A systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips

Abstract

SummaryWe systematically reviewed the observational associations of anaemia with outcomes and the effects of interventions to increase haemoglobin concentrations following hip fracture in older people. Anaemia on hospital admission was associated with increased mortality, relative risk 1.64 (95% CI 1.47-1.82), p < 0.0001. After adjustment for co-morbidities, the association of anaemia with increased mortality remained in four of eight observational studies. There was no association of postoperative transfusion with mortality after adjusting for covariates. Transfusion at 80 g.l À1 vs 100 g.l À1 increased acute myocardial infarction, relative risk 1.67 (95% CI 1.01-2.77), p = 0.05. Transfusion threshold was not associated with differences in other outcomes. There were insufficient high-quality studies to inform pre-operative blood transfusion or the use of peri-operative iron or erythropoietin. Studies for most interventions recruited too few participants to determine effects on infections, mortality or function.

Factors associated to institutionalization and mortality over three years, in elderly people with a hip fracture—An observational study

“…We believe this weak association depends on other factors such as comorbidity, complications or age, as shown in previous research [17]. Almost half of the included patients had received a blood transfusion during their stay at the acute trauma unit.…”

Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression

“…Co-administration of proton pump inhibitors may also decrease clopidogrel activity due to inhibition of cytochrome P450 2C19 (which activates the prodrug clopidogrel to its active form) [66,67]. Increases in the proportion of patients receiving a blood transfusion may have implications for increasing the risk of postoperative infection [68]. It may also require additional management strategies to reduce hidden blood loss such as platelet transfusions after 24 h of clopidogrel cessation or antifibrinolytics [69].…”

“…This question would be more effectively answered by large randomised controlled trials comparing early versus delayed surgery; current evidence would possibly not provide equipoise for such a study. Furthermore, current studies are underpowered to detect differences in infectious complications, an outcome most likely to be affected by increased transfusion requirements [68].…”

Resuscitation in hip fractures: a systematic review

“…The 2015 Cochrane Review by Brunskill et al 59 concluded that further research was needed into blood product resuscitation in the preoperative phase of hip fracture care to include frail, unstable and cognitively impaired patients in an effort to improve mortality and functional outcomes. This conclusion is supported by Parker et al 55, the FOCUS trial and Potter et al 39, each of which concludes that a trial investigating preoperative blood product resuscitation in patients with hip fracture should take place to investigate potential improvements in the outcomes for these vulnerable patients 56…”

“…Anaemia is common among the elderly, affecting 17% of all patients aged over 65 years, rising to 50% in patients presenting with hip fracture, in turn leading to compromised patient outcomes and an increased risk of mortality 5 6 37 38. The scale of this increased mortality is best described by a meta-analysis of 10 studies investigating patients with hip fracture produced by Potter et al in 2015, showing that preoperative anaemia is associated with an increase in the relative risk of mortality of 1.64 (95% CI 1.47 to 1.82) at all time points beyond 30 days 39. Similar effects are seen in elderly patients in other surgical cohorts with anaemia causing an increase in mortality of between 6% and 182% using a variety of study designs 40–45…”