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CARDIOVASCULAR ANESTHESIOLOGY

Postoperative Anemia and Quality of Life After Primary Hip Arthroplasty in Patients Over 65 Years Old

Niamh P. Conlon, FCARCSI^*, Eilis P. Bale, RGN^*, G. Peter Herbison, MSc, and Maire McCarroll, FCARCSI^*

From the *Department of Anesthesia, Cappagh National Orthopaedic Hospital, Finglas, Dublin, Ireland; and Department of Preventive and Social Medicine, Dunedin School of Medicine, Dunedin, New Zealand.

Address correspondence and reprint requests to Dr. Niamh Conlon, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710. Address e-mail to tallniamh{at}hotmail.com.

Abstract

BACKGROUND: It is uncertain whether anemia in elderly patients after primary hip arthroplasty has an effect on their quality of life.

METHODS: We conducted a prospective observational study over 3 mo to investigate the association between discharge hemoglobin levels and subjective experience of quality of life at 2 mo postoperatively in patients aged over 65 yr who were scheduled for primary hip arthroplasty. Quality of life was measured preoperatively and at 2 mo postoperatively using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Functional Assessment of Cancer Therapy Anemia (FACT-Anemia) subscale. Pearson correlation coefficients between change in SF-36 and FACT-Anemia subscale scores (from preoperatively to 2 mo postoperatively) and hemoglobin on Day 8 were calculated.

RESULTS: Eighty-seven patients were included in the study. Data were available at 2 mo postoperatively from 79 of these patients. The correlation between Day 8 postoperative hemoglobin and change in SF-36 was 0.49 (P < 0.0005) and change in FACT-Anemia subscale score was 0.46 (P =< 0.0005). The correlation was not significantly changed after adjusting for advancing age, presence of significant cardiovascular disease, or whether the patient was transfused.

CONCLUSIONS: We found a positive correlation between hemoglobin levels on discharge and change in quality of life scores from preoperatively to 2 mo postoperatively in patients over 65 yr old after primary hip arthroplasty.

Concerns with risks of transfusion,1 no evidence of benefit of transfusion,2–4 and the possibility of adverse outcomes associated with transfusion have led to a restrictive transfusion practice. Acceptance of lower transfusion thresholds have led to patients leaving hospital after surgery with lower hemoglobin levels.

Joint replacement surgery is associated with significant blood loss and often results in postoperative anemia. Elderly patients presenting for total hip replacement tend to have significant comorbidities, reduction in physiological reserves, and a disorder of hematopoiesis associated with ageing. Anemia in the elderly has been associated with increased mortality, higher incidence of cardiovascular disease, cognitive impairment, and an increased risk of falls and fractures.5 Results from a number of studies have also indicated that anemia has a substantial negative impact on both function and quality of life in the elderly.6

In evaluating surgical outcomes, quality of life has become as important as morbidity and mortality. The indications for transfusing elderly patients after hip replacement range from preventing perioperative cardiac ischemic events7 to improving exercise tolerance and facilitating functional recovery during their rehabilitation period.8 However, it has never been established if postoperative hemoglobin levels directly affect quality of life in this patient population.

This study addressed the question of whether the reduction in transfusion that has arisen out of the public concern about blood transfusion and the lack of evidence for the benefit of transfusion might have a significant negative impact on the benefit of hip replacement. We were also concerned that elderly patients having hip replacement are not gaining the full benefit of the surgery in the postoperative period because they are anemic. We thus undertook a prospective cohort study in patients older than 65 yr scheduled for primary hip arthroplasty to investigate the association between discharge hemoglobin levels and the subjective experience of quality of life at 2 mo postoperatively.

METHODS

The study was conducted in an elective orthopedic hospital. All patients are routinely prepared and screened in the Preoperative Anesthetic Assessment Clinic. Only patients with ASA l–3 are referred for surgery in this hospital.

After approval by the local Ethics Committee and written informed consent, patients aged over 65 yr, scheduled for primary elective unilateral hip arthroplasty over a 3-mo period, were prospectively enrolled. Patients with renal failure, rheumatoid arthritis, or known hematological disorder were excluded.

In hospital on the preoperative evening, hemoglobin level was measured and the patients were asked to complete the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; www.sf-36.org) and the Functional Assessment of Cancer Therapy Anemia (FACT-Anemia)9 subscale score. All patients were managed perioperatively according to standard practice with subarachnoid block, standard postoperative analgesia, fluid regimens, physiotherapy, and rehabilitation. Hemoglobin was assayed on the second postoperative day and again on the eighth postoperative day, before discharge. The current hospital protocol recommends transfusion at a transfusion trigger of 8 g/dL, with the final decision to transfuse made on an individual basis. Patients with a hemoglobin level <10 g/dL on discharge are prescribed oral iron supplementation for 6 wk. Troponin levels were also measured on the second postoperative day. Patient demographics, hematological variables, transfusions, postoperative complications, and delays in discharge were recorded.

Follow-up SF-36 and FACT-Anemia scores were returned by mail from the study patients at 2 mo postoperatively.

Sample size calculation required a minimum of 40 participants to give a good estimate of any correlation and allow adjustment for the variables in the model. Pearson correlation coefficients between change in SF-36 and FACT-Anemia scores (from preoperatively to 2 mo postoperatively) and hemoglobin were calculated. The effect of age, significant cardiovascular disease, and transfusion was determined using partial correlations. Regressions were performed and plotted to display associations.

RESULTS

Eighty-seven patients were included in the study. Data at 2 mo postoperatively were available from 79 of 87 patients. The remaining eight patients did not return their postal questionnaire. It was confirmed by contacting their general practitioners that all eight of these patients were alive at 2 mo postoperatively.

Patient Characteristics
Of the 87 patients, 46 (53%) were female and 41 (47%) were male, with a mean age of 75 yr (range, 65–88 yr). Fifteen percent had significant cardiovascular disease, which we defined for the purposes of the study as New York Heart Association Grade 3 or more.

Mean preoperative hemoglobin was 12.6 (sd 1.4) and mean preoperative ferritin was 128.0 (sd 105.0). The values for males and females, respectively, are shown in Table 1.

Outcomes
The mean total blood loss was 1062 mL (sd 587). The mean hemoglobin on Day 2 postoperatively was 9.4 g/dL (sd 1.4). Of the 87 patients, 16 (18%) were transfused. Transfusion took place during surgery or during the postoperative hospital stay. Day 8 (discharge) hemoglobin ranged from 6.8 to 12.8 g/dL with a mean of 9.7 g/dL (Fig. 1).

View larger version (40K): [in this window] [in a new window]   Figure 1. Hemoglobin levels on Day 8.

Troponin I was assayed on Day 2 postoperatively and was <0.4 (normal range) in all 87 patients.

Fourteen patients (16%) developed postoperative complications. These included pneumonia (3), deep venous thrombosis (1), pulmonary embolism (1), new-onset arrhythmia (2), left ventricular failure (1), culture positive wound infection (1), and serous wound ooze (5). Discharge was delayed in 11 (79%) of these 14 patients. No other patients had their discharge delayed. Of note there was no significant difference between the Day 8 hemoglobin of the patients who developed complications (mean, 9.58; sd 1.48) and that of the patients who did not develop complications (mean, 9.69; sd 1.29).

Forty-six of the 48 patients with a hemoglobin level of less than 10 g/dL who were prescribed oral iron on discharge reported themselves to have been compliant with therapy.

Associations Between Day 8 Hemoglobin and Quality of Life
The correlation between Day 8 postoperative hemoglobin and change in SF-36 was 0.49 (P < 0.0005) and change in FACT-Anemia was 0.46 (P 0.0005). This is illustrated in the combined plot in Figure 2.

View larger version (21K): [in this window] [in a new window]   Figure 2. The correlation between Day 8 hemoglobin and changes in Sf-36 and Fact-An scores.

After adjusting for age, the correlation for SF-36 was 0.47 (P < 0.0005) and FACT-Anemia was 0.45 (P < 0.0005), and after adjusting for presence of significant cardiovascular disease, the correlation was 0.46 (P < 0.0005) for SF-36 and 0.43 (P < 0.005) for FACT-Anemia. After adjusting for both age and the presence of significant cardiovascular disease simultaneously, the correlation for SF-36 was 0.45 (P < 0.0005) and FACT-Anemia was 0.43 (P < 0.005).

After adjusting for patients who were transfused the correlation for SF-36 was 0.47 (P < 0.0005) and FACT-Anemia was 0.47 (P < 0.0005). These results indicate that the correlation is independent of increasing age over 65 yr, the presence of significant cardiovascular disease, and transfusion.

Regression showed the improvement in SF-36 score was 8.57 for every increase of 1 g/dL in Day 8 hemoglobin and the improvement in FACT-Anemia score was 2.9.

There was no correlation between Day 8 hemoglobin and absolute value of SF-36 or FACT-Anemia either preoperatively or at 2 mo postoperatively. There was no correlation between change in SF-36 or FACT-Anemia scores and the change in hemoglobin level from pre- to postoperatively.

DISCUSSION

Our study shows an association between hemoglobin levels on discharge and change in quality of life scores from pre- to postoperatively in patients over 65 yr old after primary hip arthroplasty. Patients with lower hemoglobin on discharge consistently reported less improvement or, indeed, worsening of SF-36 and FACT-Anemia scores from preoperative scores than those with a higher hemoglobin level. Although surgical procedure was most likely to have the most important impact on change of quality of life in our patients from pre- to postoperatively, our study was designed to investigate whether some of the variability could be accounted for by difference in Day 8 hemoglobin levels. Our results suggest that treatment of anemia in the postoperative period may be useful to preserve or improve quality of life in these elderly patients.

The SF-36 has become one of the most widely used generic measures of subjective health status and has demonstrated validity across all ages, including the elderly.10 It measures the physical and mental components of health using eight scales: mental health, physical functioning, physical role, emotional role, social functioning, bodily pain, general health perceptions, and vitality. It can be scored from 0 to 100 on a norm-based scoring algorithm (www.sf-36.org). Sample questions are included in Tables 2 and 3. It is very sensitive to change and is recommended as an instrument to assess the outcomes of interventions (www.sf-36.org). The SF-36 has proven useful in surveys of general and specific populations in comparing the relative burden of diseases and in differentiating the health benefits produced by a wide range of different treatments. The FACT-Anemia subscale (Table 4) is a questionnaire assessing fatigue and anemia-related concerns in patients with cancer. Thirteen of the questions relate to fatigue whereas seven of them relate specifically to non–fatigue-based anemia symptoms.9 The FACT-Anemia subscale is scored from 0 to 80, with higher scores representing better functioning and well-being.

In our study, change in quality of life scores from pre- to postoperatively shows a positive correlation with hemoglobin concentration at discharge. This correlation is <1, indicating that hemoglobin levels do not explain all the variations in quality of life, which is also affected by other influences. We found that advancing age (over 65 yr) and transfusion did not significantly change the correlation. The improvement in SF-36 was 8.5 and in FACT-Anemia 2.9 for every 1 g/dL increase in Day 8 hemoglobin. Quality of life assessment can supplement standard end-points, such as functional recovery and survival, and lead to more informed decisions concerning transfusion triggers. Toy et al. showed decreased self-scored energy levels in acute isovolemic anemia in young, healthy resting humans,11 whereas several studies in patients with renal failure, inflammatory diseases, and cancer have shown a correlation between correcting anemia and improved quality of life. Holzner et al. showed significant correlations between hemoglobin levels and fatigue (measured with the Multidimensional Fatigue Inventory) in cancer patients undergoing chemotherapy,12 whereas McMahon et al. reported a symptomatic advantage in maintaining a physiological hemoglobin level in hemodialysis patients with a significantly improved quality of life at a hemoglobin of 14 g/dL compared with a hemoglobin of 10 g/dL.13 To our knowledge, this is the first study to show an effect of postoperative anemia on quality of life in elderly patients after primary hip arthroplasty.

The appropriate transfusion trigger in the elderly postsurgical patient is unclear. Lawrence et al.,8 in a retrospective cohort study of 5793 patients, showed that a higher postoperative hemoglobin level after hip fracture surgery was associated with a greater distance walked at time of discharge from hospital, whereas Halm et al.4 concluded, in a cohort study of 551 patients, that transfusion after hip fracture surgery reduced the risk of readmission but did not decrease mortality or improve mobility. This issue may be clarified by the results of the FOCUS trial (http://www.clinicaltrial.gov/ct/show/NCT0071032), which aims to assess two different transfusion thresholds in 2600 patients with cardiovascular disease undergoing surgical hip fracture repair. The outcomes of this study will include functional recovery, long-term survival, nursing home placement, and postoperative complications.

There is continuing concern about the adverse effects of anemia. In our patient population, the morbidity was low, and all patients were surviving at 2 mo. Hebert et al.,14 in an analysis of the impact of transfusion practice on mortality in 4470 critically ill patients, found that an increasing severity of anemia was associated with a disproportionate increase in mortality rates among the subgroup of patients with ischemic heart disease. In a large retrospective study of patients over 65 yr old who were hospitalized with acute myocardial infarction, lower hematocrit levels on admission were associated with higher 30-day mortality rates.15 Wu et al.16 showed, in a retrospective review of veterans aged 65 yr or older undergoing major noncardiac surgery, that 30-day mortality and cardiac event rates increased with positive or negative deviations from normal hematocrit levels. Adjusting for significant cardiovascular disease, defined for the purposes of our study as New York Heart Association symptoms Grade 3 or more, did not significantly change the Pearson correlation coefficient. Of note, troponin I was in the normal range in all of our 87 patients.

Much of the evidence in favor of restrictive transfusion practice is derived from the intensive care population17 and its application to other patient populations is unproven. Concerns about the risks of allogeneic blood transfusion and the lack of evidence of benefit have led to a restrictive transfusion practice and a search for transfusion alternatives in the perioperative period. These include preoperative autologous blood donation, preoperative oral or IV iron, and erythropoietin administration. Intraoperative strategies include cell salvage, acute normovolemic hemodilution, and antifibrinolytic drugs. If, despite these measures, the postoperative elderly patient has a low hemoglobin level, the decision to transfuse, and at what transfusion trigger, remains controversial.

Our study had several limitations, including the observational design. Hemoglobin levels were not assayed at 2 mo postoperatively when the patients completed the follow-up SF-36 and FACT-Anemia scores. This was for practical reasons: the patients were all followed-up in different centers at different time intervals. As the standard clinical practice is to decide to treat postoperative anemia based on the last hemoglobin before discharge, we felt this hemoglobin was appropriate to assess the effect on quality of life. Although a limiting factor, our concern and the reason behind the study was to determine whether any improvement in quality of life associated with the surgery in this elderly population might be offset by a decrease in hemoglobin. The study was limited to patients having total hip arthroplasty. This surgery, per se, usually has a positive impact on quality of life, and thus these findings may not apply to other surgical procedures.

In conclusion, given the limited numbers involved in this study, some caution is required in the interpretation of the results. However, if these findings can be corroborated by other studies, the implications of significantly improved quality of life in this elderly surgical population being dependent on higher hemoglobin levels at discharge need to be addressed, and our transfusion trigger in this patient population needs to be reconsidered.

Footnotes

Accepted for publication December 6, 2007.

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