Choosing Wisely:

Don’t transfuse asymptomatic postoperative hip fracture patients with a hemoglobin higher than 8g/dL.

Rationale and Comments: Two high-strength studies (Carson et al. and Carson et al.) support this recommendation. Carson et al. (FOCUS trial) is the largest (n = 2,016) 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 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.
Sponsoring Organizations:
  • American Academy of Orthopaedic Surgeons
  • Sources:
  • Randomized controlled trials
  • Disciplines:
  • Hematologic
  • Orthopedic
  • References: • 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.
    • 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. 1998;38(6):522-529.

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