A reply

Abstract

Dr Rajamanickam asks a very good question that is pertinent to our recent guidelines 1. The exact transfusion trigger in surgery, in the older patient, is still surrounded by some controversy, despite a recent Cochrane review 2. The advice from this review is to withhold blood until the haemoglobin concentration reaches 70–80 g.l−1, which is described as a restrictive transfusion trigger. The review includes 19 studies, involving over 6000 patients, and the in-hospital mortality was lower in those who had a restrictive policy applied. This review is dominated by one study, the Focus Study 3, which was a rehabilitation study in patients with hip fracture and contributed 2016 patients including those over 50 years, but with an average age of around 80 years. All were randomised after surgery. Many of the other included studies involved children and patients receiving critical care, who are younger than the standard elderly patient. The recent review does mention that there are no trials of transfusion triggers in those with acute coronary syndromes and that studies are also required in which the trigger is set at 60 g.l−1 2. In contrast, there is evidence from a large observational study 4 that looked at the effect of anaemia in older surgical patients who have had non-cardiac surgery. It showed a detrimental effect of anaemia on outcome from surgery. There are confounding factors at play, as pre-operative anaemia can be investigated and corrected and is often a marker of another disease process, whilst acute blood loss may just occur in the acute surgical process. Transfusion utilises a precious resource but constant vigilance around the time of surgery should be exercised in the older patient, many of whom have risk factors for ischaemic heart disease. In those with risk factors, a higher trigger, towards 90 g.l−1, may be advisable.