Liberal or restrictive transfusion in high-risk patients after hip surgery.

At last, the long-awaited FOCUS study has been published and a great trial it is! Carson et al. have made a huge contribution to the literature on transfusion thresholds and cardiovascular risk. In fact, they have added 2016 patients to the less than 5000 patients enrolled worldwide in randomized controlled trials on transfusion triggers.

Briefly, the investigators enrolled patients who were 50 years or older (mean age 81.6 years), with a history of or risk factors for cardiovascular disease and with a hemoglobin (Hb) concentration less than 10 g/dL after undergoing surgical repair of a hip fracture. Patients were randomized to a liberal transfusion strategy (to maintain Hb > 10 g/dL) or a restrictive transfusion strategy (transfusion for a Hb < 8 g/dL). Virtually all patients in the liberal group were transfused (median of 2 units) while close to 60% of patients avoided transfusion altogether (median 0 unit) in the restrictive group. ALL outcomes (including death, inability to walk 10 feet, myocardial infarction, unstable angina, functional measures, fatigue, etc.) were similar in hospital, at 30 days and at 60 days. The authors conclude that a liberal transfusion strategy does not improve outcomes in elderly patients at high cardiovascular risk.

This study should, definitely, convince those clinicians reluctant to relinquish their liberal transfusion practices for all sorts of theoretical considerations (age, cardiovascular disease, etc.). FOCUS will lead to a change in transfusion practice and is a must-read for all clinicians who transfuse or prescribe erythrocyte transfusions.

– Jean-François Hardy