[Intravenous iron, functional recovery and delirium in patients with hip fracture. FEDEREF study. Single-centre randomised, placebo-controlled, and double-blind clinical trial. 2014-001923-53: EudraCT number]

Perioperative intravenous iron to treat patients with fractured hip surgery: A systematic review and meta‐analysis

Background

Treatment of preoperative anemia with intravenous iron is common within elective surgical care pathways. It is plausible that this treatment may improve care for people with hip fractures many of whom are anemic because of pre‐existing conditions, fractures, and surgery.

Objective

To review the evidence for intravenous iron administration on outcomes after hip fracture.

Design

We followed a predefined protocol and conducted a systematic review and meta‐analysis of the use of intravenous iron to treat anemia before and after emergency hip fracture surgery. The planned primary outcome was a difference in length of stay between those treated with intravenous iron and the control group. Other outcomes analyzed were 30‐day mortality, requirement for blood transfusion, changes in quality of life, and hemoglobin concentration on discharge from the hospital.

Data Sources

EMBASE, MEDLINE, The Cochrane Library (CENTRAL, DARE) databases, Clinicaltrials.gov, and ISRCTN trial registries. Date of final search March 2022.

Eligibility Criteria

Adult patients undergoing urgent surgery for hip fracture. Studies considered patients who received intravenous iron and were compared with a control group.

Results

Four randomized controlled trials (RCT, 732 patients) and nine cohort studies (2986 patients) were included. The RCTs were at low risk of bias, and the nonrandomized studies were at moderate risk of bias. After metanalysis of the RCTs there was no significant difference in the primary outcome, length of hospital stay, between the control group and patients receiving intravenous iron (mean difference: −0.59, 95% confidence interval [CI]; −1.20 to 0.03; I² = 30%, p = 0.23). Intravenous iron was not associated with a difference in 30‐day mortality (n = 732, OR: 1.14, 95% CI: 0.62−2.1; I² = 0%, p = 0.50), nor with the requirement for transfusion (n = 732, OR: 0.85, 95% CI: 0.63−1.14; I² = 0%, p < 0.01) in the analyzed RCTs. Functional outcomes and quality of life were variably reported in three studies.

Conclusion

The evidence on the use of intravenous iron in patients with hip fracture is low quality and shows no difference in length of acute hospital stay and transfusion requirements in this population. Improved large, multicentre, high‐quality studies with patient‐centered outcomes will be required to evaluate the clinical and cost‐effectiveness of this treatment.

Effect of intravenous iron on functional outcomes in hip fracture: a randomised controlled trial

OBJECTIVES

to determine the safety and effect of intravenous iron sucrose on functional outcomes, delirium, nosocomial infections and transfusion requirements in older patients with hip fracture.

DESIGN

single-centre randomised, double-blind, placebo-controlled clinical trial.

SETTING AND PARTICIPANTS

orthogeriatric share care service at an academic tertiary care hospital. A total of 253 patients were recruited: 126 patients were assigned to intravenous iron and 127 to placebo.

METHODS

on days 1, 3 and 5 after admission, the iron group received 200 mg Venofer® (iron sucrose) in 100 ml saline and the placebo group 100 ml saline. The primary outcome was absolute functional gain, considered as Barthel index (BI) at discharge minus BI on admission. Secondary outcomes included incidence of postoperative delirium according to the confusion assessment method, proportion of patients recovering prior functional status at 3 months, postoperative transfusion requirements, haemoglobin at 3 months, incidence of nosocomial infections and safety.

RESULTS

the median participant age was 87 (interquartile range, 82.5-91.5) years. Most patients were female (72.7%), and the median previous BI was 81(59-95). No significant effect of intravenous iron was observed for the primary outcome: the median AFG score was 17.1 points (4.8-23.3) in the intravenous iron group and 16 points (6-26) in the placebo group (P = 0.369). No significant treatment effects were observed for other functional outcomes or secondary end points.

CONCLUSION

while we found no impact of intravenous iron sucrose on functional recovery, incidence of postoperative delirium, transfusion requirements, haemoglobin at 3 months, mortality and nosocomial infections rates in older patients with hip fracture, we did find that the intervention was safe.