What guidelines are used for perioperative transfusion in a patient with a neck of femur fracture and a history of Percutaneous Transluminal Coronary Angioplasty (PTCA)?

Guidelines for Perioperative Transfusion in Patients with Neck of Femur Fracture and History of PTCA

The 2014 ACC/AHA guideline and 2012 AABB guideline recommend a restrictive transfusion strategy with a hemoglobin threshold of 8 g/dL or for symptoms in patients with cardiovascular disease, including those with prior PTCA undergoing hip fracture surgery. 1

Transfusion Thresholds Based on Cardiovascular Status

For Patients with Cardiovascular Disease (including prior PTCA):

• Transfusion threshold: Hemoglobin < 8 g/dL 1
• OR presence of symptoms regardless of hemoglobin level:
  • Chest pain believed to be cardiac in origin
  • Orthostatic hypotension unresponsive to fluid challenge
  • Tachycardia unresponsive to fluid challenge
  • Congestive heart failure 1

For Patients without Cardiovascular Disease:

• Transfusion threshold: Hemoglobin < 7 g/dL 1
• The tolerance for postoperative anemia is higher in these patients 1

Evidence Supporting Restrictive Strategy

The 2014 ACC/AHA guideline cites a randomized controlled trial of 2000 patients with either CAD or CAD risk factors undergoing hip fracture surgery that compared:

• Liberal transfusion strategy (hemoglobin < 10 g/dL)
• Restrictive transfusion strategy (hemoglobin < 8 g/dL or symptoms)

This trial found no significant differences in:

• Death at 60-day follow-up
• Inability to walk at 60-day follow-up
• Myocardial infarction
• Unstable angina
• In-hospital death 1

Special Considerations for Patients with Prior PTCA

While specific guidelines for patients with prior PTCA are not explicitly stated, these patients fall under the broader category of cardiovascular disease patients, for whom:

• The 2012 AABB guideline recommends a restrictive transfusion strategy in hospitalized patients with cardiovascular disease
• Consideration of transfusion for patients with symptoms or hemoglobin < 8 g/dL 1
• Patients with cardiovascular disease have lower tolerance to anemia compared to those without cardiovascular disease 1

Perioperative Monitoring

For patients with prior PTCA undergoing hip fracture surgery:

• Measurement of troponin levels is recommended when signs or symptoms suggest myocardial ischemia or MI (Class I recommendation) 1
• ECG monitoring is recommended when signs or symptoms suggest myocardial ischemia, MI, or arrhythmia (Class I recommendation) 1
• Routine postoperative troponin screening in asymptomatic patients is not recommended (Class III: No Benefit) 1

Preoperative Anemia Management

The 2024 AHA/ACC guideline emphasizes that:

• Even mild preoperative anemia is an independent risk factor for postoperative morbidity and mortality
• Preoperative iron therapy (oral or intravenous) is reasonable for iron-deficiency anemia to reduce blood transfusions 1

Blood Conservation Strategies

Additional strategies to minimize transfusion requirements include:

• Use of tranexamic acid, which safely decreases intraoperative bleeding 1, 2
• Patient blood management protocols including erythropoietin and iron supplementation 3

Common Pitfalls to Avoid

1. Relying on day-1 postoperative hemoglobin values: The decrease in hemoglobin in the first 24 hours post-operation underestimates the ultimate lowest value, which typically occurs on day 2 4

2. Overlooking symptoms of anemia: Symptoms may be masked by analgesia or distracting pain at the surgical site 1

3. Using a liberal transfusion strategy by default: Evidence shows restrictive strategies are safe and reduce unnecessary transfusions 5

4. Failing to monitor for myocardial injury: Patients with prior PTCA are at higher risk for perioperative cardiac events and should be monitored accordingly 1

By following these guidelines, clinicians can optimize perioperative care for patients with neck of femur fracture and history of PTCA, minimizing both the risks associated with anemia and those associated with unnecessary blood transfusions.