According to study published in the New England Journal of Medicine, individuals who receive surgery require less blood after the procedure than commonly thought. The study compared two strategies for administering blood transfusions after surgery. The researchers discovered that no adverse effects from postponing transfusing were shown until patients hemoglobin concentration falls below 8 g/dL or they develop signs of anemia. The study was funded by the National Heart and Lung and Blood Institute.

NewYork-Presbyterian Hospital/Columbia University Medical Center is 1 of 47 centers taking part in the FOCUS (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) investigation.

The study was led by Dr. Jeffrey Carson, Richard C. Reynolds Professor of Medicine at the UMDNJ-Robert Wood Johnson Medical School in New Brunswick, NJ.

Dr. William Macaulay, a co-author and member of the FOCUS steering committee, explains:

“This study will help resolve the debate about how much blood patients need after surgery. More often than not, a blood transfusion isn’t necessary, even for elderly and sick patients.

The implications are enormous. Reducing the number of blood transfusions will greatly decrease blood use, potentially saving an enormous amount of money”

Dr. Macaulay is the director of the Center for Hip and Knee Replacement at NewYork-Presbyterian Hospital/Columbia University Medical Center, chief of the Division of Adult Reconstructive Surgery of the Hip and Knee, and the Nas S. Eftekhar Professor of Clinical Orthopaedic Surgery at Columbia University College of Physicians and Surgeons.

Each year in the U.S., 14.6 million units of blood are transferred. Individuals undergoing surgery receive between 60-70% of these transfusions. Older individuals received most of the blood transfusions. Usually, individuals receive a transfusion if their hemoglobin level is at or below 10 g/dL. However, an increasing number of physician’s follow a “restrictive” method using signs of anemia or a lower hemoglobin level. Furthermore, a few physicians decide to give transfusions to individuals who have cardiovascular disease or higher blood counts if they are elderly. Usually individuals have blood counts higher than 12 g/dL.

2,016 individuals aged 50+ with a history of or a risk for cardiovascular disease, were enrolled to participate in the study. Median age of participant was 82 years old. Participants were randomly assigned to two groups. One group received a blood transfusion when their hemoglobin level was below 10 g/dL (liberal group), while the other group (restrictive group) received a transfusion when they showed signs of anemia, or at a physician’s discretion if their hemoglobin level was less than 8 g/dL. For a large variety of clinical outcomes, including heart attack risk, infection, falls, symptoms such as fatigue, risk of death within 60 days and functional recovery.

Participants in the restrictive group received 65% less units of blood than the other group. 58.5% of participants in the restrictive group did receive a blood transfusion.

Dr. Macaulay, explains:

“As the medical community further embraces a restrictive approach to post-surgery blood transfusion, it’s important that physicians carefully evaluate patients for symptoms of anemia, and not just rely on hemoglobin levels. The patient’s body will often tell us when it needs blood.”

The FOCUS trial verifies discoveries of the 1999 Transfusion Requirements in Critical Care Investigators (TRICC) trial, which discovered that outcomes of a 7 g/dL transfusion threshold and a 10 g/dL threshold were comparable for individuals in an intensive care setting. No evidence of increased rates of death, heart attack, or congestive heart failure in its liberal group, despite anecdotal evidence was found.

Written by Grace Rattue