Mortality and clinical outcome of Italian patients undergoing orthopaedic surgery: effect of peri-operative blood transfusion

Background - Blood transfusion is a relevant issue for elderly and frail patients, as they are often anaemic and have chronic diseases. Transfusion of red blood cells (RBC) can potentially affect morbidity and mortality of elderly patients undergoing major orthopaedic surgery. Materials and methods - We carried out a retrospective analysis of 2,593 patients undergoing major orthopaedic surgery between 2013 and 2017 in a single research institution in the Region of Apulia. The aims of the study were: 1) to describe the characteristics of transfused patients according to a restrictive or liberal strategy of transfusion and haemoglobin (Hb) triggers and targets; 2) to investigate the effect of RBC transfusion on mortality and complications. Results - Older, women and patients with American Society of Anesthesiologists (ASA) score 3-4 were more often transfused. Those with lower admission Hb level had a higher risk of being transfused. Hb triggers were associated with the patients' age. A restrictive transfusion strategy was significantly more frequent in patients undergoing primary knee replacement and in those with higher estimated blood loss. We did not observe any significant difference of complications in patients transfused with a liberal vs restrictive strategy. Logistic regression correcting for potential confounders revealed that sex (males more than females), duration of stay in hospital, hip fracture and Charlson score >4 were good predictors of complications and/or mortality. Mortality was significantly higher in males and in older patients with ASA score 3-4. Discussion - In this large cohort of Italian patients undergoing major orthopaedic surgery males were significantly more exposed than women to complications and in-hospital mortality. Furthermore, those undergoing urgent surgery because of hip fracture had a 3-fold higher chance of complications. Charlson score >4 and ASA 3-4 are good predictors of complications and mortality, respectively.