Blood transfusion rates and predictors following geriatric hip fracture surgery

Abstract

Background:

Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery.

Methods:

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion.

Results:

In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02–1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99–5.52], p = 0.001), female sex (OR 1.61 [1.39–1.87], p < 0.001), lower BMI (OR 0.97 [0.96–0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01–1.27], p = 0.031), COPD (OR 1.30 [1.06–1.59], p = 0.011), hypertension (OR 1.17 [1.01–1.35], p = 0.038), increased OR time (OR 1.02 [1.01–1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57–3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84–6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02–1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04–1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001).

Conclusions:

Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

Keywords

Blood transfusion hip fracture outcomes postoperative complications

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References

Cummings

Rubin

Black

. The future of hip fractures in the United States. Numbers, costs, and potential effects of postmenopausal estrogen. Clin Orthop Relat Res 1990; 252: 163–166.

Stevens

Rudd

. The impact of decreasing U.S. hip fracture rates on future hip fracture estimates. Osteoporos Int 2013; 24: 2725–2728.

Engoren

Mitchell

Perring

, et al. The effect of erythrocyte blood transfusions on survival after surgery for hip fracture. J Trauma 2008; 65: 1411–1415.

Verlicchi

Desalvo

Zanotti

, et al. Red cell transfusion in orthopaedic surgery: a benchmark study performed combining data from different data sources. Blood Transfus 2011; 9: 383–387.

Spahn

. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology 2010; 113: 482–495.

Smeets

SJM

Verbruggen

JPAM

Poeze

. Effect of blood transfusion on survival after hip fracture surgery. Eur J Orthop Surg Traumatol 2018; 28: 1297–1303.

Pedersen

Mehnert

Overgaard

, et al. Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study. BMC Musculoskelet Disord 2009; 10: 167.

Klein

Spahn

Carson

. Red blood cell transfusion in clinical practice. Lancet 2007; 370: 415–426.

Carson

Altman

Duff

, et al. Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair. Transfusion 1999; 39: 694–700.

10.

Arshi

Lai

Chen

, et al. Predictors and sequelae of postoperative delirium in geriatric hip fracture patients. Geriatr Orthop Surg Rehabil 2018; 9: 215145931881482.

11.

Dunne

Malone

Tracy

, et al. Allogenic blood transfusion in the first 24 hours after trauma is associated with increased systemic inflammatory response syndrome (SIRS) and death. Surg Infect (Larchmt) 2004; 5: 395–404.

12.

Yoon

Jang

, et al. Feasibility of hip fracture surgery using a no transfusion protocol in elderly patients: a propensity score-matched cohort study. J Orthop Trauma 2017; 31: 414–419.

13.

Shokoohi

Stanworth

Mistry

, et al. The risks of red cell transfusion for hip fracture surgery in the elderly. Vox Sang 2012; 103: 223–230.

14.

García-Alvarez

Al-Ghanem

García-Alvarez

, et al. Risk factors for postoperative infections in patients with hip fracture treated by means of Thompson arthroplasty. Arch Gerontol Geriatr 2010; 50: 51–55.

15.

Koval

Rosenberg

Zuckerman

, et al. Does blood transfusion increase the risk of infection after hip fracture? J Orthop Trauma 1997; 11: 260–265.

16.

Dillon

Collins

Rice

, et al. Preoperative characteristics identify patients with hip fractures at risk of transfusion. Clin Orthop Relat Res 2005; 439: 201–206.

17.

Swain

Nightingale

Patel

. Blood transfusion requirements in femoral neck fracture. Injury 2000; 31: 7–10.

18.

Desai

Wood

Marsh

, et al. Factors affecting transfusion requirement after hip fracture: can we reduce the need for blood? Can J Surg 2014; 57: 342–348.

19.

Sathiyakumar

Estevez-Ordonez

Thakore

, et al. American society of anesthesiologists score as a predictive tool to optimize blood ordering for intraoperative transfusion in orthopaedic trauma cases. J Surg Orthop Adv 2016; 25: 105–109.

20.

Adunsky

Lichtenstein

Mizrahi

, et al. Blood transfusion requirements in elderly hip fracture patients. Arch Gerontol Geriatr 36: 75–81.

21.

Hou

Zhou

Tian

, et al. Predicting the need for blood transfusions in elderly patients with pertrochanteric femoral fractures. Injury 2014; 45: 1932–1937.

22.

Walsh

Preston

Bong

, et al. Relative risk factors for requirement of blood transfusion after total hip arthroplasty. J Arthroplasty 2007; 22: 1162–1167.

23.

Frisch

Wessell

Charters

, et al. Effect of body mass index on blood transfusion in total hip and knee arthroplasty. Orthopedics 2016; 39: e844–e849.

24.

Fazal

Bagley

Garg

. Predictors for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary nailing. Chin J Traumatol 2018; 21: 16–19.

25.

Nie

Yang

, et al. Comparison of intramedullary fixation and arthroplasty for the treatment of intertrochanteric hip fractures in the elderly: a meta-analysis. Medicine (Baltimore) 2017; 96: e7446.

26.

Harper

Navo

Ramsey

, et al. “Hidden” preoperative blood loss with extracapsular versus intracapsular hip fractures: what is the difference? Geriatr Orthop Surg Rehabil 2017; 8: 202–207.

27.

Harper

Barnes

Gregg

. Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement. J Bone Joint Surg Br 1991; 73: 73–75.

28.

Smith

Tsang

Molyneux

, et al. The hidden blood loss after hip fracture. Injury 2011; 42: 133–135.

29.

Huang

Xie

, et al. Analysis of a large data set to identify predictors of blood transfusion in primary total hip and knee arthroplasty. Transfusion 2018; 58: 1855–1862.

30.

Morritt

Kelley

, et al. Blood ordering protocol based on proposed surgical implant in fractured neck of femur patients. Ann R Coll Surg Engl 2005; 87: 445–448.

31.

Guarino

Di Matteo

Sorrenti

, et al. Bloodless surgery in geriatric surgery. Int J Surg 2014; 12(Suppl. 2): S82–S85.

32.

Carson

Duff

Berlin

, et al. Perioperative blood transfusion and postoperative mortality. JAMA 1998; 279: 199–205.

33.

Iosifidis

Iliopoulos

Panagiotou

, et al. Walking ability before and after a hip fracture in elderly predict greater long-term survivorship. J Orthop Sci 2016; 21: 48–52.

34.

Kamel

Iqbal

Mogallapu

, et al. Time to ambulation after hip fracture surgery: relation to hospitalization outcomes. J Gerontol A Biol Sci Med Sci 2003; 58: 1042–1045.

35.

Burge

Dawson-Hughes

Solomon

, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007; 22: 465–475.