Transfuse or not in #NOF…..

Carson JL, Terrin ML, Noveck H et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. New England Journal of Medicine 2011; 365: 2453-2462.

RHH Journal Club. April 18th, 2013. Dr Amy Thomas

Full-text article (if available)

To compare a liberal with a restrictive blood transfusion policy after surgery for fractured neck of femur in an elderly population with ischaemic heart disease (IHD) or with risk factors for IHD.

Background

Hb threshold for transfusion postoperatively is controversial. This trial sought to compare a liberal with a restrictive blood transfusion policy after surgery for fractured neck of femur in an elderly population with ischaemic heart disease (IHD) or with risk factors for IHD.

Study design

-Randomised controlled trial comparing a transfusion trigger of 10g/dl with 8g/dl on death or ability to walk 10ft without human help at 60 days.

-Multicentre (USA and Canada).

Methods

Population

Patients recruited 2004-2009

2016 recruited, 1007 in liberal group,1009 in restrictive group.

Having primary surgical fixation of fracture NOF, >50years old, with Hb <10g/dl up    to 3 days post op.

WITH History of IHD/Old MI on ECG/CCF/PVD/CVA/TIA

OR Hypertension/DM/Hypercholesteraemia/Smoker/Creatine>177micromol/l.

Excluded if could not walk without assistance prior to fracture, declined transfusion, multiple trauma, pathological fracture, MI within 30 pre-op, actively bleeding, hx of ischaemic chest pain with anaemia, previous participation with   contralateral fracture.

Intervention

Hb measured day 1,2,4,7 post randomisation.

All had ECG and Trop I pre-op pre-randomisation and day 4 and as clinically indicated.

Liberal group had 1 unit RCC transfusion until Hb >10g/dl

Restrictive group had 1unit RCC transfusion until Hb>8g/dl or symptoms alleviated (symptoms =cardiac chest pain/CCF/tach and hypotension after fluid resus).

All patients had telephone follow up at 30 and 60 days.

Outcomes

Primary outcome was death/inability to walk 10ft without human assistance.

Secondary outcomes included MI/unstable angina/death, place of residence.

Tertiary outcomes included pneumonia,wound infection, DVT/PE, TIA/CVA.

Validity

Randomisation done via telephone, in block randomisation.

Participants and health-care providers were not blinded.

Data collectors and outcome adjudicators were blinded.

Results

99.2% patients were followed up.

There was no significant difference in death/inability to walk 10ft without human assistance between the liberal and restrictive groups (35.3% vs 34.7% p=0.9).

There was no difference in death @30 days (5.2%liberal vs 4.3% restrictive), or        death at 60 days (7.6% liberal vs 6.6% restrictive), or MI/unstable angina/death (4.2% liberal vs 5.3% restrictive).There was no difference in place of residence,     pneumonia,wound infection, DVT/PE, TIA/CVA.

Protocol violations: 9% of “Liberal” group did not receive transfusion or were discharged with Hb<10g/dl

5.6% of “Restrictive” group received blood without symptoms at Hb>8g/dl.

Conclusions/In practice

It appears safe to use the transfusion trigger of Hb<8g/dl /presence of symptoms* in patients with cardiovascular disease after surgical fixation of fracture neck of femur.

*symptoms of cardiac chest pain,CCF, tachycardia and hypotension despite fluid resuscitation

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One thought on “Transfuse or not in #NOF…..

  1. Interesting study with surprising results. Anecdotally orthogeriatricians find the anaemia elderly are slower to mobilise. The group were not convinced of how applicable this is to the UK #NOF population. The cohort in this study had a 50% lower 30 day mortality (4 vs UK standard of 8-10%) and length of stay was incredibly short in the US centres at less than 4 day (cf UK median of 15 days!). Something is clearly very different despite the demographics looking similar.

    The study may not have detected those with critical IHD. In a recent study of MI in hip fractures, a postoperative MI was the first presentation of IHD in 50%. http://journals.lww.com/jtrauma/Abstract/2013/04000/Perioperative_myocardial_infarctions_are_common.19.aspx .

    The authors should be commended for including demented patients, however, as this high-risk population are often excluded.

    Reply

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