Perioperative Transfusion Trigger Score Versus Restrictive Transfusion in Older Non‐Cardiac Surgery Patients: A Multicenter Randomized Controlled Trial

ABSTRACT Background Restrictive transfusion (Hb < 7 g/dL) is recommended for most perioperative patients, but the optimal threshold for those with cardiovascular disease or Hb 7–10 g/dL remains uncertain. The Perioperative Transfusion Trigger Score (POTTS), which integrates adrenaline requirement, FiO 2 , temperature, and angina history, may standardize decisions and safely reduce transfusions in older non‐cardiac surgery patients. Methods This multicenter RCT in two Chinese hospitals randomized patients ≥ 60 years undergoing non‐cardiac surgery 1:1 to POTTS or control. POTTS = 6 plus points for adrenaline, FiO 2 (to maintain SpO 2 ≥ 95%), core temperature, and angina; transfusion when Hb < POTTS. Control followed 2012 AABB guideline (Hb < 7 always transfuse; > 10 not; 7–10 physician discretion). Primary outcome: proportion receiving allogeneic RBC transfusion during perioperative period (ITT population). Results 253 patients (mean age 72.3 years; 67.6% women) were randomized (May 2023‐Sept 2025). Baseline Hb similar (median 9.60 vs. 9.50 g/dL). In ITT, transfusion required in 24.00% (30/125) of POTTS vs. 35.94% (46/128) of control ( p = 0.038). Transfusion volume did not differ significantly (median 2.50 vs. 3.00 units, p = 0.520). Overall complication rates: 12.80% vs. 8.59% ( p = 0.279); one death in control group (0.85%). No significant differences in specific complications. Conclusion In patients ≥ 60 years undergoing non‐cardiac surgery, POTTS‐guided transfusion significantly reduced the proportion of patients transfused without increasing complications. Trial Registration This study was registered at http://www.chictr.org.cn (#ChiCTR2300071739)