Strong evidence supports a blood transfusion threshold of no higher than 8g/dl in asymptomatic postoperative hip fracture patients.

Management of Hip Fractures in the Elderly
Endorsed by: OTA, AGS, AAPM&R, ASBMR, USBJI, The Hip Society, AACE, ORA
Strong Evidence STRONG EVIDENCE
Rationale
Two high strength studies (Carson et al 116 and Carson et al 117) support this recommendation. Carson et al 116  (FOCUS trial) is the largest (n=2016) and most robust study to address transfusion threshold in hip fracture patients. FOCUS considered patient-centered and clinically important outcomes in a prospective, randomized, multicenter, controlled trial. This study showed that a restrictive transfusion threshold of hemoglobin 8g/dl in asymptomatic hip fracture patients with cardiovascular disease or risk factors resulted in no significant difference in primary or secondary outcomes at 30 or 60 days including mortality, independent walking ability, residence, other functional outcomes, cardiovascular events, or length of stay. Carson’s 1998 trial 117 was also a high strength study and was the pilot study that led to FOCUS. Symptoms or signs that were considered indicative of anemia appropriate for transfusion were chest pain that was deemed to be cardiac in origin, congestive heart failure, and unexplained tachycardia or hypotension unresponsive to fluid replacement.
 
Risks and Harms of Implementing this Recommendation
Implementation of this recommendation is likely to result in lower transfusion associated complications and cost. There is risk that cognitively impaired patients cannot report symptoms, so special attention to these individuals may be warranted; FOCUS automatically transfused significantly demented patients below hemoglobin 8mg/dl.
 
Future Research
Confirmatory studies by other authors would strengthen evidence. Additional studies could further risk stratify and refine transfusion thresholds in subpopulations.
 
  1. (116) Carson JL, Terrin ML, Noveck H et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011;365(26):2453-2462.
  2. (117) Carson JL, Terrin ML, Barton FB et al. A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion (Paris) 1998;38(6):522-529.