Liberal or restrictive transfusion in high-risk patients after hip surgery

Jeffrey Carson, Michael L. Terrin, Helaine Noveck, David W. Sanders, Bernard R. Chaitman, George Rhoads, George Nemo, Karen Dragert, Lauren Beaupre, Kevin Hildebrand, William Macaulay, Courtland Lewis, Donald Richard Cook, Gwendolyn Dobbin, Khwaja J. Zakriya, Fred S. Apple, Rebecca A. Horney, Jay Magaziner

Research output: Contribution to journalArticle

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Abstract

Background: The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. Methods: We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of <8 g per deciliter). The primary outcome was death or an inability to walk across a room without human assistance on 60-day follow-up. Results: A median of 2 units of red cells were transfused in the liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2% in the liberal-strategy group and 34.7% in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95% confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95% CI, -3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3% and 5.2%, respectively (absolute risk difference, -0.9%; 99% CI, -3.3 to 1.6), and rates of death on 60-day follow-up were 7.6% and 6.6%, respectively (absolute risk difference, 1.0%; 99% CI, -1.9 to 4.0). The rates of other complications were similar in the two groups. Conclusions: A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.)

Original languageEnglish (US)
Pages (from-to)2453-2462
Number of pages10
JournalNew England Journal of Medicine
Volume365
Issue number26
DOIs
StatePublished - Dec 29 2011

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Hip
Hemoglobins
Confidence Intervals
Hip Fractures
National Heart, Lung, and Blood Institute (U.S.)
Mortality
Acute Coronary Syndrome
Blood Transfusion
Anemia
Cardiovascular Diseases
Odds Ratio
Morbidity
Physicians

All Science Journal Classification (ASJC) codes

  • Medicine(all)

Cite this

Carson, J., Terrin, M. L., Noveck, H., Sanders, D. W., Chaitman, B. R., Rhoads, G., ... Magaziner, J. (2011). Liberal or restrictive transfusion in high-risk patients after hip surgery. New England Journal of Medicine, 365(26), 2453-2462. https://doi.org/10.1056/NEJMoa1012452
Carson, Jeffrey ; Terrin, Michael L. ; Noveck, Helaine ; Sanders, David W. ; Chaitman, Bernard R. ; Rhoads, George ; Nemo, George ; Dragert, Karen ; Beaupre, Lauren ; Hildebrand, Kevin ; Macaulay, William ; Lewis, Courtland ; Cook, Donald Richard ; Dobbin, Gwendolyn ; Zakriya, Khwaja J. ; Apple, Fred S. ; Horney, Rebecca A. ; Magaziner, Jay. / Liberal or restrictive transfusion in high-risk patients after hip surgery. In: New England Journal of Medicine. 2011 ; Vol. 365, No. 26. pp. 2453-2462.
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abstract = "Background: The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. Methods: We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of <8 g per deciliter). The primary outcome was death or an inability to walk across a room without human assistance on 60-day follow-up. Results: A median of 2 units of red cells were transfused in the liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2{\%} in the liberal-strategy group and 34.7{\%} in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95{\%} confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95{\%} CI, -3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3{\%} and 5.2{\%}, respectively (absolute risk difference, -0.9{\%}; 99{\%} CI, -3.3 to 1.6), and rates of death on 60-day follow-up were 7.6{\%} and 6.6{\%}, respectively (absolute risk difference, 1.0{\%}; 99{\%} CI, -1.9 to 4.0). The rates of other complications were similar in the two groups. Conclusions: A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.)",
author = "Jeffrey Carson and Terrin, {Michael L.} and Helaine Noveck and Sanders, {David W.} and Chaitman, {Bernard R.} and George Rhoads and George Nemo and Karen Dragert and Lauren Beaupre and Kevin Hildebrand and William Macaulay and Courtland Lewis and Cook, {Donald Richard} and Gwendolyn Dobbin and Zakriya, {Khwaja J.} and Apple, {Fred S.} and Horney, {Rebecca A.} and Jay Magaziner",
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Carson, J, Terrin, ML, Noveck, H, Sanders, DW, Chaitman, BR, Rhoads, G, Nemo, G, Dragert, K, Beaupre, L, Hildebrand, K, Macaulay, W, Lewis, C, Cook, DR, Dobbin, G, Zakriya, KJ, Apple, FS, Horney, RA & Magaziner, J 2011, 'Liberal or restrictive transfusion in high-risk patients after hip surgery', New England Journal of Medicine, vol. 365, no. 26, pp. 2453-2462. https://doi.org/10.1056/NEJMoa1012452

Liberal or restrictive transfusion in high-risk patients after hip surgery. / Carson, Jeffrey; Terrin, Michael L.; Noveck, Helaine; Sanders, David W.; Chaitman, Bernard R.; Rhoads, George; Nemo, George; Dragert, Karen; Beaupre, Lauren; Hildebrand, Kevin; Macaulay, William; Lewis, Courtland; Cook, Donald Richard; Dobbin, Gwendolyn; Zakriya, Khwaja J.; Apple, Fred S.; Horney, Rebecca A.; Magaziner, Jay.

In: New England Journal of Medicine, Vol. 365, No. 26, 29.12.2011, p. 2453-2462.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Liberal or restrictive transfusion in high-risk patients after hip surgery

AU - Carson, Jeffrey

AU - Terrin, Michael L.

AU - Noveck, Helaine

AU - Sanders, David W.

AU - Chaitman, Bernard R.

AU - Rhoads, George

AU - Nemo, George

AU - Dragert, Karen

AU - Beaupre, Lauren

AU - Hildebrand, Kevin

AU - Macaulay, William

AU - Lewis, Courtland

AU - Cook, Donald Richard

AU - Dobbin, Gwendolyn

AU - Zakriya, Khwaja J.

AU - Apple, Fred S.

AU - Horney, Rebecca A.

AU - Magaziner, Jay

PY - 2011/12/29

Y1 - 2011/12/29

N2 - Background: The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. Methods: We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of <8 g per deciliter). The primary outcome was death or an inability to walk across a room without human assistance on 60-day follow-up. Results: A median of 2 units of red cells were transfused in the liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2% in the liberal-strategy group and 34.7% in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95% confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95% CI, -3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3% and 5.2%, respectively (absolute risk difference, -0.9%; 99% CI, -3.3 to 1.6), and rates of death on 60-day follow-up were 7.6% and 6.6%, respectively (absolute risk difference, 1.0%; 99% CI, -1.9 to 4.0). The rates of other complications were similar in the two groups. Conclusions: A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.)

AB - Background: The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. Methods: We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of <8 g per deciliter). The primary outcome was death or an inability to walk across a room without human assistance on 60-day follow-up. Results: A median of 2 units of red cells were transfused in the liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2% in the liberal-strategy group and 34.7% in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95% confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95% CI, -3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3% and 5.2%, respectively (absolute risk difference, -0.9%; 99% CI, -3.3 to 1.6), and rates of death on 60-day follow-up were 7.6% and 6.6%, respectively (absolute risk difference, 1.0%; 99% CI, -1.9 to 4.0). The rates of other complications were similar in the two groups. Conclusions: A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.)

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