Abstract
We read with interest, the article by Partridge et al. 1 on anaemia in the older surgical patient.
We would support the view that there is enough evidence in the literature to show that even mild anaemia in older patients preoperatively does impact negatively on outcome. Furthermore, many older patients undergoing surgery have compromised cardiovascular function and studies have been consistent in showing improvement as anaemia is corrected. Anaemia has also been shown to affect adversely length of hospital stay and recovery notably in the early postoperative period. What is surprising is that results of the trials on correction of anaemia have been inconsistent throwing considerable doubt on the merits of correcting anaemia in the early postoperative period.
This discrepancy, in our view, is related to the design and the endpoints of the studies conducted so far. For example, comparing mortality at one year between iron-treated and placebo groups 2 provides little insight since most patients would have their anaemia corrected by that time with or without iron supplementation. Similarly, following hip surgery, benefits of liberal (versus restrictive) blood transfusion 3 were not shown at day 60 although there was improvement in the treated group in primary endpoints (death and ability to walk independently), and return to place of residence at day 30, but this did not reach statistical significance.
Choosing a study endpoint like length of hospital stay, performance and mobility during the first 10–14 days of inpatient stay is probably a better predictor of benefits of transfusion. 4
The studies available to date unfortunately do not answer the important questions clinicians need regarding management of anaemia in older patients. Further studies with endpoints that are more in line with daily clinical practice and short-term outcomes are needed. For now, transfusion decisions in older surgical should be influenced by symptoms as well as haemoglobin concentration.