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

Amin, Raj M. MD; DeMario, Vincent M. BS; Best, Matthew J. MD; Shafiq, Babar MD; Hasenboehler, Erik A. MD; Sterling, Robert S. MD; Frank, Steven M. MD; Khanuja, Harpal S. MD

Journal of the American Academy of Orthopaedic Surgeons: December 1, 2019 - Volume 27 - Issue 23 - p 887-894
doi: 10.5435/JAAOS-D-18-00374
Research Article

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

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

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

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

Level of Evidence: Level III, retrospective cohort study

From the Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD (Dr. Amin, Dr. Best, Dr. Shafiq, Dr. Hasenboehler, Dr. Sterling, and Dr. Khanuja), and the Department of Anesthesiology and Critical Care Medicine, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, MD (Mr. DeMario and Dr. Frank).

Correspondence to Dr. Khanuja:

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Amin, DeMario, Dr. Best, Dr. Shafiq, Dr. Hasenboehler, Dr. Sterling, Dr. Frank, and Dr. Khanuja.

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Copyright 2019 by the American Academy of Orthopaedic Surgeons.
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