrospective Observational Cohort Study

Background

Patients having hip fracture surgery are at high risk for postoperative delirium. Red blood cell (RBC) transfusion may increase postoperative delirium risk by causing neuroinflammation. We hypothesized that RBC transfusion would be associated with postoperative delirium in patients having hip fracture surgery.

Methods

An observational cohort study was performed using the United States National Surgical Quality Improvement Program (NSQIP) participant use files for hip fracture from 2016 to 2018. Propensity score analysis and inverse probability of treatment weighting (IPTW) were used to reduce bias from confounding. An IPTW adjusted odds ratio for developing postoperative delirium was calculated for patients who received RBC transfusion during surgery or in the 72 hours after.

Results

There were 20,838 patients who had eligible current procedural terminology (CPT) codes for primary hip fracture surgery and complete study data. After employing strict exclusions to balance covariates and reduce bias, 3,715 patients remained in the IPTW cohort. Of these, 626 patients (16.9%) received RBC transfusion and 665 patients (17.9%) developed postoperative delirium. IPTW adjustment led to good covariate balance between patients who received RBC transfusion and those who did not. Patients who received RBC transfusion had significantly higher odds of postoperative delirium, IPTW adjusted odds ratio = 1.21, 95% CI = 1.03 to 1.43, and P = 0.02. Discharge location also differed significantly between patients who received RBC transfusion and those who did not (P < 0.001) with in-hospital mortality or referral to hospice occurring in 1.6% of patients who received RBC transfusion and 1.3% of patients who were not transfused.

Conclusion

RBC transfusion is associated with increased odds of postoperative delirium after hip fracture surgery and may be associated with worse clinical outcome.

Can early surgery reduce the need to packed red blood cell transfusion in elderly patients with intertrochanteric femur fractures?

INTRODUCTION

This study was designed to compare and analyse the amount of packed red blood cell transfusions (PRBCTs) in relation to surgical timing in elderly patients undergoing cephalomedullary nailing due to intertrochanteric fractures.

MATERIALS AND METHODS

A total of 110 patients (24 men, 86 women) who had received cephalomedullary nailing for intertrochanteric fractures were retrospectively investigated. A restrictive transfusion strategy was followed during the peri-operative period. Patient characteristics and fracture classifications, methods of anaesthesia, time interval from admission to surgery (TI) and operative duration (OD) were investigated. The amount of PRBCTs was measured and categorised as pre-operative, post-operative and entire peri-operative values. The patients were divided into early surgery (ES) and delayed surgery (DS) groups based on surgical treatment within or after 48 h of admission. In addition, multiple regression analysis including TI and other factors likely to affect blood loss and PRBCT was conducted to objectively evaluate the impact of TI on the amount of the entire peri-operative PRBCT.

RESULTS

The patients had a mean age of 82.6 years (range, 68-98), mean TI of 41.1 h (range, 5-110) and mean OD of 37 min (range, 15-90). Although the amount of pre-operative PRBCT was significantly different between the ES and DS groups (36.2 ml vs. 168.3 ml, p < 0.001), they displayed no remarkable difference regarding post-operative and the entire peri-operative amount of PRBCTs (279.7 ml vs. 189.8 ml, p = 0.064 and 315.9 ml vs. 358.0 ml, p = 0.992, respectively). The results from multiple regression analysis demonstrated that TI did not significantly affect the amount of the entire peri-operative PRBCT.

CONCLUSIONS

If an appropriate transfusion strategy is adopted, TI does not seem to affect the amount of peri-operative PRBCT in elderly patients with intertrochanteric fractures. Nevertheless, careful transfusion management with a view to compensating for any drop in pre-operative haemoglobin is necessary when surgery is delayed.

Postoperative haemoglobin estimation in elderly hip fractures

OBJECTIVE

The purpose of our study was to analyze the effect of postoperative hemoglobin check on the day of surgery and 1 day postoperatively in elderly hip fracture patients with an aim to determine an optimum timing of postoperative hemoglobin check.

MATERIAL AND METHODS

A retrospective study of 253 patients. Age, Charlson morbidity index, fracture type, time from admission to surgery, type of surgery, preoperative hemoglobin, postoperative hemoglobin, hemoglobin drop, day of postoperative hemoglobin measurement, blood transfusion, length of hospital stay, and 30-day mortality were recorded.

RESULTS

One hundred and sixty-three patients (Group I) had postoperative hemoglobin check on the first postoperative day and 90 patients (Group II) on the day of surgery. Mean age in Group I was 82 years and 80 years in Group II. Mean Charlson morbidity index for Group I was 5.9 and Group II was 5.7. There was a significantly higher hemoglobin drop in Group I (P < 0.05) but no difference in blood transfusion requirement, length of stay, or 30-day mortality in the two groups (P > 0.05).

CONCLUSION

Our results suggest that postoperative hemoglobin measurement on the day of surgery is not a true reflection of hemoglobin drop and recommend estimation of hemoglobin on the first postoperative day.

Safety and efficacy of a strategy of vitamin K antagonist reversal with prothrombin complex concentrates compared to vitamin K in patients with hip fracture

Background:

Increased preoperative delay in patients with hip fractures may be responsible for increased morbidity and mortality. We hypothesized that a strategy of reversal of vitamin K antagonist (VKA) by prothrombin complexes concentrates (PCCs), as compared to vitamin K, is safe and reduces preoperative delay and hospital length of stay (LOS).

Methods:

In this pilot study, we reviewed the records of patients admitted to a university-affiliated hospital for hip fracture between Jan. 1, 2012, and Dec. 31, 2016, who were taking VKA. Patients were stratified according to reversal strategy (vitamin K v. PCC). Adverse effects, time to surgery, LOS and mortality were collected from the electronic medical record and were compared between the 2 study groups and a control group not treated with VKA.

Results:

A total of 141 patients were included in the study: 65 in the vitamin K group, 26 in the PCC group and 50 in the control group. The median preoperative delay in the PCC group (20 h [interquartile range (IQR)] 13–25 h]) and the control group (20 h [IQR 15–33 h]) was lower than that in the vitamin K group (45 h [IQR 31–52 h]) (p < 0.001). Patients in the PCC group had a shorter median hospital LOS than those in the vitamin K group (6 d [IQR 4–9 d] v. 8 d [IQR 6–11 d], p < 0.05). No difference was observed in the proportion of patients who received a red blood cell transfusion, or had thrombotic or hemorrhagic complications. No difference in mortality at 12 months was observed between the groups.

Conclusion:

In patients with hip fracture, the use of PCCs as compared to vitamin K to reverse the effect of VKA significantly reduced preoperative delay and hospital LOS, and was not associated with an increase in the rates of thrombotic or hemorrhagic complications. Prospective studies involving a greater number of patients are required to confirm these promising results.

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND

Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.

AIM

To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.

METHODS

In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.

RESULTS

Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.

CONCLUSION

The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Blood transfusion rates and predictors following geriatric hip fracture surgery

BACKGROUND

Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion.

RESULTS

In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02-1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99-5.52], p = 0.001), female sex (OR 1.61 [1.39-1.87], p < 0.001), lower BMI (OR 0.97 [0.96-0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01-1.27], p = 0.031), COPD (OR 1.30 [1.06-1.59], p = 0.011), hypertension (OR 1.17 [1.01-1.35], p = 0.038), increased OR time (OR 1.02 [1.01-1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57-3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84-6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02-1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04-1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001).

CONCLUSIONS

Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

The Correlation Between Timing of Surgery and the Need for RBC Transfusions in the Geriatric Intertrochanteric Fracture Population

Objective:

To identify whether the timing of surgery affects red blood cell (RBC) transfusion requirements in the elderly with intertrochanteric fractures.

Methods:

We retrospectively studied all patients undergoing surgical fixation of their intertrochanteric fractures in our hospital between January 2009 and December 2018 and analyzed the relationship between the timing of surgery and RBC transfusion.

Results:

A total of 679 patients were included in this study. The need for RBC transfusion was lower in the patients who underwent surgery within 12 h after admission (timing of surgery <12 h, <12 h group) than those who underwent surgery over 12 h after admission (timing of surgery >12 h, >12 h group) (P = 0.046); lower in the the patients who underwent surgery within 24 h after admission (timing of surgery <24 h, <24 h group) than in those who underwent surgery over 24 h after admission (timing of surgery >24 h, >24 h group) (P = 0.008), and lower in the <24 h group compared to the patients who underwent surgery within 48 h after admission (timing of surgery <48 h, <48 h group) (P = 0.035). Moreover, the need for RBC transfusion was lower in the <24 h group (in the first 24 h from admission to surgery) than in the 24-48 h group (in the second 24 h from admission to surgery) (P = 0.016), and also lower in the <24 h group compared to the 48-72 h group (in the third 24 h from admission to surgery) (P = 0.047). However, there were no differences between the <12 h group and 12-24 h group, between the <12 h group and <24 h group, and between the 12-24 h group and <24 h group, respectively.

Conclusion:

Timing of surgery within 24 h contributes to the reduction of RBC transfusion in the elderly with intertrochanteric fractures.

Hip fracture and mortality: study of specific causes of death and risk factors

The leading causes of mortality in our study were pneumonia, diseases of the circulatory system, and dementias. In patients with hip fractures, the emphasis should be placed not only on measures to prevent falls and osteoporosis, but also on preventing functional decline and pneumonia.

PURPOSE

To describe the specific causes of death in patients who died up to 2 years after sustaining a hip fracture, how many of those deaths were directly related to the hip fracture, and the risk factors for mortality.

METHODS

A retrospective review of the clinical data of all patients admitted with hip fractures between December 2009 and September 2015. Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems (ICD10) RESULTS: In the first 2 years after hip fracture, 911 patients (32.7%) died. The leading causes of mortality were pneumonia 177 (19.4%), diseases of the circulatory system 146 (16%), and dementias 126 (13.9%). Thirty patients (3.2%) died from causes directly related to hip fracture or surgery. Mortality risk factors with a higher relative risk were advanced age, male sex, higher comorbidity, delirium, and medical complications during admission.

CONCLUSIONS

Pneumonia and circulatory system diseases were the commonest causes of death in our study. In patients with hip fractures, emphasis should be placed on preventing functional decline and pneumonia. In a few patients, death was directly related to the hip fracture, although decompensation of chronic illness as a result of hip fracture and fracture-related functional decline may have been indirect causes. Patients with worse conditions at admission had the highest risk of mortality.

Development of a Nomogram to Predict Postoperative Transfusion in the Elderly After Intramedullary Nail Fixation of Femoral Intertrochanteric Fractures

Purpose

The aim of our study was to explore the risk factors related to blood transfusion after intramedullary nail fixation of elderly femoral intertrochanteric fracture (FTF) and establish a nomogram prediction model.

Patients and Methods

We conducted a retrospective study including elderly FTF patients treated by intramedullary nail between January 2017 and December 2019. Perioperative information was obtained retrospectively, uni- and multivariate regression analyses were performed to determine risk factors for blood transfusion. A nomogram model was established to predict the risk of blood transfusion, and consistency coefficient (C-index) and correction curve were used to evaluate the prediction performance and consistency of the model.

Results

Of 148 patients, 119 were finally enrolled in the study and and 46 patients (38.7%) received a blood transfusion after the operation. Logistic regression analysis the female, lower preoperative Hb, ASA score >2, general anesthesia, and higher intraoperative blood loss were independently associated with the blood transfusion. The accuracy of the contour map for predicting transfusion risk was 0.910.

Conclusion

These risk factors are shown on the nomogram and verified. Through the assessment of the risk of blood transfusion and the intervention of modifiable risk factors, we may be able to reduce the blood transfusion rate to a certain extent, so as to further guarantee the safety of the elderly patients during the perioperative period.

Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions

BACKGROUND

Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear.

METHODS

This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery.

RESULTS

There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.

CONCLUSIONS

Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.

Intravenous Iron May Improve Outcomes in Elderly Patients With Operative Hip Fractures

Introduction:

Hip fractures are common injuries with high morbidity and mortality rates. These patients often become anemic and require allogenic blood transfusion. Transfusions are costly with potential complications. This study examines the effect of intravenous (IV) iron on patients with hip fractures, undergoing surgery within 48 hours, and being treated with a highly restrictive transfusion protocol.

Materials and Methods:

A retrospective chart review performed on patients admitted to a level 1 tertiary care center with fractures of the proximal femur from December 2015 to December 2017 included 239 patients. Patients who received 300 mg of IV iron when their hemoglobin fell below 11 g/dL were compared to a control group of patients who never received IV iron with respect to transfusion rate, 30-day readmission rate, nosocomial infections, length of stay, and hospital costs.

Results:

There were no significant differences in transfusion rates (P = .118). There was a trend toward decreased length of stay (P = .063) and 30-day readmission rates (P = .051) with a 59% reduction in the odds of 30-day readmission when a patient received IV iron. There were no differences in nosocomial infection rates or cost of hospitalization.

Discussion:

This study presents a compelling argument for further research regarding the use of IV iron in elderly patients undergoing surgery for a hip fracture. Length of stay and transfusion rates are increased in patients with intertrochanteric fractures and undergoing intramedullary nailing. A higher number of these patients in the IV iron group may have falsely increased these rates. A prospective, randomized, controlled trial is needed to assess the true effects of perioperative IV iron.

Conclusions:

This study showed no significant benefit to IV iron use in elderly patients undergoing surgical treatment of hip fracture. The decrease in 30-day readmission rate should be further examined with a prospective randomized controlled trial.

The effect of implant choice on varus angulation and clinical results in the management of subtrochanteric fractures

Introduction

The aim of this study was to evaluate the effects of implant choice on varus angulation in the management of subtrochanteric fractures.

Methods

Between 2011 and 2016, 58 patients were included in the study and femur locking plate (PF-LCP; Group 1 = 27) and proximal femoral nails (PFN; Group 2 = 31) were compared retrospectively.

Results

In group 1, femoral NSA was measured 131,37 ± 1,95 and last follow-up angle was 127,33 ± 2,40. (p = 0,025). The mean Harris hip score was 67.59 ± 17.74 and 63.29 ± 13.83 in Group 1 and Group 2, respectively (p = 0.406).

Conclusions

Plate fixation is not as successful as proximal nails at preventing varus angulation.

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures

INTRODUCTION

In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population.

METHODS

In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation.

RESULTS

After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival.

DISCUSSION

A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Safety of Continuing Antiplatelet Medication Among Elderly Patients Undergoing Urgent Hip Fracture Surgery

Elderly patients with hip fractures who are receiving antiplatelet therapy are commonly encountered in clinical practice. This study sought to elucidate the safety of urgent hip surgery without termination of antiplatelet medication among patients taking a combination of aspirin and dipyridamole, aspirin alone, or dipyridamole alone. This retrospective cohort study included 176 patients 55 years or older who had uncomplicated hip fractures and underwent surgery within 48 hours after admission. On the basis of the preoperative medication regimen, the patients were divided into the following 4 groups: those receiving aspirin and dipyridamole combined (n=29); those receiving aspirin alone (n=63); those receiving dipyridamole alone (n=28); and those not receiving antiplatelet medication (n=56). Main outcomes, including total blood loss, transfusion rate, and 1-year mortality, were analyzed. There was no significant difference in total blood loss, transfusion rate, or 1-year mortality among the 4 groups. The group receiving aspirin and dipyridamole combined preoperatively had increased intraoperative blood loss (mean, 309.14±189.15 mL) compared with the group not receiving antiplatelet medication (mean, 214.64±119.21 mL; P=.005). There was no significant difference in the hazard ratio (P>.05) for 1-year mortality among the 4 groups after adjusting for confounding covariates, including age, sex, Charlson Comorbidity Index, and duration of hospital stay. Patients receiving antiplatelet medication, including aspirin, dipyridamole, or both, who have uncomplicated hip fractures may undergo urgent surgery without a significant difference in total blood loss, transfusion rate, or 1-year mortality compared with patients not receiving anti-platelet medication. [Orthopedics. 2019; 42(5):268-274.].

Efficacy and safety of tranexamic acid in geriatric hip fracture with hemiarthroplasty: a retrospective cohort study

BACKGROUND

Geriatric hip fracture patients are particularly susceptible to blood loss and venous thromboembolism (VTE) during hemiarthroplasty, yet relatively few studies have examined the safety and efficacy of tranexamic acid (TXA) in these patients.

METHODS

This cohort study of hip fracture patients (≥65 years) undergoing hemiarthroplasty between January 2013 and September 2016 involved 289 patients who received 15 mg/kg TXA prior to surgery and 320 who received no TXA. All patients underwent a fast-track program including nutrition, blood, and pain management; VTE prophylaxis; early mobilization; and early intake. The primary outcome was red cell transfusion requirement. Secondary outcomes included blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay. Multivariate logistic regression and meta-analysis of the literature were also performed to control for confounding factors and identify risk factors of red cell transfusion.

RESULTS

The proportion of patients receiving at least 1 U of erythrocytes was significantly lower in the TXA group (8.65%) than in the control group (24.06%, OR 0.299, p < 0.001). Mean Hb level was significantly higher in the TXA group on postoperative day 1 (111.70 ± 18.40 vs 107.29 ± 18.70 g/L, p = 0.008) and postoperative day 3 (108.16 ± 17.25 vs 104.22 ± 15.16 g/L, p = 0.005). A significantly higher proportion of TXA patients began to ambulate within 24 h after surgery (37.02% vs 26.25%, p = 0.004), and their length of hospitalization was significantly shorter (11.82 ± 4.39 vs 15.96 ± 7.30 days, p = 0.003). TXA did not increase risk of DVT (OR 0.70, 95%CI 0.25 to 1.97). Logistic regression showed that, after adjusting for covariates, TXA was associated with 62% lower risk of red blood cell transfusion (0.327, 95%CI 0.214 to 0.696), and a similar result was obtained in meta-analysis of unadjusted data from the present study and the literature (OR 0.33, 95%CI 0.25 to 0.43).

CONCLUSION

TXA appears to be safe and effective for reducing blood loss and red blood cell transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty.

Intraoperative blood transfusion predicts postoperative delirium among older patients undergoing elective orthopedic surgery: A prospective cohort study

OBJECTIVES

To evaluate the roles of preoperative anemia and intraoperative blood transfusion in the development of postoperative delirium among older patients undergoing elective orthopedic surgery.

METHODS

This prospective cohort study recruited subjects aged 60 years old and above who were admitted for elective orthopedic surgery in a tertiary medical center during April 2011 to December 2013. Demographic data (age, gender, body mass index [BMI], and educational level), surgery-related factors (American Society of Anesthesiology [ASA] class, type of anesthesia and surgery, and intraoperative blood transfusion), results of geriatric assessment (hearing/visual impairment, cognition, depressive mood, comorbidity, malnutrition, polypharmacy, activities of daily living [ADL], and instrumental activities of daily living [IADL]), laboratory data, length of hospital stay, and the development of postoperative delirium were collected for analysis.

RESULTS

Overall, 461 patients (mean age: 73.5 ± 7.5 years, 42.1% males) were enrolled for study, and 37 (8.0%) of them developed postoperative delirium. We categorized all subjects into four groups based on anemia on admission and blood transfusion during operation or not. Multivariate logistic regression showed that subjects with anemia on admission and received intraoperative blood transfusion were at higher risk of developing postoperative delirium (adjusted odds ratio 3.090; 95% confidence interval [CI], 1.070-8.926) and those without anemia on admission but received intraoperative blood transfusion were at marginal risk (adjusted odds ratio 2.906; 95% CI, 0.912-9.259) after adjustment for covariates.

CONCLUSIONS

Anemic older patients receiving intraoperative blood transfusion during operation were at the greatest risk for postoperative delirium when they underwent elective orthopedic surgery. Further intervention study is needed to reduce the risk of postoperative delirium for these patients.

Factors affecting blood loss and blood transfusion in patients with proximal humeral fractures

BACKGROUND

The aim of this study was to determine the amount of blood loss and the rate of blood transfusion in patients receiving surgery for proximal humeral fractures depending on the treatment and fracture classification. Moreover, factors associated with blood loss and blood transfusion were analyzed.

METHODS

The study included 420 patients who had received surgery for proximal humeral fractures. Data from medical records were collected retrospectively. The calculated blood loss and the transfusion rate were analyzed depending on the type of surgery (plate fixation, arthroplasty, and others) or the fracture classification (2-, 3-, and 4-part fractures). The extent of blood loss and the need for transfusion were correlated with potential risk factors. A score to estimate the probability of blood transfusion was developed.

RESULTS

Average blood loss was 284 mL, and the transfusion rate was 14.5% for all proximal humeral fractures. Shoulder arthroplasty was associated with higher blood loss (353 mL, P < .01) and a higher blood transfusion rate (27.3%, P < .01) than plate fixation (263 mL and 10.9%, respectively). The fracture classification had no effect on either factor. Significant risk factors for blood loss were male sex, body mass index, surgery time, time until surgery, and vitamin K antagonists. Age, blood loss, American Society of Anesthesiologists score greater than 2, vitamin K antagonists, coronary artery disease (CAD), peripheral artery disease (PAD), and renal disease were associated with a higher transfusion rate.

CONCLUSION

Blood loss could be affected by a shorter surgery time and by choosing an adequate time until surgery. The consideration of risk factors and the use of a transfusion risk score allow more elaborate ordering of cross-matched blood units and can decrease institutional costs.

Impact of postoperative haemoglobin on length of stay post fractured hip repair in patients with standardised perioperative management

INTRODUCTION:

Perioperative blood transfusion is not without risk and effort should be made to limit patients' exposure to allogeneic blood. However, there is conflicting data regarding the impact of anaemia on postoperative recovery in patients with repaired hip fractures. It is hypothesised that for a given baseline functional status and fracture type, lower postoperative haemoglobin will increase rehabilitation time and prolong total length of hospital stay.

METHODS:

This is a retrospective study on data collected prospectively on patients entered into the Clinical Pathway aged >65 years admitted to Queen Mary Hospital (QMH) with a fractured neck of femur during 2011-2013. Potential predictor variables were analysed with linear regression with respect to total length of stay and those that reached a significance level of 0.05 were included in further analysis.

RESULTS:

1092 patients were admitted to QMH with a suspected fractured neck of femur; data from 747 patients were analysed. The fracture sites were neck of femur (50%), intertrochanteric (48%) and subtrochanteric fracture (2%). Approximately 30% of patients received blood transfusions. Of these only the development of postoperative medical complications statistically prolonged hospital stay. No relationship was seen with haemoglobin levels cut-off above and below 10 g/dl with the result remaining non-significant down to a cut-off of above and below 8 g/dl.

DISCUSSION:

This study revealed that post-surgical haemoglobin level of between 8 g/dl and 10 g/dL did not have an impact on the total length of hospital stay. The development of postoperative medical complications was the only factor that prolonged the total length of stay.

Impact of preadmission anti-inflammatory drug use on the risk of RBC transfusion in elderly hip fracture patients: a Danish nationwide cohort study, 2005-2016

BACKGROUND

Do prescription drugs with anti-inflammatory properties such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and statins increase the risk of postoperative bleeding measured with RBC transfusion in elderly hip fracture surgery patients?

STUDY DESIGN AND METHODS

Using the Danish Multidisciplinary Hip Fracture Database, 74,791 patients aged 65 years or older with surgery-treated hip fracture were identified during 2005-2016, and their use of NSAIDs, corticosteroids, and statins was ascertained. For each drug, patients were categorized as nonusers (no prescription ≤365 days prior to surgery), former users (one prescription 91-365 days), and current users (one prescription ≤90 days). Information on surgical treatment, transfusion, other medication and comorbidities were collected using Danish nationwide registries. A log-binomial model was used to estimate relative risks for RBC transfusion within 7 days of surgery and corresponding 95% confidence intervals. Adjustments were made for patient- and surgery-related factors.

RESULTS

Former and current users of NSAIDs, corticosteroids, and statins accounted for 22%, 10%, and 24%, respectively. Current users of NSAIDs had an increased adjusted relative risk of transfusion (1.07; confidence interval, 1.04-1.10) compared to nonusers. There was no association between current users of corticosteroids and statins and risk of transfusion.

CONCLUSION

NSAID use within 90 days of a hip fracture surgery was associated with an increased risk of RBC transfusion. Thus, current use of NSAIDs can be associated with an increased risk of postoperative bleeding, but we cannot rule out the influence of confounding.

Hospital stay and blood transfusion in elderly patients with hip fractures

Neck of femur (NOF) fractures in elderly patients are the most frequent condition which an orthopaedic surgeon confronts nowadays. The incidence of these fractures is increasing as the population continues to age. These patients absorb the majority of the resources in the hospitals, as their healthcare demands are increased. This study included all patients who were admitted to our hospital between January and October 2015 following a neck of femur fracture. A total of 336 patients were included (72.3% female). We gathered demographic and hospitalisation data from patients' files. Haemoglobin (Hb) levels at admission and transfusion data were also collected. Male patients appeared to have a relatively higher risk of mortality than females (p=0.01). Patients with high ASA grade (IV) had a higher mortality rate (p=0.01). Age, delay of surgery, type of surgery, AMTS and Hb at admission and type of fracture on the other hand did not have a significant impact on mortality (p>0.05). Patients who needed transfusion during their hospitalisation had significantly lower Hb at admission (p=0.044). More specifically, patients who had Hb<110 at admission were more likely to need transfusion (p<0.001). Hospitalisation of patients who needed transfusion was significantly prolonged. In our effort to deliver the best services to our patients, this study considers transfusing the elderly patients with low Hb at admission (Hb<110) pre-operatively, with a view to increasing their reserves for the operation and potentially speeding up the rehabilitation process and decreasing their hospitalisation time.

What Is the Influence of a Delay to Surgery >24 Hours on the Rate of Red Blood Cell Transfusion in Elderly Patients With Intertrochanteric or Subtrochanteric Hip Fractures Treated With Cephalomedullary Nails?

OBJECTIVES

To evaluate the influence of delay to surgery >24 hours on the rate of red blood cell transfusion in a selected population of hip fracture patients.

DESIGN

Cohort study.

SETTING

Tertiary care university hospital.

PATIENTS

A consecutive series of 987 patients (714 females) with a mean age of 86.3 (range 50-106) years operated with an intramedullary nail due to an unstable intertrochanteric or subtrochanteric hip fracture.

INTERVENTION

Patients operated with an intramedullary nail due to an unstable intertrochanteric or subtrochanteric hip fracture.

MAIN OUTCOME MEASURES

Red blood cell transfusion rate, mortality, and postoperative length of stay were analyzed. Logistic regression analysis was used to adjust for anticoagulants, acetylsalicylic acid class, fracture type, preoperative hemoglobin (Hb) value, and time to surgery. Follow-up time was 1 year.

RESULTS

There was an increased preoperative transfusion rate among patients delayed for more than 24 hours to surgery (22%), compared with those operated within 24 hours (6.1%) (P < 0.001). After adjusting for anticoagulants, acetylsalicylic acid class, fracture type, preoperative Hb value, and time to surgery, it was found that anticoagulants [relative risk (RR), 2.0; confidence interval (CI), 1.1-3.5] and surgery delayed for more than 24 hours (RR, 3.9; CI, 2.3-6.1) were significantly associated with an increased rate of preoperative transfusions, although an increasing preoperative Hb value was associated with a lower rate of transfusions (RR, 0.3; CI, 0.2-0.4).

CONCLUSION

We found an increased rate of preoperative transfusions among patients with unstable intertrochanteric or subtrochanteric hip fractures operated with an intramedullary nail that were delayed for surgery more than 24 hours.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study

Background

Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods.

The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect.

Methods

A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared.

Results

There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02).

Conclusion

We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe.

Impact of a patient blood management program within an Orthogeriatric care service

BACKGROUND

Patient blood management (PBM) performs multidisciplinary strategies to optimize red blood cell (RBC) transfusion. Orthogeriatric share care models (surgeon and geriatrician manage the patient together from admission) have the goal of improving outcomes in hip fracture patients.

MATERIAL AND METHODS

A prospective observational study was conducted. Patients aged ≥70 years undergoing hip fracture (HF) surgery were consecutively included. When admitted on the orthogeriatric service a PBM protocol was applied based on: perioperative antithrombotic management, intravenous iron sucrose administration and restrictive transfusion criteria. Risk factors, clinical and functional effects of transfusion and its requirements were assessed to audit our model.

RESULTS

A total of 383 patients participated (women, 78.8%; median age, 86 (82-90) years). 210 patients (54.8%) were transfused. Age (OR = 1.055, 95% CI 1.017-1.094; p = 0.004) and Hemoglobin (Hb) level on admission (OR = 0.497, 95% CI 0.413-0.597; p < 0.001) were found to be significant risk factors for transfusion. Transfusion increased length of stay (b = 1.37, 95% CI 0.543-2.196; p = 0.001) but did not have an effect on other variables.

DISCUSSION

The PBM program established within an orthogeriatric service showed positive outcomes in terms of clinical complications, mortality, delirium or functional recovery in transfused patients, whereas it did not impact on shorter length of stay. The risk of transfusion on admission was predicted with the lower Hb levels on admission, along with the age of the patients. New measurements as homogenous restrictive transfusion criteria, a single-unit RBC transfusion and the assessment of the intravenous iron efficacy are need to be applied as a result of the high transfusion requirements.

Introduction of national guidelines for restrictive blood transfusion threshold for hip fracture patients--a consecutive cohort study based on complete follow-up in national databases

Background

Randomized controlled trials have demonstrated that a restrictive red blood cell (RBC) transfusion strategy lowers transfusion frequency without affecting mortality. However, the external validity of these trials has not been tested in a large cohort. The purpose was to estimate the effect of introducing a National Clinical Guideline (NCG) for a restrictive hemoglobin transfusion threshold on transfusion frequency and mortality in hip fracture patients > 65 years old.

Methods

A consecutive cohort study of hip fracture patients > 65 years old residing in the southern region of Denmark was conducted using prospectively gathered data from registers during two separate 1-year time periods. The first period from October 1, 2012, to September 30, 2013, included 1494 patients and used a liberal transfusion threshold, whereas the second period from October 1, 2015, to September 30, 2016, including 1414 participants used a restrictive threshold from the NCG. Participant data for age, sex, body mass index, Charlson Comorbidity Index, time to surgery, and death were retrieved from the Danish Interdisciplinary Registry of Hip Fractures and were merged with RBC transfusion and medication data extracted from the Danish Transfusion and Odense Pharmacoepidemiological Databases, respectively. Cox proportional hazards models were used to test relative mortality risk for the restrictive group compared with the liberal group at 30 and 90 days.

Results

Overall RBC transfusions decreased from 42 to 30% (p < 0.001). The 30-day mortality rate (95% CI) was 9% (8;11) in the restrictive group and 13% (11;14) in the liberal group (p < 0.008), whereas the adjusted relative mortality risk was 0.72 (0.57;0.91). The 90-day mortality rate was 15% (13;17) in the restrictive group and 19% (17;21) in the liberal group, whereas the adjusted relative mortality risk was 0.78 (0.65;0.94).

Conclusion

These data suggest that the introduction of an NCG on restrictive blood transfusion leads to lower transfusion frequency in hip fracture patients > 65 years old. Even though this reduction is associated with decreased mortality at both 30 and 90 days, it may be explained by other issues than restrictive transfusion strategy. There has been an improvement in the mortality of hip fracture patients in Denmark, and we suggest that a restrictive transfusion strategy does not lead to increased mortality.

Predictors for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary nailing

PURPOSE

The aim of our study was to determine predictive factors and requirement for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary device.

METHODS

Seventy-nine patients with extra capsular hip fractures treated with cephalo-medullary nailing were included in the study. Age, sex, ASA grade, timing of surgery, preoperative and postoperative haemoglobin, length of hospital stay, fracture type, number of units transfused and 30-day mortality were recorded.

RESULTS

The mean age was 82.3 years. Forty-seven patients underwent a short nail and 32 patients a long nail; 53.4% patients required blood transfusion postoperatively. Transfusion was required in 71.8% of the long nails (p < 0.05), 65.8% patients above the age of 80 (p < 0.05), 100% of the patients with hemoglobin below 90 g/L and 20 patients with a ASA grade of 3 (p < 0.05). 78.5% patients with A2 fracture and 75% of A3 fractures needed blood transfusion (p > 0.05). Length of hospital stay in non-transfusion group was 13 days and in transfusion group was 19 days (p < 0.05). 55.1% operated within 36 h and 47.6% operated after 36 h of admission needed transfusion (p > 0.05). Thirty-day mortality in patients needing blood transfusion was 5% and in non-transfusion group was 3.7% (p > 0.05).

CONCLUSION

Patient age, ASA grade, preoperative haemoglobin and length of nail are reliable predictors for perioperative blood transfusion in extra capsular hip fractures in elderly patients treated with cephalo-medullary nailing and reinforce a selective transfusion policy.

Effect of tranexamic acid use on blood loss and thromboembolic risk in hip fracture surgery: systematic review and meta-analysis

INTRODUCTION

Intravenous tranexamic acid (IV TXA) is a recognised pharmaceutical intervention utilised to minimise blood loss and allogenic blood transfusion. However, the use of IV TXA in hip fracture surgery remains inconclusive. We conducted a meta-analysis to investigate the role of TXA in operative hip fracture management on operative and total blood loss, allogenic blood transfusion requirements and impact on venous thromboembolic (VTE) event incidence.

METHODS

A systematic computerised literature search of PubMed, Medline, Embase, Ovid, The Cochrane Controlled Trials Register, Trip and Google was conducted. We reviewed the efficacy of IV TXA on perioperative blood loss, total blood loss, pre- and postoperative haemoglobin differences, duration of surgery, allogenic blood transfusion requirements and VTE events.

RESULTS

8 studies were eligible including 6 randomised control trials and 2 cohort studies. Patients receiving IV TXA had reduced mean total blood loss of 442.9 mls (95% CI, 426.5-459.3; p<0.00001), reduced operative blood loss of 88.5 mls (95% CI, 59.9-117.2; p<0.00001), a decrease in the need for allogenic blood transfusion (OR 0.37; 95% CI, 0.26-0.53; p<0.00001) and a reduction in pre- and postoperative haemoglobin difference (p = 0.013.) There was no significant increase in VTE risk (OR 1.59; 95% CI 0.67-3.75; p>0.29) or significant difference on duration of surgery seen with IV TXA usage (p>0.06).

CONCLUSIONS

Our review demonstrated the efficacy of IV TXA in minimising perioperative, reducing total blood loss and lowering the necessity for allogenic blood transfusions with no significant increased risk in VTE events.

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study

OBJECTIVES

A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery.

SETTINGS

23 Austrian centres randomly selected and stratified by region and level of care.

PARTICIPANTS

We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR).

MAIN OUTCOME MEASURES

Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5.

RESULTS

In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories.

CONCLUSIONS

The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.

Assessing the impact of fracture pattern on transfusion requirements in hip fractures

PURPOSE

Hip fractures in the elderly represent a major source of morbidity and mortality, with allogeneic blood transfusions (ABTs) associated with increased mortality. This study assesses the ABT requirements between the most common patterns of hip fracture; intertrochanteric (IT) and intracapsular (IC). The impact of operation type on transfusion rates was also assessed.

METHODS

A retrospective study was performed for all patients entered on the national hip fracture database over 1 year in a teaching hospital. Records of 559 patients were reviewed and, following exclusion criteria, 474 were evaluated (198 IT, 276 IC). Baseline haematological parameters and ABTs were identified using hospital systems. Analysis was performed in SPSS, using independent samples t tests, one-way ANOVAs and Chi square tests.

RESULTS

Patient groups were matched on gender, anaesthetic type, American Society of Anesthesiologist (ASA) grade, cognitive score and coagulation parameters. A significantly greater proportion of IT patients required an ABT during admission (39.4 vs. 22.5 %, p < 0.001). For IT fractures a greater proportion of patients required an ABT when undergoing an intramedullary nail operation compared with those requiring a dynamic hip screw (67.4 vs. 32.0 %, p < 0.001). Similarly, for IC fractures transfusion rates in patients undergoing an internal fixation were significantly lower than those undergoing hemiarthroplasty or arthroplasty (9.4 vs. 26.4 vs. 20.8 %, p = 0.033).

CONCLUSION

Patients with IT hip fractures are significantly more likely to require an ABT than those with IC hip fractures. Patients undergoing an intramedullary nail for IT fractures have significantly higher transfusion rates than for other types of operation.