Hip Fracture Surgery without Transfusion in Patients with Hemoglobin Less Than 10 g/dL

Background: Hip fracture surgery is associated with blood loss, which may lead to adverse patient outcomes. The hemoglobin level declines gradually in most hip fracture cases involving femoral neck fractures and intertrochanteric fractures. It decreases further after hip fracture surgery due to perioperative bleeding. We developed a protocol, which avoids transfusion in hip fracture surgery, and reviewed the hemodynamic outcomes of patients with hemoglobin less than 10 g/dL without transfusion. Methods: From 2014 to 2019, we retrospectively recruited 34 patients with hip fractures and a hemoglobin level less than 10 g/dL, who refused to undergo transfusion. There were 19 patients with femoral neck fractures and 15 patients with intertrochanteric fractures. Our patient blood management (PBM) protocol involving 4,000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) was applied to all included patients. Intraoperatively, a cell saver and tranexamic acid were used. Postoperatively, the protocol was maintained until the patients' hemoglobin level reached 10 g/dL. We evaluated the feasibility of our protocol, perioperative complications, and hemodynamic changes. Results: Nineteen patients with femoral neck fractures underwent bipolar hemiarthroplasty and 15 patients with intertrochanteric frac-tures underwent internal fixation with a cephalomedullary nail. The mean hemoglobin level was 8.9 g/dL (range, 7.3-9.9 g/dL) preoperatively, 7.9 g/dL (range, 6.5-9.3 g/dL) immediately postoperatively, 7.7 g/dL (range, 4.3-9.5 g/dL) on postoperative day 1, 7.4 g/dL (range, 4.2-9.4 g/dL) on postoperative day 3, 8.1 g/dL (range, 4.4-9.7 g/dL) on postoperative day 5, 8.5 g/dL (range, 4.5-9.9 g/dL) on post-operative day 7, and 9.9 g/dL (range, 5.7-11.1 g/dL) on postoperative day 14. The average intraoperative bleeding was 206.2 +/- 78.7 mL. There was no case associated with complications of anemia. Conclusions: Hip fracture surgery in patients with hemoglobin less than 10 g/dL was feasible without the need for transfusion using our PBM protocol in 34 patients. Using this protocol, the operation was conducted safely despite the anemic condition of patients with fractures whose hemoglobin was less than 10 g/dL.