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

Abstract

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.

Six‐month outcomes after restrictive or liberal transfusion for cardiac surgery (TRICS III trial)

“…The study was not powered to detect smaller differences in outcome. Further data to support restrictive thresholds in cardiac surgery may come from a meta‐analysis of the trials of transfusion triggers in cardiac surgery (Brown et al, ; Mazer et al, ; Murphy et al , 2015; Mazer et al, ).…”

The aging human recipient of transfusion products

“…The incidence of transfusion also varies between different surgical services. According to a large prospective cohort study the transfusion trigger is increasing with patient age [35], although a more liberal transfusion strategy in elderly patients is neither supported by clinical evidence nor by practice guidelines. The author's explanation was that clinicians transfused because of suspected but not necessarily diagnosed co-morbidities.…”

What Is a Reference Standard?

“…2 This nineteenth-century observation was illustrated by Henry Marks and still serves us well today (Fig. 3 The study is informative to the journal's readers to discuss hemoglobin concentration triggers in the context of age, but what if the values change depending on method of measurement? Based on the work of Carabini and colleagues in the twenty-first century, one wonders whether the method of measurement may affect the conclusions for a variety of medical investigations that may or may not use CBC or ABG hemoglobin concentrations to test a certain hypothesis.…”

“…I often say that when you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre [sic] and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely in your thoughts advanced to the state of Science, whatever the matter may be." 3 They accepted their hypothesis partly based on, "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." 1).…”