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Less blood needed post-surgery, says NEJM study

December 15, 2011

NEW YORK -- Patients need less blood after surgery than is widely thought. A new study comparing two plans for giving blood transfusions following surgery showed no ill effects from postponing transfusion until patients develop signs of anemia or their hemoglobin concentration falls below 8 g/dL.

Results of the National Heart and Lung and Blood Institute-funded study are published in today's edition of the New England Journal of Medicine. NewYork-Presbyterian Hospital/Columbia University Medical Center is one of 47 centers participating in the FOCUS (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) study, 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, says, "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," continues Dr. Macaulay, 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.

In the United States, 14.6 million units of blood are transfused each year. Between 60 and 70 percent of blood transfusions are given to patients undergoing surgery and the majority of blood transfusions are given to older patients. Commonly, patients are given a transfusion if their hemoglobin level is at or below 10 g/dL, although a growing number of physicians follow a "restrictive" approach using a lower threshold or symptoms of anemia. In addition, some physicians choose to give blood transfusions to patients with higher blood counts if they are elderly or have cardiovascular disease. Normally, people have blood counts above 12 g/dL.

The study followed 2,016 patients aged 50 years or older with a history of or risk factors for cardiovascular disease, who underwent surgery for hip fracture. They were randomized into two groups: one that received a transfusion when their hemoglobin level fell below 10 g/dL (liberal group) and another that received a transfusion when they had symptoms of anemia, or at a physician's discretion if their hemoglobin was below 8 g/dL (restrictive group). The two groups had similar results for a large array of clinical outcomes, including risk for death within 60 days; functional recovery; risk for heart attack, infection, and falls; and symptoms such as fatigue. Median age was 82 years.

The difference in blood use was striking. Patients in the restrictive group received 65 percent fewer units of blood than the liberal group, and 58.5 percent of patients in the restrictive group did not receive any blood transfusion.

"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," says Dr. Macaulay.

The FOCUS trial confirms findings of the 1999 Transfusion Requirements in Critical Care Investigators (TRICC) trial, which found that outcomes of a 7 g/dL transfusion threshold and a 10 g/dL threshold were similar for patients in an intensive care setting. FOCUS did not find evidence of increased rates of death, heart attack, or congestive heart failure in its liberal group, despite anecdotal evidence.
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Columbia University Medical Center

Columbia University Medical Center provides international leadership in basic, pre-clinical and clinical research, in medical and health sciences education, and in patient care. The Medical Center trains future leaders and includes the dedicated work of many physicians, scientists, public health professionals, dentists, and nurses at the College of Physicians & Surgeons, the Mailman School of Public Health, the College of Dental Medicine, the School of Nursing, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. Established in 1767, Columbia's College of Physicians and Surgeons was the first institution in the country to grant the M.D. degree and is now among the most selective medical schools in the country. Columbia University Medical Center is home to the largest medical research enterprise in New York City and state and one of the largest in the United States. For more information, please visit http://www.cumc.columbia.edu.

NewYork-Presbyterian Hospital

NewYork-Presbyterian Hospital, based in New York City, is the nation's largest not-for-profit, non-sectarian hospital, with 2,409 beds. The Hospital has nearly 2 million inpatient and outpatient visits in a year, including 12,797 deliveries and 195,294 visits to its emergency departments. NewYork-Presbyterian's 6,144 affiliated physicians and 19,376 staff provide state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine at five major centers: NewYork-Presbyterian Hospital/Weill Cornell Medical Center, NewYork-Presbyterian Hospital/Columbia University Medical Center, NewYork-Presbyterian/Morgan Stanley Children's Hospital, NewYork-Presbyterian/The Allen Hospital and NewYork-Presbyterian Hospital/Westchester Division. One of the most comprehensive health care institutions in the world, the Hospital is committed to excellence in patient care, research, education and community service. NewYork-Presbyterian is the #1 hospital in the New York metropolitan area and is consistently ranked among the best academic medical institutions in the nation, according to U.S.News & World Report. The Hospital has academic affiliations with two of the nation's leading medical colleges: Weill Cornell Medical College and Columbia University College of Physicians and Surgeons. For more information, visit http:/wwwww.nyp.org.

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