Red blood cell transfusion for people undergoing hip fracture surgery

Establishment of a predictive model for blood transfusion after femoral head replacement in elderly patients

OBJECTIVES

The study aimed to establish a nomogram predictive model for blood transfusion after artificial femoral head replacement surgery in elderly patients with intertrochanteric fractures.

PATIENTS AND METHODS

Two hundred five elderly patients (55 males, 150 females; mean age: 82.1±6.6 years; range, 63 to 103 years) with intertrochanteric femoral fractures who underwent artificial femoral head replacement surgery between January 2015 and May 2023 were retrospectively analyzed. The patients were randomly divided into two groups: the training group (n=143) and the validation group (n=62). Within the training group, patients were further categorized into the nontransfused (n=86) and transfused (n=57) groups. Perioperative data were collected for logistic regression analysis to identify risk factors for postoperative blood transfusion. A nomogram model was developed to predict the need for blood transfusion, with assessments including the C-index, receiver operating characteristic curve, decision curve analysis, and clinical impact curve.

RESULTS

Logistic regression analysis showed that low preoperative hemoglobin levels, high intraoperative bleeding volume, high drainage volume, the use of wire reinforcement, and history of cerebral infarction were the independent risk factors for transfusion after femoral head replacement. Both decision curve analysis and clinical impact curves indicated that the prediction model could be used as a good prediction tool for blood transfusion after artificial femoral head replacement for intertrochanteric femoral fractures in the elderly.

CONCLUSION

A nomogram prediction model that effectively assesses the risk of blood transfusion in elderly patients undergoing femoral head replacement for intertrochanteric femoral fractures was established in this study. This model demonstrated high predictive accuracy and consistency, providing a valuable tool for clinicians to identify high-risk patients and implement early interventions to reduce the need for postoperative blood transfusions.

Allogeneic Blood Transfusion and Risk of Postoperative Complications in Patients with Mild and Moderate Anemia of Any Cause? A Retrospective Cohort Study in Total Revision Hip Surgery

Introduction

Patients undergoing revision total hip surgery (RTHS) have a high prevalence of mild and moderate preoperative anemia, associated with adverse outcomes. The aim of this study was to investigate the association of perioperative allogeneic blood transfusions (ABT) and postoperative complications in preoperatively mild compared to moderate anemic patients undergoing RTHS who did not receive a diagnostic anemia workup and treatment before surgery.

Methods

We included 1,765 patients between 2007 and 2019 at a university hospital. Patients were categorized according to their severity of anemia using the WHO criteria of mild, moderate, and severe anemia in the first Hb level of the case. Patients were grouped as having received no ABT, 1-2 units of ABT, or more than 2 units of ABT. Need for intraoperative ABT was assessed in accordance with institutional standards. Primary endpoint was the compound incidence of postoperative complications. Secondary outcomes included major/minor complications and length of hospital and ICU stay.

Results

Of the 1,765 patients, 31.0% were anemic of any cause before surgery. Transfusion rates were 81% in anemic patients and 41.2% in nonanemic patients. The adjusted risks for compound postoperative complication were significantly higher in patients with moderate anemia (OR 4.88, 95% CI: 1.54-13.15, p = 0.003) but not for patients with mild anemia (OR 1.93, 95% CI: 0.85-3.94, p < 0.090). Perioperative ABT was associated with significantly higher risks for complications in nonanemic patients and showed an increased risk for complications in all anemic patients. In RTHS, perioperative ABT as a treatment for moderate preoperative anemia of any cause was associated with a negative compound effect on postoperative complications, compared to anemia or ABT alone.

Discussion

ABT is associated with adverse outcomes of patients with moderate preoperative anemia before RTHS. For this reason, medical treatment of moderate preoperative anemia may be considered.

Association between perioperative blood transfusion and length of hospital stay in patients with osteoporotic fractures

BACKGROUND

Few studies have examined the relationship between perioperative blood transfusion (PBT) and length of hospital stay (LOS) in patients with osteoporotic fractures. This research aims to study the association between PBT and LOS.

METHODS

This is a retrospective cross-sectional study from the Affiliated Kunshan Hospital of Jiangsu University, Suzhou, China, involving 2357 osteoporotic fractures (OPF) patients who received surgical treatment during hospitalization from January 2017 and March 2022. Multiple linear regression was used to analyze the relationship between PBT and LOS. In the analysis, PBT volume was the dependent variable, whereas LOS was the independent variable. Simultaneously, age, gender, body mass index, hemoglobin, primary diagnosis, American Society of Anesthesiologists, creatinine (Cr), anesthesia, surgical method, and Charlson comorbidity index were included as covariates. The generalized additive model was then used to study nonlinear associations. Two piecewise linear regression exemplary evaluated the inception results for smoothing the curve.

RESULTS

Our results proved that PBT was positively correlated with LOS in the fully adjusted model (β, 0.21; 95% CI, 0.04 to 0.37; P < 0.0001). Furthermore, a "U-shape" nonlinear relationship existed between PBT and LOS. When the concentration of PBT was between 0 and 1.5 units, it was manifested as a negative correlation between PBT and LOS. However, there was a positive association between PBT and LOS when PBT levels exceeded 1.5 units.

CONCLUSIONS

This study demonstrated that PBT and LOS in the OPF population were independent with a nonlinear relationship. These results suggest that PBT may be protective for patients with long LOS. If these findings are confirmed, the LOS in OPF patients can be regulated through appropriate perioperative blood transfusion.

Application of machine learning model in predicting the likelihood of blood transfusion after hip fracture surgery

OBJECTIVE

Anemia is one of the common adverse reactions after hip fracture surgery. The traditional method to solve anemia is allogeneic transfusion. However, the transfusion may lead to some complications such as septicemia and fever. So far, few studies have reported roles of machine learning in predicting whether blood transfusion is needed or not after hip fracture surgery. Therefore, the purpose of this study is to develop machine learning models to predict the likelihood of postoperative blood transfusion in patients undergoing hip fracture surgery.

METHODS

This study enrolled 1355 patients who underwent hip fracture surgery at the Affiliated Hospital of Qingdao University from January 2016 to December 2021. Among all patients, 210 cases received postoperative blood transfusion. All patients were randomly divided into a training group and a testing group at a ratio of 7:3. In the training group, univariate and multivariate logistic regression analyses were used to determine independent risk factors for the postoperative transfusion. Then, based on these independent risk factors, tenfold cross-validation method was utilized to develop five machine learning models, including logistic, multilayer perceptron (MLP), extreme gradient boosting (XGBoost), random forest (RF), and support vector machine (SVM). The receiver operating characteristic (ROC) curve, area under ROC curve (AUC), and Matthews correlation coefficient (MCC) were generated to evaluate the performance of the models. Calibration plot and decision curve analysis (DCA) were used to test the performance, stability, and clinical applicability of the models. The models were validated using the testing group; and the ROC curve, MCC, calibration plot, and DCA curves were also generated to validate the performance, stability, and clinical applicability of the models. To further verify the robustness of the model, we randomly grabbed 70% of the samples in the testing set, performed 1000 iterations, and calculated the AUC and confidence interval of the five models. Finally, we used SHapley Additive exPlanations (SHAP) to explain these models.

RESULTS

Multivariate logistic regression analysis showed that there were 8 independent risk factors, including age, blood transfusion history, albumin (ALB), globulin (GLO), total bilirubin (TBIL), indirect bilirubin (IBIL), hemoglobin (HB), and blood loss > 200 ml. We finally selected five independent risk factors including HB, GLO, age, IBIL, and blood loss > 200 ml. Based on these five independent risk factors, we generated six characteristic variables, namely HB, HB × HB, HB × blood loss, GLO × HB, age, age × IBIL, and established five machine learning models using a tenfold cross-validation method. In the training group, the AUC values of logistic, RF, MLP, SVM, and XGB were 0.9320, 0.8911, 0.9327, 0.9225, and 0.8825, respectively, and the average AUC was 0.9122 ± 0.0212. The MCC values were 0.65, 0.77, 0.65, 0.66, and 0.68, respectively, and the calibration plot and DCA performed well. In the testing group the AUC values of logistic, RF, MLP, SVM, and XGB were 0.8483, 0.7978, 0.8576, 0.8598, and 0.8216, respectively. The average AUC was 0.8370 ± 0.0238, and the MCC values were 0.41, 0.35, 0.40, 0.41, and 0.41, respectively. The calibration plot and DCA in the testing group also showed good performance. The AUC values and confidence intervals of the 1000-iteration model were: logistic (AUC, min confidence interval [CI]-max confidence interval [CI] 0.848, 0.804-0.903), RF (AUC, minCI-maxCI 0.797, 0.734-0.857), MLP (AUC, minCI-maxCI 0.858, 0.812-0.902), SVM (AUC, minCI-maxCI 0.859, 0.819-0.910), and XGB (AUC, minCI-maxCI 0.821, 0.764-0.894). The model performed well. Finally, according to SHAP, among all five models, HB played the most important role in model prediction and interpretation.

CONCLUSION

The five models we developed all performed well in predicting the likelihood of blood transfusion after hip fracture surgery. Therefore, we believed that the prediction model based on machine learning had great application prospects in clinical practice, which could help clinicians better predict the risk of blood transfusion after hip fracture surgery.

Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews

BACKGROUND

Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT.

OBJECTIVES

To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery.

METHODS

In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality.

MAIN RESULTS

We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL.

AUTHORS' CONCLUSIONS

Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.

Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures

BACKGROUND

Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications.

OBJECTIVES

To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones.

SEARCH METHODS

We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data.

MAIN RESULTS

We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence).  It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence).  We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect.  Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants).  All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo   Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here.

AUTHORS' CONCLUSIONS

We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration).  We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.

Perioperative Management and Outcomes of Hip Fracture Patients with Advanced Chronic Kidney Disease

Aims

To explore clinical characteristics, perioperative management and outcomes of Hip Fracture patients with advanced Chronic Kidney Disease (HF-aCKD) compared to the general Hip Fracture population without aCKD (HF-G) within a large volume tertiary hospital in Western Australia.

Methods

Retrospective chart review of patients admitted with hip fracture (HF) to a single large volume tertiary hospital registered on Australian and New Zealand Hip Fracture Registry (ANZHFR). We compared baseline demographic and clinical frailty scale (CFS) of HF-aCKD (n = 74), defined as eGFR < 30 mls/min/1.73 m2, with HF-G (n = 452) and determined their outcomes at 120 days.

Results

We identified 74 (6.97%) HF patients with aCKD. General demographics were similar in HF-aCKD and HF-G populations. 120-days mortality for HF-aCKD was double that of HF-G population (34% vs 17%, P = .001). For dialysis patients, 120-days mortality was triple that of HF-G population (57%). Except for the fit category of HF-aCKD group, higher CFS was associated with higher 120-days mortality in both groups. Of all HF-aCKD patients, 96% had operative intervention and 48% received blood transfusion. There were no new starts to dialysis peri-operatively. Each point reduction in eGFR below 12 mL/min/1.73 m2 was associated with 3% increased probability of death in hospital.

Conclusions

120-days mortality was double in HF-aCKD and triple in HF-dialysis that of the HF-G within our institution. Clinical frailty scale can be useful in predicting mortality after HF in frail aCKD patients. High rate of blood transfusions was observed in HF-aCKD group. Further studies with larger HF-aCKD numbers are required to explore these associations in detail.

The Efficacy and Safety of Intravenous Iron in Geriatric Hip Fracture Surgeries: A Systematic Review and Meta-Analysis

BACKGROUND

With the increasing evidence provided by recent high-quality studies, the intravenous iron appears to be a reliable therapy for blood administration in geriatric patients with hip fractures. Here, this systematic review and meta-analysis were aimed to assess the effectiveness and safety of intravenous iron in geriatric patients sustaining hip fractures.

METHODS

Potential pertinent literatures evaluating the effects of intravenous iron in the geriatric patients undergoing hip fractures were identified from Web of Science, PubMed, Embase, and Scopus. We performed a pairwise meta-analysis using fixed- and random-effects models, and the pooling of data was carried out by using RevMan 5.1.

RESULTS

Four randomized controlled trials and four observational studies conform to inclusion criteria. The results of meta-analysis showed that intravenous iron reduced transfusion rates compared to the control group, yet the result did not reach statistical significance. The intravenous iron was related to lower transfusion volumes, shorter length of stay, and a reduced risk of nosocomial infections. And there was no significant difference in terms of the mortality and other complications between the treatment group and the control group.

CONCLUSION

Current evidence suggests that intravenous iron reduces the transfusion volume, length of hospital stay, and risk of nosocomial infections. It takes about 7 days for intravenous iron to elevate hemoglobin by 1 g/dl and about 1 month for 2 g/dl. The safety profile of intravenous iron is also reassuring, and additional high-quality studies are needed.

Randomised controlled trial comparing intraoperative cell salvage and autotransfusion with standard care in the treatment of hip fractures: a protocol for the WHITE 9 study

INTRODUCTION

People who sustain a hip fracture are typically elderly, frail and require urgent surgery. Hip fracture and the urgent surgery is associated with acute blood loss, compounding patients' pre-existing comorbidities including anaemia. Approximately 30% of patients require a donor blood transfusion in the perioperative period. Donor blood transfusions are associated with increased rates of infections, allergic reactions and longer lengths of stay. Furthermore, there is a substantial cost associated with the use of donor blood. Cell salvage and autotransfusion is a technique that recovers, washes and transfuses blood lost during surgery back to the patient. The objective of this study is to determine the clinical and cost effectiveness of intraoperative cell salvage, compared with standard care, in improving health related quality-of-life of patients undergoing hip fracture surgery.

METHODS AND ANALYSIS

Multicentre, parallel group, two-arm, randomised controlled trial. Patients aged 60 years and older with a hip fracture treated with surgery are eligible. Participants will be randomly allocated on a 1:1 basis to either undergo cell salvage and autotransfusion or they will follow the standard care pathway. Otherwise, all care will be in accordance with the National Institute for Health and Care Excellence guidance. A minimum of 1128 patients will be recruited to obtain 90% power to detect a 0.075-point difference in the primary endpoint: EuroQol-5D-5L HRQoL at 4 months post injury. Secondary outcomes will include complications, postoperative delirium, residential status, mobility, allogenic blood use, mortality and resource use.

ETHICS AND DISSEMINATION

NHS ethical approval was provided on 14 August 2019 (19/WA/0197) and the trial registered (ISRCTN15945622). After the conclusion of this trial, a manuscript will be prepared for peer-review publication. Results will be disseminated in lay form to participants and the public.

TRIAL REGISTRATION NUMBER

ISRCTN15945622.

[Rational therapy with erythrocyte concentrates - Update 2022]

The use of red blood cell concentrates must follow the dictates of a rational indication. To further ensure this, the "Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives" 1 of the German Medical Association, published in 2009 and last revised in part in 2014, were systematically revised in 2020. This article presents them.

Transfusion in orthopaedic surgery : a retrospective multicentre cohort study

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

Methods

We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma.

Results

Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon.

Conclusion

Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies.

Cite this article: Bone Jt Open 2021;2(10):850–857.

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.

The risk factors of heart failure in elderly patients with hip fracture: what should we care

BACKGROUND

Heart failure is a common adverse postoperative complication in elderly patients. It is necessary to explore the risk factors of heart after the operation of elderly patients with hip fracture during hospitalization.

METHODS

Patients with hip fractures admitted to our hospital from January 1, 2019 to December 31 2020 were included, all the patients received internal fixation surgery. The characteristics of patients with and without postoperative heart failure were compared. Multivariate logistic regression analyses were applied to analyze the risk factors of heart failure in elderly patients with hip fracture.

RESULTS

A total of 283 patients with hip fractures were included, the incidence of heart failure was 12.37 %. There were significant differences in the age, hypertension, anemia hypoalbuminemia and duration of surgery between heart failure and no heart failure group(all p < 0.05). There were no significant differences in the gender, BMI, diabetes mellitus, hyperlipidemia, history of heart failure, cognitive dysfunction, type of fracture, preoperative oxygen saturation, white blood cell count, platelet count, red blood cell count, creatinine, alanine aminotransferase, aspartate aminotransferase and estimated blood loss during surgery between heart failure and no heart failure group(all p > 0.05). Logistic regression analyses indicated that age ≥ 70y(OR2.446, 95% CI1.044 ~ 4.149), hypertension(OR2.152, 95% CI1.125 ~ 4.023), anemia(OR3.094, 95% CI1.294 ~ 5.907), hypoalbuminemia(OR2.377, 95% CI1.205 ~ 4.537), duration of surgery ≥ 120 min(OR1.683, 95% CI1.094 ~ 2.782) were the risk factors of heart failure in elderly patients with hip fracture(all p < 0.05).

CONCLUSIONS

The incidence of postoperative heart failure in elderly patients with hip fracture is relatively high, which is the result of a combination of high-risk factors. Peri-period risk assessment and prevention of related risks are the keys to a good prognosis for patients.

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.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Preoperative risk factors for postoperative blood transfusion after hip fracture surgery: establishment of a nomogram

Background

This study aimed to explore the preoperative risk factors related to blood transfusion after hip fracture operations and to establish a nomogram prediction model. The application of this model will likely reduce unnecessary transfusions and avoid wasting blood products.

Methods

This was a retrospective analysis of all patients undergoing hip fracture surgery from January 2013 to January 2020. Univariate and multivariate logistic regression analyses were used to evaluate the association between preoperative risk factors and blood transfusion after hip fracture operations. Finally, the risk factors obtained from the multivariate regression analysis were used to establish the nomogram model. The validation of the nomogram was assessed by the concordance index (C-index), the receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and calibration curves.

Results

A total of 820 patients were included in the present study for evaluation. Multivariate logistic regression analysis demonstrated that low preoperative hemoglobin (Hb), general anesthesia (GA), non-use of tranexamic acid (TXA), and older age were independent risk factors for blood transfusion after hip fracture operation. The C-index of this model was 0.86 (95% CI, 0.83–0.89). Internal validation proved the nomogram model’s adequacy and accuracy, and the results showed that the predicted value agreed well with the actual values.

Conclusions

A nomogram model was developed based on independent risk factors for blood transfusion after hip fracture surgery. Preoperative intervention can effectively reduce the incidence of blood transfusion after hip fracture operations.

Transfusion timing relative to surgery does not impact outcomes in hip fracture patients

PURPOSE

The purpose of this study is to determine the effects of blood transfusion timing in hip fracture patients.

METHODS

A consecutive series of hip fracture patients 55 years and older who required a blood transfusion during hospitalization were reviewed for demographic, injury, clinical outcome, and cost information. A validated risk predictive score (STTGMA) was calculated for each patient. Patients were stratified to preoperative, intraoperative, or postoperative first transfusion cohorts. The intraoperative and postoperative cohorts were matched by STTGMA, sex, and procedure to the preoperative cohort. Baseline patient characteristics and outcomes were compared before and after matching.

RESULTS

Prior to matching, the preoperative cohort was more often male (p < 0.001) with increased Charlson comorbidity index (p = 0.012), ASA class (p < 0.002), STTGMA (p < 0.001), total transfused volume (p = 0.002), incidence of inpatient mortality (p = 0.045), myocardial infarction (p = 0.005) and cardiac arrest (p = 0.014). After matching, the preoperative cohort had increased total transfused volume (p = 0.015) and decreased pneumonia incidence (p = 0.040).

CONCLUSION

Matching STTGMA score, sex, and procedure results in non-inferior outcomes among hip fracture patients receiving preoperative first blood transfusions compared to intraoperative and postoperative transfusions.

Perioperative red blood cell infusion and deep vein thrombosis in patients with femoral and pelvic fractures: a propensity score matching

BACKGROUND

The relationship between perioperative red blood cell (RBC) infusion and deep vein thrombosis (DVT) has not been determined.

OBJECTIVES

To analyze the time-event relationship between perioperative RBC infusion and DVT in patients with femoral and pelvic fractures after adjusting for confounding factors and to provide reference for optimizing DVT risk factors.

METHODS

The clinical data of 569 patients with femoral and pelvic fractures who received surgical treatment from May 2018 to December 2019 were retrospectively analyzed. Propensity score matching (PSM) was performed on 20 covariates of DVT. With the formation or progression of DVT after RBC infusion as the end point, the time-event relationship between perioperative RBC infusion and DVT in patients was analyzed by binary logistic regression.

RESULTS

After 1:1 PSM of 569 patients included in this study, 126 patients were in the transfusion group and the non-transfusion group, respectively. Before PSM (P = 0.023, OR = 1.496 [95% CI, 1.058-2.115]), perioperative RBC infusion was associated with DVT formation for femoral and pelvic fractures. This conclusion was still obtained after PSM (P = 0.038, OR = 1.728, 95% CI = (1.031, 2.896)). The risk of DVT in patients with RBC infusion of 2-4U and > 4U is 1.833 and 2.667 times that of ≤ 2U, respectively. After excluding patients who received preoperative RBC infusion and had DVT formation or progression prior to RBC infusion, perioperative RBC infusion was still associated with the formation of DVT in femoral and pelvic fractures (P = 0.037, OR = 2.231 [95% CI, 1.049-4.745]).

CONCLUSION

Perioperative RBC infusion is one of the causes of DVT in patients with femoral and pelvic fractures, and the risk of DVT is positively correlated with the amount of RBC infusion.

Perioperative Transfusion Associated With Increased Morbidity and Mortality in Geriatric Patients Undergoing Hip Fracture Surgery

Introduction:

Both conservative and liberal transfusion thresholds, in regard to hematocrit and hemoglobin levels, have been widely studied with varying outcomes. The aim of this study was to evaluate if transfusion administered peri- (anytime during the admission), pre-, intra-, or postoperatively an its association with morbidity and mortality in the geriatric population undergoing hip surgery.

Methods:

This study was an institutional review board approved retrospective analysis of data collected from 841 patients at a single urban institution who underwent surgical repairs for hip fractures from 2008 to 2010.

Results:

Our analysis included data from 841 surgical patients. Mean patient age was 83, 74% were female, 48% received spinal anesthesia while 52% underwent general anesthesia. Out of 841 patients, 425 were transfused during the perioperative period. Most transfusions occurred postoperatively. Perioperative, intraoperative and postoperative transfusion was associated with an increase in post-operative AKI. Intraoperative blood transfusion was associated with an increase in morbidity (11.6% increased to 22.2%) by 1.9 fold, AKI (3.9% increased to 11.1%) by 2.8 fold, as well as an increase in mortality (5.2 increased to 15.6%) within 60 days by 3 fold.

Conclusions:

This may suggest that patients transfused prior to surgery, despite having met a specific trigger hemoglobin level earlier, may have been treated before deteriorating to a point that would cause future systemic implications.

Rationale Therapie mit Erythrozytenkonzentraten – Update 2020

Der Einsatz von Erythrozytenkonzentraten muss dem Gebot einer rationalen Indikation folgen. Um dies weiter zu gewährleisten, wurden die 2009 publizierten und zuletzt 2014 in Teilen revidierten „Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten“ 1 der Bundesärztekammer 2020 einer systematischen Novellierung unterzogen. Der Artikel stellt sie vor.

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.

Red blood cell transfusions and the survival in patients with cancer undergoing curative surgery: a systematic review and meta-analysis

Allogenic red blood cell transfusions exert a potential detrimental effect on the survival when delivered to cancer patients undergoing surgery with curative intent. We performed a systematic review and meta-analysis to assess the association between perioperative allogenic red blood cell transfusions and risk of death as well as relapse after surgery for localized solid tumors. PubMed, the Cochrane Library, and EMBASE were searched from inception to March 2019 for studies reporting the outcome of patients receiving transfusions during radical surgery for non-metastatic cancer. Risk of death and relapse were pooled to provide an adjusted hazard ratio with a 95% confidence interval [hazard ratio (HR) (95% confidence interval {CI})]. Mortality and relapse associated with perioperative transfusion due to cancer surgery were evaluated among participants (n = 123 studies). Overall, RBC transfusions were associated with an increased risk of death [HR = 1.50 (95% CI 1.42-1.57), p < 0.01] and relapse [HR = 1.36 (95% CI 1.26-1.46), p < 0.01]. The survival was reduced even in cancer at early stages [HR = 1.45 (1.36-1.55), p < 0.01]. In cancer patients undergoing surgery, red blood cell transfusions reduced the survival and increased the risk of relapse. Transfusions based on patients' blood management policy should be performed by applying a more restrictive policy, and the planned preoperative administration of iron, if necessary, should be pursued.

Association of iron supplementation with risk of transfusion, hospital length of stay, and mortality in geriatric patients undergoing hip fracture surgeries: a meta-analysis

AIMS

To assess the efficacy and safety of iron supplementation for perioperative anemia in geriatric patients with hip fracture.

METHODS

A systematic search was conducted for studies published using PubMed, EMBASE and Cochrane Library Databases that compared iron supplementation with placebo in patients undergoing hip fracture surgery. The outcomes were blood transfusion rate and volume, length of stay, infection and mortality (last follow-up). Sub-group and sensitivity analyses were performed in cases of substantial heterogeneity.

RESULTS

The meta-analysis (6 studies: 1201 patients) indicated that iron supplements were not associated with reducing blood transfusion rate (OR 0.92, 95% CI 0.60-1.41; P = 0.69), but high heterogeneity (I² = 61%) was detected and a significant association was found in sensitivity analysis of four studies (n = 637; OR 0.68, 95% CI 0.49-0.95; P = 0.02). A significant reduction was detected in transfusion volume (two studies: n = 234; MD - 0.45 units/patient, 95% CI - 0.74 to - 0.16; P = 0.002), hospital stay (five studies: n = 998; MD - 1.42, 95% CI - 2.18 to - 0.67; P = 0.0002) and caused no increased risk of mortality (five studies: n = 937; OR 0.94, 95% CI 0.65-1.36; P = 0.76) and infection (four studies: n = 701; OR 0.58, 95% CI 0.38-0.90; P = 0.01). Sub-group analyses of four studies showed that the preoperative intravenous use of iron at 200-300 mg (two studies) may be the beneficial option for hip fractures patients.

CONCLUSIONS

Iron supplementation, especially preoperative intravenous use of 200-300 mg iron, is safe and associated with reducing transfusion requirement and hospital stay. Unfortunately, data were too limited to draw a definite conclusion. Further evaluation is required before recommending iron supplementation for older patients with hip fracture surgeries.

Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews

BACKGROUND

There are no overviews of systematic reviews investigating haemoglobin thresholds for transfusion. This is important as the literature on transfusion thresholds has grown considerably in recent years. Our aim was to synthesise evidence from systematic reviews and meta-analyses of the effects of restrictive and liberal transfusion strategies on mortality.

METHODS

This was a systematic review of systematic reviews (overview). We searched MEDLINE, Embase, Web of Science Core Collection, PubMed, Google Scholar, and the Joanna Briggs Institute EBP Database, from 2008 to 2018. We included systematic reviews and meta-analyses of randomised controlled trials comparing mortality in patients assigned to red cell transfusion strategies based on haemoglobin thresholds. Two independent reviewers extracted data and assessed methodological quality. We assessed the methodological quality of included reviews using AMSTAR 2 and the quality of evidence pooled using an algorithm to assign GRADE levels.

RESULTS

We included 19 systematic reviews reporting 33 meta-analyses of mortality outcomes from 53 unique randomised controlled trials. Of the 33 meta-analyses, one was graded as high quality, 15 were moderate, and 17 were low. Of the meta-analyses presenting high- to moderate-quality evidence, 12 (75.0%) reported no statistically significant difference in mortality between restrictive and liberal transfusion groups and four (25.0%) reported significantly lower mortality for patients assigned to a restrictive transfusion strategy. We found few systematic reviews addressed clinical differences between included studies: variation was observed in haemoglobin threshold concentrations, the absolute between group difference in haemoglobin threshold concentration, time to randomisation (resulting in transfusions administered prior to randomisation), and transfusion dosing regimens.

CONCLUSIONS

Meta-analyses graded as high to moderate quality indicate that in most patient populations no difference in mortality exists between patients assigned to a restrictive or liberal transfusion strategy.

TRIAL REGISTRATION

PROSPERO CRD42019120503.

Unstable intertrochanteric fractures are associated with a greater hemoglobin drop during the perioperative period: a retrospective case control study

Background

With an increase in the elderly population, the occurrence of hip fractures, femoral neck fractures, and intertrochanteric fractures (ITFs) is also increasing. It is important to establish effective perioperative methods that would help reduce the morbidity and mortality rates associated with ITFs. The purpose of this study was to determine the effects of ITFs according to the AO classification for perioperative hemoglobin drop.

Methods

Seventy-six patients with ITFs classified as AO 31-A1 or A2 and fixated with intramedullary nails participated in this retrospective cohort study. Medical records of these patients were retrospectively reviewed from September 2016 to August 2018. The perioperative hemoglobin drop was chosen as the main outcome measure and calculated as the difference between pre- and postoperative hemoglobin levels. Multivariate linear regression analysis was performed and included the following variables: AO classification (A1.1-A2.1 [stable] vs. A2.2-A2.3 [unstable]), time interval between injury and surgery, age, body mass index, and the use of anticoagulants.

Results

Among the 76 patients who met the inclusion criteria, a significantly higher hemoglobin drop was observed in the AO 31 A2.2-A2.3 (unstable) group than in the AO 31 A1.1-A2.1 (stable) group (p = 0.04). The multivariate analysis also showed a greater hemoglobin drop in the unstable group (p < 0.05).

Conclusions

Patients with unstable ITFs exhibited a greater hemoglobin drop and a hidden blood loss was suspected around the fracture site. We believe that this should be taken into consideration when presurgical blood transfusion is being planned for patients with unstable ITFs, to reduce associated postoperative complications, especially in patients with severe anemia or high risk of mortality.

Evaluation for Perioperative Blood Transfusion during Major Abdominal Procedures in a Pediatric Population: A Retrospective Observation Cohort Study

Objectives

The purpose of this study was to examine modifiable factors and their impact on perioperative blood transfusion for pediatric patients with major abdominal procedures.

Methods

This is a retrospective review of 1,506 patients who underwent major abdominal surgical procedures in a tertiary medical center from January 2008 to June 2018. Clinical data about blood administration including triggers and targets for intra- or postoperative transfusion were collected and analyzed. The inappropriate transfusion (transfusion > 8.0 g/dL of hemoglobin [Hb] trigger) and overtrans-fusion criteria (target transfusion > 10.0 g/dL or > 2 g/dL of target minus trigger level) were applied to examine the intraoperative factors with the intraoperative transfusion practice. Perioperative morbidity was further assessed based on the inappropriate transfusion and overtransfusion status.

Results

Intraoperative transfusion was used in 468 (31.1%) of the 1,506 patients included in the study. Among them, 212 (45.3%) intraoperative transfusion episodes were classified as inappropriate, and 135 cases (28.8%) were confirmed as overtransfusion. On univariate analysis, inappropriate transfusions were observed more commonly among patients with younger age (p < 0.001) and who underwent hepatic resection (p < 0.001) or intestinal resection (p < 0.001). Overtransfusion was also associated with elevated trigger of 8.0 g/dL Hb (p = 0.006) and younger age (p = 0.003). No perioperative complications were associated with inappropriate transfusions and overtransfusion under multivariate analysis.

Conclusions

Overtransfusion was common in hepatic resection and younger age, but to definitely prove this hypothesis, a prospective randomized trial needs to be performed.

Utilization, effectiveness, and safety of tranexamic acid use in hip fracture surgery: A population-based study

Objective

To assess the effect of tranexamic acid (TXA) use in hip fracture surgery.

Methods

A retrospective cohort study was performed using the Premier Healthcare database. A propensity score matching approach was applied to assess associations between TXA use and blood transfusion, perioperative complications, length of stay (LOS), and hospitalization cost.

Results

In 153,169 patients, TXA use was associated with a 17% decrease in odds of blood transfusion, no increase in the risk of perioperative complications, 16% shorter LOS, and minimal effects on hospitalization cost.

Conclusion

Our results are in support of a wider use of TXA in hip fracture surgery.

Level of evidence

Level III.

Resuscitation in hip fractures: The practicality and clinical effectiveness of pre-operative resuscitation of patients with hip fracture using blood products

Introduction

This study aimed to determine the practicality and estimate the effect of administering pre-operative blood product resuscitation to a consecutive, prospectively recruited cohort of 100 patients admitted to a single centre with a hip fracture with all other treatment unchanged.

Method

100 patients aged 65 years or over admitted acutely to our unit with unilateral fractured femoral neck during the study period were included in this study, regardless of cognitive function. Patients were excluded only if there were relevant medical comorbidities or consent was declined. Each patient was resuscitated with a single unit of packed red cells in the immediate perioperative period in addition to standard care. The primary outcome was to establish the feasibility of the study protocol employed in using blood products to resuscitate eligible patients and recording reasons for any failures to include eligible patients. Additional data regarding mortality at 30 days following injury, subsequent blood product use, any transfusion related adverse reactions and total blood product use was measured.

Results

We were able to show that it is safe and practicable to deliver blood as an early resuscitative strategy in the frail elderly hip fracture population. The mortality rate of the study cohort was 3%. No adverse reaction was observed in any of the 99 patients given blood as a result of the resuscitation strategy and no morbidity was seen that could be attributed to the effect of giving blood. The total amount of blood received by comparable cohorts in the study period and the two preceding years were similar.

Conclusions

The study suggests that in the hip fracture population it is both practical and beneficial to move away from reactive transfusion regimens, and instead centre efforts instead on optimal resuscitation at the initial presentation.

Anesthetic management of geriatric patients

The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.

Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: protocol for an overview of systematic reviews

INTRODUCTION

There has been a significant increase in the number of systematic reviews and meta-analyses of randomised controlled trials investigating thresholds for red blood cell transfusion. To systematically collate, appraise and synthesise the results of these systematic reviews and meta-analyses, we will conduct an overview of systematic reviews.

METHODS AND ANALYSIS

This is a protocol for an overview of systematic reviews. We will search five databases: MEDLINE, Embase, Web of Science Core Collection, PubMed (for prepublication, in process and non-Medline records) and Google Scholar. We will consider systematic reviews and meta-analyses of randomised controlled trials evaluating the effect of haemoglobin thresholds for red blood cell transfusion on mortality. Two authors will independently screen titles and abstracts retrieved in the literature search and select studies meeting the eligibility criteria for full-text review. We will extract data onto a predefined form designed to summarise the key characteristics of each review. We will assess the methodological quality of included reviews and the quality of evidence in included reviews.

ETHICS AND DISSEMINATION

Formal ethics approval is not required for this overview as we will only analyse published literature. The findings of this study will be presented at relevant conferences and submitted for peer-review publication. The results are likely to be used by clinicians, policy makers and developers of clinical guidelines and will inform suggestions for future systematic reviews and randomised controlled trials.

PROSPERO REGISTRATION NUMBER

CRD42019120503.

[Clinical study of recombinant human erythropoietin combined with iron to correct perioperative anemia in elderly patients with intertrochanteric fractures]

OBJECTIVE

To investigate the effectiveness of recombinant human erythropoietin (rHuEPO) combined with iron in treatment of anemia in elderly patients with intertrochanteric fractures during perioperative period.

METHODS

A clinical data of 71 patients with intertrochanteric fractures met the inclusion criteria between April 2016 and October 2017 was retrospectively analyzed. All patients were treated with closed reduction and proximal femoral intramedullary nail fixation. Thirty-one patients were treated with rHuEPO and iron before operation as trial group, and 40 patients were not treated with rHuEPO and iron as control group. There was no significant difference in gender, age, body mass index, cause of injury, fracture side and classification, American Society of Anesthesiologists (ASA) classification, combined medical diseases, time from fracture to admission, preoperative hospital stay, and operation time between the two groups ( P>0.05).The hemoglobin levels before operation and at 1, 3, and 7 days after operation, number of blood transfusion, blood transfusion rate, blood transfusion volume, postoperative hospital stay, complications were recorded and compared.

RESULTS

After operation, 8 patients (25.8%) in trial group and 22 patients (55.0%) in control group received blood transfusion; the blood transfusion volume was (1.96±0.85) units in trial group and (3.19±1.61) units in control group. There were significant differences in blood transfusion rate and volume between the two groups ( P<0.05). There was no significant difference in preoperative hemoglobin level between the two groups ( P>0.05). The postoperative hemoglobin level was higher in trial group than in control group, and the difference between the two groups was significant at 7 days ( P<0.05). The postoperative hospital stay was (6.16±3.97) days in trial group and (9.25±4.47) days in control group, showing significant difference between the two groups ( P<0.05). There were 8 patients (25.8%) with pulmonary infection in trial group and 14 (35.0%) in control group after operation; 6 patients (19.4%) with deep venous thrombosis in trial group and 8 (20.0%) in control group. There was no significant difference in the incidences of complications between the two groups ( P>0.05). All patients were discharged from hospital normally, and no one died during hospitalization.

CONCLUSION

The application of rHuEPO combined with iron before operation in elderly patients with intertrochanteric fractures can rapidly increase the hemoglobin level after operation, shorten the hospital stay, and do not increase the risk of deep venous thrombosis after operation.

Clinical Outcomes Associated With Allogeneic Red Blood Cell Transfusions in Spinal Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The objectives of this systematic review were to report the available clinical evidence on patient outcomes associated with perioperative allogeneic red blood cell (RBC) transfusions in adult patients undergoing spinal surgery and to determine whether there is any evidence to support an association between transfusion timing and clinical outcomes.

METHODS

A systematic review of the PubMed, EMBASE, and Cochrane Library databases was performed to identify all articles examining outcomes of adult spinal surgery patients who received perioperative allogeneic RBC transfusions. The level of evidence for each study was assessed using the "Oxford Levels of Evidence 2" classification system. Meta-analysis was not performed due to the heterogeneity of reports.

RESULTS

A total of 2759 unique citations were identified and 76 studies underwent full-text review. Thirty-four studies were selected for analysis. All the studies, except one, were retrospective. Eleven studies investigated intraoperative or postoperative transfusions. Only one article compared outcomes related to intraoperative versus postoperative transfusions.

CONCLUSIONS

Perioperative transfusion is associated with increased rates of postoperative complications, especially infectious complications, and prolonged length of stay. Some evidence suggests that a dose-response relationship may exist between morbid events and the number of RBC units administered, but these findings are inconsistent. Because of the heterogeneity of reports and inconsistent findings, the incidence of specific complications remains unclear. Limited research activity has focused on intraoperative versus postoperative transfusions, or the effect of transfusion on functional outcomes of spine surgery patients. Further research is warranted to address these clinical issues.

Preoperative antithrombotic therapy and risk of blood transfusion and mortality following hip fracture surgery: a Danish nationwide cohort study

Hip fracture surgery is associated with high risk of bleeding and mortality. The patients often have cardiovascular comorbidity, which requires antithrombotic treatment. This study found that preoperative use of oral anticoagulants was not associated with transfusion or mortality following hip fracture surgery, whereas increased risk may exist for antiplatelet drugs.

INTRODUCTION

Hip fracture surgery is associated with high bleeding risk and mortality; however, data on operative outcomes of hip fracture patients admitted while on antithrombotic therapy is sparse. We examined if preoperative antithrombotic treatment was associated with increased use of blood transfusion and 30-day mortality following hip fracture surgery.

METHODS

Using data from the Danish Multidisciplinary Hip Fracture Registry, we identified 74,791 hip fracture surgery patients aged ≥ 65 years during 2005-2016. Exposure was treatment with non-vitamin K antagonist oral anticoagulant (NOAC), vitamin K antagonists (VKA), or antiplatelet drugs at admission for hip fracture. Outcome was blood transfusion within 7 days postsurgery and death within 30 days.

RESULTS

A 45.3% of patients received blood transfusion and 10.6% died. Current NOAC use was associated with slightly increased risk of transfusion (adjusted relative risk (aRR) 1.07, 95% confidence interval (CI) 1.01-1.14), but similar mortality risk (adjusted hazard ratio (aHR) 0.88, 95% CI 0.75-1.03) compared with non-users. The pattern remained when restricting to patients with short surgical delay (< 24 h). VKA users did not have increased risk of transfusion or mortality. The risks of transfusion (aRR 1.15 95% CI 1.12-1.18) and 30-day mortality (aHR 1.18 95% CI 1.14-1.23) were increased among antiplatelet users compared with non-users.

CONCLUSIONS

In an observational setting, neither preoperative NOAC nor VKA treatments were associated with increased risk of 30-day postoperative mortality among hip fracture patients. NOAC was associated with slightly increased risk of transfusion. Preoperative use of antiplatelet drugs was associated with increased risk of transfusion and mortality.

An international consensus statement on the management of postoperative anaemia after major surgical procedures

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

Age of transfused red blood cells and health outcomes in two surgical cohorts

RATIONALE

Red blood cells (RBC) undergo morphologic and biochemical changes during storage which may lead to adverse health risks upon transfusion. In prior studies, the effect of RBC age on health outcomes has been conflicting. We designed the study to assess the effects of RBC units' storage duration on health outcomes specifically for hospitalized patients undergoing hip fracture surgery or coronary artery bypass grafting (CABG) surgery.

METHODS

Using International Classification of Diseases (ICD) 9 codes, hip fracture surgery and CABG surgery patients, who received RBC transfusions between 2008 and 2013, were retrospectively identified from the electronic medical records system. Hip fracture surgery and CABG cohorts were sub-divided into 3 blood age groups based upon RBC unit age at the time of transfusion: young blood (RBC units stored less than or equal to 14 days), old blood (RBC units were stored for greater than or equal to 28 days), or mixed blood for the remaining patients. Outcome variables were 30-day, 90-day, and inpatient mortality as well as hospital length of stay.

RESULTS

A total of 3,182 patients were identified: 1,121 with hip fractures and 2,061 with CABG. Transfusion of old blood was associated with higher inpatient mortality in the hip fracture surgery cohort (OR 166.8, 95% CI 1.067-26064.7, p = 0.04) and a higher 30-day mortality in the CABG cohort (OR 4.55, 95% CI 1.01-20.49, p = 0.03).

CONCLUSIONS

Transfusing RBC units stored for greater than or equal to 28 days may be associated with a higher mortality for patients undergoing hip fracture or CABG.

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.

Red blood cell transfusion policy: a critical literature review

The issue of the most appropriate red blood cell transfusion policy has been addressed by a number of randomised controlled trials, conducted over the last decades, comparing the effects on patients' outcome of restrictive blood transfusion strategies (transfusing when the haemoglobin concentration is less than 7 g/dL to 8 g/dL) vs more liberal ones (transfusing when the haemoglobin concentration is less than 9 g/dL to 10 g/dL) in a variety of clinical settings. In parallel, various systematic reviews and meta-analyses have tried to perform pooled analyses of the data from these randomised controlled trials and their results have been utilised by scientific societies to provide recommendations and guidelines on red blood cell transfusion thresholds. All these aspects will be critically discussed in this narrative review.

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.

Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis

OBJECTIVE

To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices.

DESIGN

Systematic review and meta-analysis.

SETTING, PARTICIPANTS, INTERVENTIONS

Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot.

RESULTS

Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias.

CONCLUSIONS

The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?'

PROSPERO REGISTRATION NUMBER

CRD42015024757.

Should surgery be delayed in patients taking direct oral anticoagulants who suffer a hip fracture? A retrospective, case-controlled observational study at a UK major trauma centre

OBJECTIVE

To determine whether not waiting for the elimination of direct oral anticoagulants (DOACs) has an effect on the amount of perioperative bleeding in patients who undergo operative treatment of a hip fracture.

DESIGN

Observation, retrospective case-control study.

SETTING

A single UK major trauma centre.

PARTICIPANTS

Patients who sustained a hip fracture were identified using the National Hip Fracture Database (NHFD). All those found to be taking a DOAC at the time of fracture were identified (n=63). A matched group not taking a DOAC was also identified from the NHFD (n=62).

MAIN OUTCOME

Perioperative drop in haemoglobin concentration.

RESULTS

There was no relationship between admission to operation interval and perioperative change in haemoglobin concentration in patients taking DOACs (regression coefficient=-0.06 g/L/hour; 95% CI -0.32-0.20; p=0.64). No relationship was found between the time from admission to operation interval and the probability of transfusion (OR=0.94; 95% CI 0.85 to 1.90; p=0.16) or reoperation (OR=1.04; 95% CI 0.93 to 1.16; p=0.49). One mortality was recorded in the DOAC group within 30 days of admission, and this compared with five in the matched group of patients (p=0.2).

CONCLUSIONS

Delaying surgery in patients who sustain a hip fracture who are taking a DOAC drug has not been shown to reduce perioperative bleeding or affect their mortality in this study.

Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review

Background

Benefits and risks of liberal and restrictive transfusion regimens are under on-going controversial discussion. This systematic review aimed at assessing both regimens in terms of pre-defined outcomes with special focus on patients undergoing major orthopaedic surgery.

Methods

We performed a literature search for mortality, morbidity and related outcomes following peri-operative blood transfusion in patients with major orthopaedic surgery in electronic databases. Combined outcome measure estimates were calculated within the scope of meta-analyses including randomised clinical trials comparing restrictive versus liberal blood transfusion regimens (e.g. MH risk ratio, Peto odds ratio).

Results

A total of 880 publications were identified 15 of which were finally included (8 randomised clinical trials (RCTs) with 3,693 patients and 6 observational studies with 4,244,112 patients). Regarding RCTs, no significant differences were detected between the transfusion regimes for all primary outcomes (30-day mortality, thromboembolic events, stroke/transitory ischaemic attack, myocardial infarction, wound infection and pneumonia) and a secondary outcome (length of hospital stay), whereas there was a significantly reduced risk of receiving at least one red blood concentrate under a restrictive regimen.

Conclusion

The results of this systematic review do not suggest an increased risk associated with either a restrictive or a liberal transfusion regimen in patients undergoing major orthopaedic surgery.

Modernising Hip Fracture Anaesthesia

Hip fracture carries a 30-day mortality of around 8% in the United Kingdom. This figure has remained relatively unchanged despite modern developments in anaesthetic technique. These range from improvements in perioperative analgesia and mortality scoring systems, changes to intra-operative anaesthetic technique and strategies to reduce the requirement for blood transfusion. In this article, we review the current literature on the perioperative management of patients undergoing hip fracture surgery including some of the current controversies.

Mortality and cardiorespiratory complications in trochanteric femoral fractures: a ten year retrospective analysis

PURPOSE

Despite intense research and innovations in peri-operative management, a high mortality rate and frequent systemic complications in trochanteric femoral fractures persist. The aim of the present study was to identify predictive factors for mortality and cardio-respiratory complications after different treatment methods in a ten year period at a level I trauma centre.

METHODS

Retrospectively, all patients above 60 years of age with trochanteric femoral fracture between January 2000 and May 2011 were analyzed at a level I trauma centre. Demographic variables, comorbidities, and data regarding the surgical procedures, including required transfusions and post-operative complications, were evaluated, and the in-hospital mortality was recorded. The grade of osteoporosis was classified radiographically using the Singh index.

RESULTS

The in-hospital mortality rate was 8.2% among 437 patients (male/female ratio = 110/327, mean age = 81 years) with extramedullary open (n = 144), intramedullary (n = 166), and extramedullary minimally invasive (n = 125) procedures. Significant influential factors on in-hospital mortality were identified with binary logistic regression analysis: an age of ≥90 years (P = 0.011), male sex (P = 0.003), a high American Society of Anesthesiologists (ASA) grade (3-5, P = 0.042), and a high osteoporosis grade (Singh index 3-1, P = 0.011). A total of 21.5% of the study population suffered cardio-respiratory complications post-operatively. The specific mortality was 28.7% (P < 0.001), which was influenced by a high ASA grade (3-5, P = 0.002) and a high transfusion rate (P = 0.004). Minimally invasive locked plating was associated with increased cardio-respiratory complications (P = 0.031).

CONCLUSIONS

This study identified high patient age, distinctive comorbidities, male sex, and high osteoporosis grade as significant risk factors for increased in-hospital mortality in the treatment of trochanteric femoral fractures. Furthermore, high ASA grade and a liberal transfusion regime led to an increased incidence of cardio-respiratory complications. Patient-specific characteristics, especially osteoporosis grade and pre-existing medical conditions, may assist in the identification of high-risk patients and allow a patient-specific geriatric co-management plan.

Predisposing factors for recurrence of chronic posttraumatic osteomyelitis: a retrospective observational cohort study from a tertiary referral center in Brazil

BACKGROUND

The incidence of posttraumatic osteomyelitis (PTO) is increasing despite new treatment strategies. Assessment of patients' outcomes following PTO is challenging due to multiple variables. The study goals are to determine the frequency of recurrence following PTO treatment and identify factors predisposing patients to treatment failure.

METHODS

Between August 01, 2007 to August 30, 2012, a single-center retrospective cohort study was performed among 193 patients diagnosed with PTO following orthopedic surgery for fracture care. Bone and soft tissues were collected for cultures and PTO was defined according to CDC/NHSN criteria. Patient, injury, surgery-associated variables, and microbiological records were reviewed for risk factors associated to recurrence of PTO. Univariate and multivariable analyses using logistic regression were performed, with p <0.05 considered significant.

RESULTS

Thirty-eight patients (20%) of 192 diagnosed and treated for PTO failed their treatment. Factors associated with recurrence were age between 61 and 80 years [hazard ratio (HR) = 6.086, 95% confidence interval (CI) = 2.459;15.061, p = <0.001], age above 80 years [HR = 9.975 (95% CI = 3.591;27.714), p = <0.001], intraoperative blood transfusion [HR = 2.239 (95% CI = 1.138;4.406), p = 0.020], and positive culture for Pseudomonas aeruginosa [HR = 2.700 (95% CI = 1.370;5.319), p = 0.004].

CONCLUSIONS

Risk factors associated with recurrence of PTO are difficult to measure. The present study revealed that elderly patients, intraoperative blood transfusions, and infection due to P. aeruginosa were independently associated with recurrence of PTO. These factors should warn clinicians of a higher failure rate following treatment of PTO. Trial registration: ISRCTN71648577. Registered 18 May 2017. Retrospectively registered.

Restrictive versus liberal transfusion strategies for red blood cell transfusion after hip or knee surgery: A systematic review and meta-analysis

BACKGROUND

Red blood cell (RBC) transfusions are commonly used in surgical patients, but accompanied by many risks such as metabolic derangement, and allergic and febrile reactions. Indications for transfusion in patients after hip or knee surgery have not been definitively evaluated and remain controversial. We performed a meta-analysis to compare the benefits and harms of restrictive versus liberal transfusion strategies in patients after hip or knee surgery.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies through September 2015. The main clinical outcomes reported in randomized controlled trials (RCTs) included 30-day mortality, infection rate, cardiogenic complications, and length of hospital stay. The meta-analysis program of the Cochrane Collaboration (RevMan version 5.3.0) was used for data analysis. Statistical heterogeneity was assessed by both Cochran chi-squared test (Q test) and I test. Begg and Egger test were used to assess potential publication bias.

RESULTS

We identified 10 eligible RCTs, involving 3788 patients in total. In patients undergoing hip or knee surgery, we found no differences in mortality, or the incidence rates of pneumonia, wound infection, myocardial infarction, or congestive heart failure, between restrictive and liberal thresholds for RBC transfusion (P > .05).

CONCLUSION

Restrictive transfusion has no advantage over the liberal strategy. However, considerably less patients received blood transfusion via the restrictive strategy than with the liberal counterpart. Due to variations in the included studies, additional larger scale and well-designed studies are required to validate these conclusions.

Resuscitation in hip fractures: a systematic review

To evaluate the evidence for the resuscitation of patients with hip fracture in the preoperative or perioperative phase of their treatment and its impact on mortality.

DESIGN

We searched MEDLINE, EMBASE, CENTRAL and PROSPERO databases using a systematic search strategy for randomised trials and observational studies investigating the fluid resuscitation of any patient with hip fracture. No language limits were applied to the search, which was complemented by manually screening the reference lists of appropriate studies.

OUTCOME MEASURES

Mortality at 1 week, 30 days and 1 year following surgery.

RESULTS

Two hundred and ninety-eight citations were identified, and 12 full manuscripts were reviewed; no studies satisfied the inclusion criteria. The background literature showed that the mortality for these patients at 30 days is approximately 8.5% and that bone cement implantation syndrome is insufficient to explain this. The literature was explored to define the need for an interventional investigation into the preoperative resuscitation of patients with hip fracture.

CONCLUSIONS

Patients with hip fracture show similar physiological disturbance to major trauma patients. Nineteen per cent of patients presenting with hip fracture are hypoperfused and 50% show preoperative anaemia suggesting that under resuscitation is a common problem that has not been investigated. A properly conducted interventional trial could improve the outcome of these vulnerable patients.