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Perioperative Blood Transfusion and Postoperative Mortality
Jeffrey L. Carson, MD;
Amy Duff, MHS;
Jesse A. Berlin, ScD;
Valerie A. Lawrence, MD, MSc;
Roy M. Poses, MD;
Elizabeth C. Huber, MD;
Dorene A. O'Hara, MD, MSE;
Helaine Noveck, MPH;
Brian L. Strom, MD, MPH
JAMA. 1998;279:199-205.
Context.— The risks of blood transfusion have been studied extensively but the benefits and the hemoglobin concentration at which patients should receive a transfusion have not.
Objective.— To determine the effect of perioperative transfusion on 30- and 90-day postoperative mortality.
Design.— Retrospective cohort study.
Setting.— A total of 20 US hospitals between 1983 and 1993.
Participants.— A total of 8787 consecutive hip fracture patients, aged 60 years or older, who underwent surgical repair.
Main Outcome Measures.— Primary outcome was 30-day postoperative mortality; secondary outcome was 90-day postoperative mortality. The "trigger" hemoglobin level was defined as the lowest hemoglobin level prior to the first transfusion during the time period or, for patients in the nontranfused group, as the lowest hemoglobin level during the time period.
Results.— Overall 30-day mortality was 4.6% (n=402; 95% confidence interval [CI], 4.1%-5.0%); overall 90-day mortality was 9.0% (n=788; 95% CI, 8.4%-9.6%). A total of 42% of patients (n=3699) received a postoperative transfusion. Among patients with trigger hemoglobin levels between 80 and 100 g/L (8.0 and 10.0 g/dL), 55.6% received a transfusion, while 90.5% of patients with hemoglobin levels less than 80 g/L (8.0 g/dL) received postoperative transfusions. Postoperative transfusion did not influence 30- or 90-day mortality after adjusting for trigger hemoglobin level, cardiovascular disease, and other risk factors for death: for 30-day mortality, the adjusted odds ratio (OR) was 0.96 (95% CI, 0.74-1.26); for 90-day mortality, the adjusted hazard ratio was 1.08 (95% CI, 0.90-1.29). Similarly, 30-day mortality after surgery did not differ between those who received a preoperative transfusion and those who did not (adjusted OR, 1.23; 95% CI, 0.81-1.89).
Conclusions.— Perioperative transfusion in patients with hemoglobin levels 80 g/L (8.0 g/dL) or higher did not appear to influence the risk of 30- or 90-day mortality in this elderly population. At hemoglobin concentrations of less than 80 g/L (8.0 g/dL), 90.5% of patients received a transfusion, precluding further analysis of the association of transfusion and mortality.
From the Division of General Internal Medicine, Departments of Medicine (Dr Carson and Mss Duff and Noveck) and Anesthesia (Dr O'Hara), University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology (Drs Berlin and Strom), and Division of General Internal Medicine, Department of Medicine (Dr Strom), University of Pennsylvania School of Medicine, Philadelphia; Division of General Medicine, Audie Murphy Division, South Texas Veterans Health Care System and Department of Medicine, University of Texas at San Antonio (Dr Lawrence); Division of General Internal Medicine, Department of Medicine, Brown University School of Medicine, Providence, RI, and Memorial Hospital of Rhode Island, Pawtucket (Dr Poses); and Division of General Internal Medicine, Medical College of Virginia, Richmond (Dr Huber).
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