Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

Abstract

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1–2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08–1.15) and the HR for discharge was 0.78 (95% CI: 0.74–0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05–1.15) and HR for discharge was 0.82 (95% CI: 0.78–0.87). Pre-operative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended.

Harnessing the potential of data‐driven strategies to optimise transfusion practice

“…Any literature search readily identifies multiple publications to this effect. [6][7][8][9] Slightly under 2.2 million blood components were issued in 2022 in the UK, 10 yet data from successive audits of practice suggest that as many as 20% of transfused blood components may have been given outside national standards and recommendations (Table 1). 2 A national audit in 2016 of the use of red cells showed that 16% of all red blood cell transfusions were considered inappropriate across 170 sites with 4328 participants.…”

“…There are many examples of the complexity and variation in the practice of transfusion medicine: the many types of components that differ in their degree of matching requirements, the blood count and haemostasis test thresholds that trigger their use, the storage age, the volume that is prescribed and the additional specifications that may be applied. Any literature search readily identifies multiple publications to this effect 6–9 . Slightly under 2.2 million blood components were issued in 2022 in the UK, 10 yet data from successive audits of practice suggest that as many as 20% of transfused blood components may have been given outside national standards and recommendations (Table 1).…”

Extension of patient safety initiatives to perioperative care

“…This strategy has continued being fundamental during the COVID-19 outbreak to reduce the blood products’ demand [17]. There is still a large space to improvement for its implementation as it has recently been reported that perioperative anemia is undertreated in elderly patients in Europe [18 ▪ ].…”