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Odds of Transfusion for Older Adults Compared to Younger Adults Undergoing Surgery

Brown, Charles H. IV MD, MHS*; Savage, William J. MD, PhD; Masear, Courtney G. MD*; Walston, Jeremy D. MD; Tian, Jing MS§; Colantuoni, Elizabeth PhD§; Hogue, Charles W. MD*; Frank, Steven M. MD*

doi: 10.1213/ANE.0000000000000033
Cardiovascular Anesthesiology: Research Report

BACKGROUND: Recent randomized controlled trials have shown no benefit for transfusion to a hemoglobin >10 g/dL compared with lower hemoglobin thresholds in the perioperative period, even among older adults. Nevertheless, physicians may choose to transfuse older adults more liberally than younger adults. It is unclear whether older patients have higher odds than younger patients of being transfused in the perioperative period. Our objective in this study was to determine whether the odds of transfusion are higher in older patients than in younger patients in the perioperative period.

METHODS: We conducted this retrospective observational cohort study at a tertiary care academic medical center. We included adults who had undergone a surgical procedure as an inpatient at our institution from January 2010 to February 2012. The primary analysis compared the odds of transfusion for patients >65 years old with the odds of transfusion in younger patients based on multilevel multivariable logistic regression analyses including adjustment for comorbidities, surgical service, lowest in-hospital hemoglobin value, gender, and estimated surgical blood loss and accounted for clustering by the surgeon and procedure.

RESULTS: We included 20,930 patients in this analysis. In multilevel models adjusted for comorbidities, surgical service, estimated surgical blood loss, and lowest in-hospital hemoglobin value, with surgeon and procedure as random effects, patients >65 years old had 62% greater odds (odds ratio, 1.62; 95% confidence interval, 1.40–1.88; P < 0.0001) of being transfused than did younger patients. When patients were stratified by lowest in-hospital hemoglobin (7.00–7.99, 8.00–8.99, 9.00–9.99, and ≥10.00 g/dL), the odds of transfusion generally increased with each additional decade of age in every stratum, except for that containing patients in whom the lowest in-hospital hemoglobin did not decrease below 10 g/dL. When the odds of transfusion were compared between younger and older patients, significant differences were observed among surgical services (P = 0.02) but not among anesthesia specialty divisions (P = 0.9).

CONCLUSIONS: Older adults have greater odds of receiving red blood cell transfusion in the perioperative period than do younger patients, despite the lack of evidence supporting higher hemoglobin triggers in elderly patients. Further research is needed to determine whether transfusion practice in the elderly is an opportunity for education to improve blood management.

Published ahead of print January 9, 2014

From the *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Transfusion Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and Division of Geriatric Medicine and Gerontology, Johns Hopkins Medical Institutions, Baltimore, Maryland; and §Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland.

Accepted for publication October 14, 2013.

Published ahead of print January 9, 2014

Funding: NIH KL-2 Clinical Research Scholars Program, NIH (R03 AG042331), and the Jahnigen Career Development Award (CB); American Society of Hematology Scholar Award (WS); Mid-Atlantic Affiliate of the American Heart Association and the NIH (R01 HL092259) (CH); and the New York Community Trust (SF).

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Charles H. Brown IV, MD, MHS, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Zayed 6208 1800 Orleans St., Baltimore, MD 21287. Address e-mail to

© 2014 International Anesthesia Research Society