Original Study
The Effects of Blood Transfusion on Delirium Incidence

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Abstract

Background

Both anemia and blood transfusion could be precipitating factors for delirium; hence in postoperative patients with anemia at high risk for delirium, it is controversial whether transfusion is the best option. The aim of this study is to investigate the association of anemia and delirium and the role of blood transfusion within the multicomponent prevention strategy of delirium.

Methods

We conducted a substudy of a multicenter randomized controlled trial. Four hundred fifteen patients aged 65 to 102 years old admitted for hip fracture surgery were enrolled. Delirium was assessed daily using criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Data on hemoglobin values and transfusion were collected from the electronic medical records.

Results

One hundred fifteen (32.5%) patients experienced delirium during hospitalization, 238 (57.5%) had a hemoglobin level ≤ 6.0 mmol/L (9.7 g/dL) at any time during hospitalization, and 140 (33.7%) received a blood transfusion. Anemia (a hemoglobin level ≤ 6.0 mmol/L [9.7 g/dL]) was associated with delirium (odds ratio, 1.81; 95% confidence interval, 1.15-2.86). Blood transfusion was a protective factor for delirium in patients with the lowest measured hemoglobin level ≤ 6.0 mmol/L (9.7 g/dL) (odds ratio, 0.26; 95% confidence interval, 0.10-0.70).

Conclusion

Low hemoglobin level is associated with delirium, and receiving a blood transfusion is associated with a lower delirium incidence. It would be interesting to investigate the effect of blood transfusion as part of the multicomponent treatment of delirium in patients with anemia.

Section snippets

Study Design and Setting

Data from a multicenter RCT of which the protocol17 and the results18 have been published previously were used. This trial investigated whether prophylactic in-hospital use of melatonin could prevent delirium after hip fracture, which could not be demonstrated. The study was conducted between November 2008 and May 2012 in the surgical, orthopedic, and trauma surgery wards of the Academic Medical Center and Tergooi Hospitals in The Netherlands. The study was undertaken in compliance with the

Participants and Baseline Data

From the 452 eligible patients, we included 415 patients in our subanalysis (Figure 1). Table 1 shows the baseline characteristics of all included patients. One hundred thirty-five (32.5%) patients experienced delirium during hospitalization. They were significantly older and had higher scores on the Charlson Comorbidity Index. Additionally, they had lower hemoglobin levels, more often received a blood transfusion, had a longer length of hospital stay, and a higher rate of 30-day mortality.

Discussion

In this study of 415 older hip fracture patients, a hemoglobin level ≤ 6.0 mmol/L (9.7 g/dL) was found to be associated with developing postoperative delirium. Blood transfusion was found to be a protective factor for the development of delirium.

We have found a low hemoglobin level to be associated with incident delirium. This is in line with the current literature that shows a consistent association between lower hemoglobin levels and higher delirium risk.4, 5, 6, 7

Maldonado et al27 suggested

Conclusion

Physicians can be advised to give blood transfusions to their patients at risk for delirium with anemia (hemoglobin level ≤ 6.0 mmol/L or 9.7 g/dL) to decrease the risk for delirium, taking all other indications and contraindications into account. It would be interesting to investigate the effect of blood transfusion in the treatment of delirium in patients with anemia in an RCT, especially because we have found positive associations between receiving blood transfusion and delirium incidence.

References (48)

  • E.R. Marcantonio et al.

    The association of intraoperative factors with the development of postoperative delirium

    Am J Med

    (1998)
  • J.N. McAlpine et al.

    The incidence and risk factors associated with postoperative delirium in geriatric patients undergoing surgery for suspected gynecologic malignancies

    Gynecol Oncol

    (2008)
  • F. Schneider et al.

    Risk factors for postoperative delirium in vascular surgery

    Gen Hosp Psychiatry

    (2002)
  • M. Stransky et al.

    Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation

    J Cardiothorac Vasc Anesth

    (2011)
  • K. Yamagata et al.

    Risk factors for postoperative delirium in patients undergoing head and neck cancer surgery

    Int J Oral Maxillofac Surg

    (2005)
  • T. Hasegawa et al.

    Risk factors associated with postoperative delirium after surgery for oral cancer

    J Cranio Maxillo Facial Surg

    (2015)
  • Y.X. Fan et al.

    Comparison of restrictive and liberal transfusion strategy on postoperative delirium in aged patients following total hip replacement: A preliminary study

    Arch Gerontol Geriatr

    (2014)
  • P.L. Dautzenberg et al.

    Revised practice guidelines ‘Delirium in adults and the elderly’

    Ned Tijdschr Geneeskd

    (2014)
  • F. Bilotta et al.

    Postoperative delirium: Risk factors, diagnosis and perioperative care

    Minerva Anestesiol

    (2013)
  • C.S. Burkhart et al.

    Delirium in the intensive care unit

    Ther Umschau

    (2010)
  • Y. Lin et al.

    Meta-analysis of factors which influence delirium following cardiac surgery

    J Card Surg

    (2012)
  • M. Behrends et al.

    Association between intraoperative blood transfusions and early postoperative delirium in older adults

    J Am Geriatr Soc

    (2013)
  • A. Avall et al.

    Postoperative inflammatory response after autologous and allogeneic blood transfusion

    Anesthesiology

    (1997)
  • J. Cerejeira et al.

    The immunology of delirium

    Neuroimmunomodulation

    (2014)

    • Cited by (0)

    The original trial was funded by an unrestricted grant (No. 311020301) from the Dutch National Program of Innovative Care for vulnerable older persons (a program operated by ZonMw, a Dutch institute that funds health research and stimulates the use of knowledge to help improve health and health care in The Netherlands).

    Sponsor's role: None.

    The authors declare no conflict of interest.

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