Postoperative blood transfusion strategy in frail, anemic elderly patients with hip fracture: the TRIFE randomized controlled trial

Abstract

Background and purpose: Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery.

Patients and methods: We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days.

Results: No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1-5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1-3.6; p = 0.01).

Interpretation: According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.

Figure 1.

CONSORT flow diagram for enrollment, allocation, follow-up, and analysis

Figure 2.

Intention to treat: repeated measurements on recovery from physical disabilities before fracture until postoperative days 10, 30 and 90, presented as median score with interquartile range, in residents from nursing homes and sheltered housing facilities.

Figure 3.

Kaplan-Meier plots of 90-day survival rates after hip fracture in residents from nursing homes and sheltered housing facilities, by intention-to-treat analysis.

Figure 4

Mean hemoglobin concentrations (in g/dL) measured on days 3, 10, 17, 24, and 30 after hip fracture surgery (with 95% confidence intervals) according to blood transfusion strategy (liberal or restrictive).