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Grandone E, Tiscia GL, Ostuni A, Marongiu F, Barcellona D. Navigating anemia and anticoagulation in elderly patients undergoing orthopedic surgery: strategies for preventing complications and implementing treatments. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:450-458. [PMID: 38814879 PMCID: PMC11390616 DOI: 10.2450/bloodtransfus.640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/21/2023] [Indexed: 06/01/2024]
Abstract
BACKGROUND Elderly populations face an increased risk of anemia, leading to elevated transfusion requirements during surgery, especially major orthopedic procedures. Anemia itself increases the risk of thromboembolic events, thus compounding complications in elderly individuals. Polypharmacy and the prevalent use of oral anticoagulants (OAC), particularly for atrial fibrillation, contribute to bleeding risks in this population. Data available in the literature on the peri-operative management of anemia in patients taking OAC is limited and often heterogeneous. MATERIALS AND METHODS This narrative case-based review focuses on the peri-operative management of elderly patients on OAC undergoing major orthopedic surgery. PubMed/Medline was used to search for relevant literature. RESULTS With reference to two cases, we critically evaluate the literature, and focus on risk factors, and preventive and therapeutic strategies as fundamental tools to reduce bleeding and correct anemia as soon as possible in elderly patients undergoing major orthopedic surgery. DISCUSSION Peri-operative management of these patients, especially those on OAC, requires a balanced approach considering bleeding and thrombotic risks. Intravenous iron therapy and tranexamic acid emerge as valuable strategies in minimizing transfusion requirements and optimizing patients' outcomes.
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Affiliation(s)
- Elvira Grandone
- Obstetrics and Gynaecology Department, University of Foggia, Foggia, Italy
- Thrombosis and Hemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
- Department of Obstetrics Gynaecology and Perinatal Medicine, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Giovanni L Tiscia
- Thrombosis and Hemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | - Angelo Ostuni
- Immunohematology and Transfusion Medicine Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Francesco Marongiu
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
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Arun Kumar S, Prabhu S, Sanghvi A, Gogtay M, Suresh MG, Khosla H, Singh Y, Mishra AK, George S. Paradigm shift in transfusion practices during early COVID-19 pandemic: A single center retrospective study. World J Virol 2024; 13:92944. [PMID: 38984074 PMCID: PMC11229847 DOI: 10.5501/wjv.v13.i2.92944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/21/2024] [Accepted: 06/03/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND The advent of coronavirus disease 2019 (COVID-19) unveiled the worst national blood crisis that the United States had witnessed in over a decade. With the pandemic influencing the different stages of the acquisition of blood products outside the hospital setting, we aimed to explore the possible barriers contributing to the shortage of blood products within the medical community. AIM To assess the adherence to restrictive blood transfusion practices for patients in the COVID era and pre-COVID era. METHODS We conducted a retrospective cross-sectional study on hospitalized patients distinguishing the pattern of blood transfusion during the COVID and pre-COVID era in a community hospital. Data was tabulated to include the number of red blood cell (RBC) transfusions and if transfusions met restrictive blood transfusion criteria as per institutional guidelines. Chi-square was applied to test the statistical association between qualitative variables. Unpaired t test and Mann Whitney U test were applied respectively to test the mean difference of quantitative variables. RESULTS A total of 208 patients were included in the study, of which 108 were during COVID era and 100 were during pre-COVID era. The leading reason for admission in both the COVID era and pre-COVID era transfused patients was shortness of breath (53.7% and 36% P = 0.001), followed by gastrointestinal bleeding (25.9% and 21% P = 0.001). There was a higher percentage of RBC transfusions in the intensive care unit in the COVID-era group than in the pre-COVID era group (38.9% vs 22%, P = 0.008). The restrictive transfusion criteria were met in 62% vs 79% in the COVID and pre-COVID eras, respectively (P = 0.008). CONCLUSION The COVID-era group received RBC transfusions with less stringent adherence to restrictive blood transfusion practices in comparison to pre-COVID era group.
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Affiliation(s)
- Sumukh Arun Kumar
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Sushmita Prabhu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Ankushi Sanghvi
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Maya Gogtay
- Department of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Mithil Gowda Suresh
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Harshit Khosla
- Hospice and Palliative Care, UTHSC and McGovern School of Medicine, Texas, TX 77030, United States
| | - Yuvaraj Singh
- Department of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, MA 01655, United States
| | - Ajay Kumar Mishra
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Susan George
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
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Qaadri SM, Luthra TS, Budhu K, Sagi O. A 42-year-old woman with abnormal uterine bleeding-leiomyoma (AUB-L) reporting a hemoglobin of 1.6 g/dL: a case report. J Med Case Rep 2024; 18:284. [PMID: 38898492 PMCID: PMC11188282 DOI: 10.1186/s13256-024-04593-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Abnormal uterine bleeding, formerly known as menometrorrhagia, is estimated to occur in up to one-third of women, commonly at menarche or perimenopause. Among many other causes, abnormal uterine bleeding is known to be caused by leiomyomas, and is itself a leading cause of severe iron deficiency and iron deficiency anemia in women. Rarely, abnormal uterine bleeding can lead to critically low hemoglobin values of less than 2 g/dL. We report here a case of a woman with abnormal uterine bleeding caused by leiomyomas presenting with severely low hemoglobin. CASE PRESENTATION We report the case of a 42-year-old Asian American woman who presented to the emergency department with chronic abnormal uterine bleeding and symptoms of anemia, including multiple syncopal episodes and abnormally pale skin but otherwise alert and oriented. Laboratory tests found a record-low hemoglobin of 1.6 g/dL and hematocrit of 6%. Transabdominal pelvic ultrasound revealed a lower uterine segment/cervical fibroid measuring 7.5 × 5 × 7.8 cm (length × depth × width). Patient was diagnosed with abnormal uterine bleeding-leiomyoma and received five units of packed red blood cells, one unit of fresh frozen plasma, Venofer infusions, tranexamic acid, and medroxyprogesterone. She was discharged from the hospital after 4 days. CONCLUSION To date, only a handful of cases have been reported of female patient survival following severely low hemoglobin caused by abnormal uterine bleeding. This case adds to this literature, highlighting the remarkable degree of compensation that can lead to an alert, ambulatory, and oriented patient with abnormal uterine bleeding caused by leiomyoma.
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Affiliation(s)
- Shamsa M Qaadri
- St. George's University School of Medicine, West Indies, Grenada.
| | | | - Kumarie Budhu
- St. George's University School of Medicine, West Indies, Grenada
| | - Or Sagi
- Department of Obstetrics & Gynecology, The Brooklyn Hospital Center, New York, USA
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4
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Radford M, Estcourt LJ, Sirotich E, Pitre T, Britto J, Watson M, Brunskill SJ, Fergusson DA, Dorée C, Arnold DM. Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support. Cochrane Database Syst Rev 2024; 5:CD011305. [PMID: 38780066 PMCID: PMC11112982 DOI: 10.1002/14651858.cd011305.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND An estimated one-quarter to one-half of people diagnosed with haematological malignancies experience anaemia. There are different strategies for red blood cell (RBC) transfusions to treat anaemia. A restrictive transfusion strategy permits a lower haemoglobin (Hb) level whereas a liberal transfusion strategy aims to maintain a higher Hb. The most effective and safest strategy is unknown. OBJECTIVES To determine the efficacy and safety of restrictive versus liberal RBC transfusion strategies for people diagnosed with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without a haematopoietic stem cell transplant (HSCT). SEARCH METHODS We searched for randomised controlled trials (RCTs) and non-randomised studies (NRS) in MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1982), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2023, Issue 2), and eight other databases (including three trial registries) to 21 March 2023. We also searched grey literature and contacted experts in transfusion for additional trials. There were no language, date or publication status restrictions. SELECTION CRITERIA We included RCTs and prospective NRS that evaluated restrictive versus liberal RBC transfusion strategies in children or adults with malignant haematological disorders receiving intensive chemotherapy or radiotherapy, or both, with or without HSCT. DATA COLLECTION AND ANALYSIS Two authors independently screened references, full-text reports of potentially relevant studies, extracted data from the studies, and assessed the risk of bias. Any disagreement was discussed and resolved with a third review author. Dichotomous outcomes were presented as a risk ratio (RR) with a 95% confidence interval (CI). Narrative syntheses were used for heterogeneous outcome measures. Review Manager Web was used to meta-analyse the data. Main outcomes of interest included: all-cause mortality at 31 to 100 days, quality of life, number of participants with any bleeding, number of participants with clinically significant bleeding, serious infections, length of hospital admission (days) and hospital readmission at 0 to 3 months. The certainty of the evidence was assessed using GRADE. MAIN RESULTS Nine studies met eligibility; eight RCTs and one NRS. Six hundred and forty-four participants were included from six completed RCTs (n = 560) and one completed NRS (n = 84), with two ongoing RCTs consisting of 294 participants (260 adult and 34 paediatric) pending inclusion. Only one completed RCT included children receiving HSCT (n = 6); the other five RCTs only included adults: 239 with acute leukaemia receiving chemotherapy and 315 receiving HSCT (166 allogeneic and 149 autologous). The transfusion threshold ranged from 70 g/L to 80 g/L for restrictive and from 80 g/L to 120 g/L for liberal strategies. Effects were reported in the summary of findings tables only for the trials that included adults to reduce indirectness due to the limited evidence contributed by the prematurely terminated paediatric trial. Evidence from RCTs Overall, there may be little to no difference in the number of participants who die within 31 to 100 days using a restrictive compared to a liberal transfusion strategy, but the evidence is very uncertain (three studies; 451 participants; RR 1.00, 95% CI 0.27 to 3.70, P=0.99; very low-certainty evidence). There may be little to no difference in quality of life at 0 to 3 months using a restrictive compared to a liberal transfusion strategy, but the evidence is very uncertain (three studies; 431 participants; analysis unable to be completed due to heterogeneity; very low-certainty evidence). There may be little to no difference in the number of participants who suffer from any bleeding at 0 to 3 months using a restrictive compared to a liberal transfusion strategy (three studies; 448 participants; RR 0.91, 95% CI 0.78 to 1.06, P = 0.22; low-certainty evidence). There may be little to no difference in the number of participants who suffer from clinically significant bleeding at 0 to 3 months using a restrictive compared to a liberal transfusion strategy (four studies; 511 participants; RR: 0.94, 95% CI 0.74 to 1.19, P = 0.60; low-certainty evidence). There may be little to no difference in the number of participants who experience serious infections at 0 to 3 months using a restrictive compared to a liberal transfusion strategy (three studies, 451 participants; RR: 1.20, 95% CI 0.93 to 1.55, P = 0.17; low-certainty evidence). A restrictive transfusion strategy likely results in little to no difference in the length of hospital admission at 0 to 3 months compared to a liberal strategy (two studies; 388 participants; analysis unable to be completed due to heterogeneity in reporting; moderate-certainty evidence). There may be little to no difference between hospital readmission using a restrictive transfusion strategy compared to a liberal transfusion strategy (one study, 299 participants; RR: 0.89, 95% CI 0.52 to 1.50; P = 0.65; low-certainty evidence). Evidence from NRS The evidence is very uncertain whether a restrictive RBC transfusion strategy: reduces the risk of death within 100 days (one study, 84 participants, restrictive 1 death; liberal 1 death; very low-certainty evidence); or decreases the risk of clinically significant bleeding (one study, 84 participants, restrictive 3; liberal 8; very low-certainty evidence). No NRS reported on the other eligible outcomes. AUTHORS' CONCLUSIONS Findings from this review were based on seven studies and 644 participants. Definite conclusions are challenging given the relatively few included studies, low number of included participants, heterogeneity of intervention and outcome reporting, and overall certainty of evidence. To increase the certainty of the true effect of a restrictive RBC transfusion strategy on clinical outcomes, there is a need for rigorously designed and executed studies. The evidence is largely based on two populations: adults with acute leukaemia receiving intensive chemotherapy and adults with haematologic malignancy requiring HSCT. Despite the addition of 405 participants from three RCTs to the previous review's results, there is still insufficient evidence to answer this review's primary outcome. If we assume a mortality rate of 3% within 100 days, we would need a total of 1492 participants to have an 80% chance of detecting, at a 5% level of significance, an increase in all-cause mortality from 3% to 6%. Further RCTs are needed overall, particularly in children.
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Affiliation(s)
- Michael Radford
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Canada
- Department of Oncology, Hamilton Health Sciences Centre, Hamilton, Canada
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Emily Sirotich
- Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tyler Pitre
- Medicine, University of Toronto, Toronto, Canada
| | - Joanne Britto
- Oncology, Hamilton Health Sciences Centre, Hamilton, Canada
| | - Megan Watson
- Medicine, University of Toronto, Toronto, Canada
| | - Susan J Brunskill
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Carolyn Dorée
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Donald M Arnold
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Ontario, Canada
- McMaster University, Hamilton, Canada
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Sucandy I, Ross S, DeLong J, Tran M, Qafiti F, Pechman D, Snow T, Docimo S, Lim-Dy A, Christodoulou M, Renton D. TAVAC: comprehensive review of currently available hemostatic products as adjunct to surgical hemostasis. Surg Endosc 2024; 38:2331-2343. [PMID: 38630180 DOI: 10.1007/s00464-024-10806-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/21/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND The use of hemostatic agents by general surgeons during abdominal operations is commonplace as an adjunctive measure to minimize risks of postoperative bleeding and its downstream complications. Proper selection of products can be hampered by marginal understanding of their pharmacokinetics and pharmacodynamics. While a variety of hemostatic agents are currently available on the market, the choice of those products is often confusing for surgeons. This paper aims to summarize and compare the available hemostatic products for each clinical indication and to ultimately better guide surgeons in the selection and proper use of hemostatic agents in daily clinical practice. METHODS We utilized PubMed electronic database and published product information from the respective pharmaceutical companies to collect information on the characteristics of the hemostatic products. RESULTS All commercially available hemostatic agents in the US are described with a description of their mechanism of action, indications, contraindications, circumstances in which they are best utilized, and expected results. CONCLUSION Hemostatic products come with many different types and specifications. They are valuable tools to serve as an adjunct to surgical hemostasis. Proper education and knowledge of their characteristics are important for the selection of the right agent and optimal utilization.
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Affiliation(s)
- Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA.
| | - Sharona Ross
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | | | - Michael Tran
- University of California Irvine, Irvine, CA, USA
| | - Fred Qafiti
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - David Pechman
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Bayshore, NY, USA
| | - Tim Snow
- Sentara Martha Jefferson Medical And Surgical Associates, Charlottesville, VA, USA
| | | | | | | | - David Renton
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Wang S, Wang C, Gao Y, Tian Y, Liu J, Wang Y. Risk factors of 30-day and long-term mortality and outcomes in open repair of thoracoabdominal aortic aneurysm. J Cardiothorac Surg 2024; 19:170. [PMID: 38566230 PMCID: PMC10986091 DOI: 10.1186/s13019-024-02666-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Open repair of thoracoabdominal aortic aneurysm (TAAA) was characterized by significant risk of postoperative mortality and morbidity. The aim of this study was to determine the perioperative predictors of early and long-term mortality in patients undergoing open repair of TAAA. Besides, the postoperative outcomes in patients with open repair of TAAA were described. METHODS This is a single-center retrospective study, and 146 patients with open repair of TAAA from January 4, 2011, to November 22, 2018 was involved. Categorical variables were analyzed by the Chi-square test or Fisher's exact test, and continuous variables were analyzed by the independent sample t-test and the WilCoxon rank-sum test. Multivariate Logistic regression and Cox regression were applied to identify the predictors of 30-day and long-term mortality, respectively. The Kaplan Meier curves were used to illustrate survival with the Log-rank test. RESULTS The 30-day mortality was 9.59% (n = 14). Older than 50 years, the intraoperative volume of red blood cell (RBC) and epinephrine use were independently associated with postoperative 30-day mortality in open repair of TAAA. Long-term mortality was 17.12% (n = 25) (median of 3.5 years (IQR = 2-5 years) of follow-up). Prior open thoracoabdominal aortic aneurysm (TAAA) repair, aortic cross-clamping (ACC) time, intraoperative volume of RBC and use of epinephrine were independently correlated with long-term mortality. CONCLUSIONS Identifying perioperative risk factors of early and long-term mortaliy is crucial for surgeons. Intraoperative volume of RBC and use of epinephrine were predictors of both early and long-term mortality. In addition, patients of advanced age, prior open repair of TAAA and prolonged ACC time should be paid more attention.
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Affiliation(s)
- Sudena Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yuchen Gao
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yu Tian
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jia Liu
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yuefu Wang
- Department of Surgery Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
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Yu Y, Fu Y, Li W, Sun T, Cheng C, Chong Y, Han R, Cui W. Red blood cell transfusion in neurocritical patients: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:106. [PMID: 38504153 PMCID: PMC10949741 DOI: 10.1186/s12871-024-02487-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Anemia can lead to secondary brain damage by reducing arterial oxygen content and brain oxygen supply. Patients with acute brain injury have impaired self-regulation. Brain hypoxia may also occur even in mild anemia. Red blood cell (RBC) transfusion is associated with increased postoperative complications, poor neurological recovery, and mortality in critically ill neurologic patients. Balancing the risks of anemia and red blood cell transfusion-associated adverse effects is challenging in neurocritical settings. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE (PubMed) from inception to January 31, 2024. We included all randomized controlled trials (RCTs) assessing liberal versus restrictive RBC transfusion strategies in neurocritical patients. We included all relevant studies published in English. The primary outcome was mortality at intensive care unit (ICU), discharge, and six months. RESULTS Of 5195 records retrieved, 84 full-text articles were reviewed, and five eligible studies were included. There was no significant difference between the restrictive and liberal transfusion groups in ICU mortality (RR: 2.53, 95% CI: 0.53 to 12.13), in-hospital mortality (RR: 2.34, 95% CI: 0.50 to 11.00), mortality at six months (RR: 1.42, 95% CI: 0.42 to 4.78) and long-term mortality (RR: 1.22, 95% CI: 0.64 to 2.33). The occurrence of neurological adverse events and most major non-neurological complications was similar in the two groups. The incidence of deep venous thrombosis was lower in the restrictive strategy group (RR: 0.41, 95% CI: 0.18 to 0.91). CONCLUSIONS Due to the small sample size of current studies, the evidence is insufficiently robust to confirm definitive conclusions for neurocritical patients. Therefore, further investigation is encouraged to define appropriate RBC transfusion thresholds in the neurocritical setting.
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Affiliation(s)
- Yun Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Yuxuan Fu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Wenying Li
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, 5 Shijingshan Rd, Shijingshan District, Beijing, PR China
| | - Tiantian Sun
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, PR China
| | - Chan Cheng
- Department of Anesthesiology, Beijing Stomatological Hospital Affiliated to Capital Medical University, No.4 Tiantan Xili, Dongcheng District, Beijing, 100050, PR China
| | - Yingzi Chong
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Weihua Cui
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China.
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Li X, Jiang HY, Zhao YJ, Liu SZ, Pan LX. Establishment and validation of a nomogram to predict postoperative anemia after total hip arthroplasty. BMC Musculoskelet Disord 2024; 25:141. [PMID: 38355520 PMCID: PMC10865598 DOI: 10.1186/s12891-024-07264-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 02/06/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Anemia is a common complication of total hip arthroplasty (THA). In this study, we evaluated the preoperative risk factors for postoperative anemia after THA and developed a nomogram model based on related preoperative and intraoperative factors. METHODS From January 2020 to May 2023, 927 THA patients at the same medical center were randomly assigned to either the training or validation cohort. The correlation between preoperative and intraoperative risk factors and postoperative anemia after THA was evaluated using univariate and multivariate logistic regression analysis. A nomogram was developed using these predictive variables. The effectiveness and validation for the clinical application of this nomogram were evaluated using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). RESULTS Through univariate and multivariate logistic regression analysis, 7 independent predictive factors were identified in the training cohort: Lower body mass index (BMI), extended operation time, greater intraoperative bleeding, lower preoperative hemoglobin level, abnormally high preoperative serum amyloid A (SAA) level, history of cerebrovascular disease, and history of osteoporosis. The C-index of the model was 0.871, while the AUC indices for the training and validation cohorts were 84.4% and 87.1%, respectively. In addition, the calibration curves of both cohorts showed excellent consistency between the observed and predicted probabilities. The DCA curves of the training and validation cohorts were high, indicating the high clinical applicability of the model. CONCLUSIONS Lower BMI, extended operation time, increased intraoperative bleeding, reduced preoperative hemoglobin level, elevated preoperative SAA level, history of cerebrovascular disease, and history of osteoporosis were seven independent preoperative risk factors associated with postoperative anemia after THA. The nomogram developed could aid in predicting postoperative anemia, facilitating advanced preparation, and enhancing blood management. Furthermore, the nomogram could assist clinicians in identifying patients most at risk for postoperative anemia.
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Affiliation(s)
- Xiang Li
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, 1111 Jiangnan Street, Ningbo, 315000, China
- Health Science Center, Ningbo University, 818 Fenghua Street, Ningbo, 315211, China
| | - Hong-Yang Jiang
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, 1111 Jiangnan Street, Ningbo, 315000, China
- Health Science Center, Ningbo University, 818 Fenghua Street, Ningbo, 315211, China
| | - Yong-Jie Zhao
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, 1111 Jiangnan Street, Ningbo, 315000, China
- Health Science Center, Ningbo University, 818 Fenghua Street, Ningbo, 315211, China
| | - Si-Zhuo Liu
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, 1111 Jiangnan Street, Ningbo, 315000, China
- Health Science Center, Ningbo University, 818 Fenghua Street, Ningbo, 315211, China
| | - Ling-Xiao Pan
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, 1111 Jiangnan Street, Ningbo, 315000, China.
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9
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Wang Y, Zhu Z, Duan D, Xu W, Chen Z, Shen T, Wang X, Xu Q, Zhang H, Han C. Ultra-restrictive red blood cell transfusion strategies in extensively burned patients. Sci Rep 2024; 14:2848. [PMID: 38310116 PMCID: PMC10838330 DOI: 10.1038/s41598-024-52305-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/17/2024] [Indexed: 02/05/2024] Open
Abstract
In recent years, due to the shortage of blood products, some extensive burn patients were forced to adopt an "ultra-restrictive" transfusion strategy, in which the hemoglobin levels of RBC transfusion thresholds were < 7 g/dl or even < 6 g/dl. This study investigated the prognostic impacts of ultra-restrictive RBC transfusion in extensive burn patients. This retrospective multicenter cohort study recruited extensive burns (total body surface area ≥ 50%) from three hospitals in Eastern China between 1 January 2016 and 30 June 2022. Patients were divided into an ultra-restrictive transfusion group and a restrictive transfusion group depending on whether they received timely RBC transfusion at a hemoglobin level < 7 g/dl. 1:1 ratio propensity score matching (PSM) was performed to balance selection bias. Modified Poisson regression and linear regression were conducted for sensitive analysis. Subsequently, according to whether they received timely RBC transfusion at a hemoglobin level < 6 g/dl, patients in the ultra-restrictive transfusion group were divided into < 6 g/dl group and 6-7 g/dl group to further compare the prognostic outcomes. 271 eligible patients with extensive burns were included, of whom 107 patients were in the ultra-restrictive transfusion group and 164 patients were in the restrictive transfusion group. The ultra-restrictive transfusion group had a significantly lower RBC transfusion volume than the restrictive transfusion group (11.5 [5.5, 21.5] vs 17.3 [9.0, 32.5] units, p = 0.004). There were no significant differences between the two groups in terms of in-hospital mortality, risk of infection, hospital length of stay, and wound healing time after PSM or multivariate adjustment (p > 0.05). Among the ultra-restrictive transfusion group, patients with RBC transfusion threshold < 6 g/dl had a significantly higher hospital mortality than 6-7 g/dl (53.1% vs 21.3%, p = 0.001). For extensive burn patients, no significant adverse effects of ultra-restrictive RBC transfusion were found in this study. When the blood supply is tight, it is acceptable to adopt an RBC transfusion threshold of < 7 g/dL but not < 6 g/dL.
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Affiliation(s)
- Yiran Wang
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, 310009, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
| | - Zhikang Zhu
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, 310009, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
| | - Deqing Duan
- Department of Burns, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wanting Xu
- Department of Burn Injury, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zexin Chen
- Center of Clinical Epidemiology & Biostatistics, Department of Scientific Research, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
| | - Tao Shen
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, 310009, China
| | - Xingang Wang
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, 310009, China.
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China.
| | - Qinglian Xu
- Department of Burn Injury, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
| | - Hongyan Zhang
- Department of Burns, The First Affiliated Hospital of Nanchang University, Nanchang, China.
| | - Chunmao Han
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, 310009, China.
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China.
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10
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Uden H, Büttner F, von Heymann C, Krämer M, Kaufner L, Vorderwülbecke G, Hardt S, Kruppa J, Balzer F, Spies C. Allogeneic Blood Transfusion and Risk of Postoperative Complications in Patients with Mild and Moderate Anemia of Any Cause? A Retrospective Cohort Study in Total Revision Hip Surgery. Transfus Med Hemother 2024; 51:12-21. [PMID: 38314244 PMCID: PMC10836862 DOI: 10.1159/000530135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/26/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Patients undergoing revision total hip surgery (RTHS) have a high prevalence of mild and moderate preoperative anemia, associated with adverse outcomes. The aim of this study was to investigate the association of perioperative allogeneic blood transfusions (ABT) and postoperative complications in preoperatively mild compared to moderate anemic patients undergoing RTHS who did not receive a diagnostic anemia workup and treatment before surgery. Methods We included 1,765 patients between 2007 and 2019 at a university hospital. Patients were categorized according to their severity of anemia using the WHO criteria of mild, moderate, and severe anemia in the first Hb level of the case. Patients were grouped as having received no ABT, 1-2 units of ABT, or more than 2 units of ABT. Need for intraoperative ABT was assessed in accordance with institutional standards. Primary endpoint was the compound incidence of postoperative complications. Secondary outcomes included major/minor complications and length of hospital and ICU stay. Results Of the 1,765 patients, 31.0% were anemic of any cause before surgery. Transfusion rates were 81% in anemic patients and 41.2% in nonanemic patients. The adjusted risks for compound postoperative complication were significantly higher in patients with moderate anemia (OR 4.88, 95% CI: 1.54-13.15, p = 0.003) but not for patients with mild anemia (OR 1.93, 95% CI: 0.85-3.94, p < 0.090). Perioperative ABT was associated with significantly higher risks for complications in nonanemic patients and showed an increased risk for complications in all anemic patients. In RTHS, perioperative ABT as a treatment for moderate preoperative anemia of any cause was associated with a negative compound effect on postoperative complications, compared to anemia or ABT alone. Discussion ABT is associated with adverse outcomes of patients with moderate preoperative anemia before RTHS. For this reason, medical treatment of moderate preoperative anemia may be considered.
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Affiliation(s)
- Henning Uden
- Department of Anesthesia and Intensive Care Medicine, Sana Klinikum Lichtenberg, Berlin, Germany
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Franziska Büttner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian von Heymann
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Krämer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berufsausübungsgemeinschaft Reinhardt/Krämer, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Hardt
- Centre for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jochen Kruppa
- Hochschule Osnabrück – University of Applied Sciences, Osnabrück, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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11
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Ahn H(S, Lenet T, Gilbert RWD, Mallick R, Shaw JLV, Fergusson DA, McIsaac DI, Martel G. Accuracy of point-of-care testing devices for haemoglobin in the operating room: meta-analysis. BJS Open 2024; 8:zrad148. [PMID: 38266123 PMCID: PMC10807999 DOI: 10.1093/bjsopen/zrad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/24/2023] [Accepted: 10/29/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Point-of-care tests (POCT) for haemoglobin are increasingly used to guide intraoperative transfusion. However, their accuracy compared to central laboratory tests is unknown. The objective was to perform a systematic review and meta-analysis of method comparison studies assessing the accuracy of POCT versus central laboratory haemoglobin tests in patients undergoing surgery. METHODS Electronic databases were searched from inception to April 2020 (updated August 2023). Any methodological approach comparing haemoglobin measurements between POCT and central laboratory in patients undergoing surgery under anaesthesia in the operating room were included. Data abstraction was guided by PRISMA and risk of bias was assessed by QUADAS-2. Data were extracted independently and in duplicate by two reviewers. Outcomes included mean differences between POCT and central laboratory haemoglobin with associated standard deviations and 95% limits of agreement (LOA). RESULTS Of 3057 citations, 34 studies were included (n = 2427, 6857 paired measurements). Several devices were compared (pulse co-oximetry, n = 25; HemoCue, n = 10; iSTAT, n = 6; blood gas analysers, n = 10; haematology analyser, n = 2). Median sample size was 41 patients, and 11 studies were funded by device manufacturers. Fifteen of 34 studies had low risk of bias. Pooled mean differences (95% LOA) were: pulse co-oximeters 2.3 g/l (-25.2-29.8), HemoCue -0.3 g/l (-11.1-10.5), iSTAT -0.3 g/l (-8.4-7.8) and blood gas analysers -2.6 g/l (-17.8-12.7). CONCLUSION All POCT examining intraoperative haemoglobin measurement yielded pooled mean difference LOAs larger than the allowable limit difference of ±4 g/dl. Intraoperative haemoglobin measured by POCT should not be considered interchangeable with central laboratory values and caution is necessary when using these tests to guide intraoperative transfusion.
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Affiliation(s)
- Hilalion (San) Ahn
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Richard W D Gilbert
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Julie L V Shaw
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology & Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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12
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Blanca D, Parrella G, Consonni D, Villa S, Ceriani G, Cespiati A, Figini G, Ghigliazza G, Maira D, Oberti G, Scaramellini N, Schinco GL, Tafuri F, Montano N, Cappellini MD, Motta I. Anemia management and transfusion strategy in internal medicine units: Less is more. Eur J Intern Med 2023; 115:48-54. [PMID: 37225593 DOI: 10.1016/j.ejim.2023.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/08/2023] [Accepted: 05/17/2023] [Indexed: 05/26/2023]
Abstract
Blood transfusion is one of the most overused procedures, especially in elderly patients. Despite the current transfusion guidelines recommending a restrictive transfusion strategy in stable patients, the clinical practice varies according to physicians' experience and implementation of patient blood management. This study aimed to evaluate the anemia management and transfusion strategy in anemic elderly hospitalized and the impact of an educational program. We enrolled ≥ 65-year-old patients who presented or developed anemia during admission to a tertiary hospital's internal medicine and geriatric units. Patients with onco-hematological disorders, hemoglobinopathies and active bleeding were excluded. In the first phase, anemia management was monitored. In the second phase, the six participating units were divided into two groups and two arms: Educational (Edu) and non-educational (NE). During this phase, physicians in the Edu arm underwent an educational program for the appropriate use of transfusion and anemia management. In the third phase, anemia management was monitored. Comorbidities, demographic and hematological characteristics were similar in all phases and arms. The percentages of transfused patients during phase 1 were 27.7% in NE and 18.5% in the Edu arm. During phase 3, it decreased to 21.4% in the NE and 13.6% in the Edu arm. Hemoglobin levels at discharge and after 30 days were higher in the Edu group despite reduced use of blood transfusion. In conclusion, a more restrictive strategy was comparable or superior to the more liberal one in terms of clinical outcomes, with the advantage of saving red blood cell units and reducing related side effects.
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Affiliation(s)
- Deborah Blanca
- Internal Medicine, Immunology and Allergology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Università degli Studi di Milano, Milan, Italy
| | | | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Villa
- Department of Transfusion Medicine and Hematology, Biological Resource Center and Precision Medicine Lab, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuliana Ceriani
- High Care Internal Medicin Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Annalisa Cespiati
- Unit of Internal Medicine and Metabolic Disease, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Italy
| | - Giovanni Figini
- High Care Internal Medicin Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriele Ghigliazza
- Università degli Studi di Milano, Milan, Italy; UOC Medicina Generale Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Diletta Maira
- Unit of Internal Medicine and Metabolic Disease, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Oberti
- Università degli Studi di Milano, Milan, Italy; Unit of Internal Medicine and Metabolic Disease, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Natalia Scaramellini
- Unit of Internal Medicine and Metabolic Disease, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Francesco Tafuri
- UOC Medicina Generale Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Internal Medicine, Immunology and Allergology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Maria Domenica Cappellini
- Unit of Internal Medicine and Metabolic Disease, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Irene Motta
- Unit of Internal Medicine and Metabolic Disease, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
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13
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Ilgaz Koçyiğit Ö, Koçyiğit M, Güllü AÜ, Şenay Ş, Toraman F, Alhan C. Preoperative Anemia and Female Gender are Risk Factors for Transfusion in Patients Undergoing Coronary Artery Bypass Grafting with a Restrictive Transfusion Strategy. Turk J Anaesthesiol Reanim 2023; 51:324-330. [PMID: 37587675 DOI: 10.4274/tjar.2023.22856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
Objective Red blood cell (RBC) transfusion in cardiac surgery is associated with increased morbidity and mortality. Even when using patient blood management methods, blood transfusions may still be needed in cardiac surgery. This study examined the risk factors for blood transfusion in isolated coronary artery bypass graft (CABG) surgery with a restrictive transfusion strategy, along with individualized patient blood management. Methods We enrolled 198 patients (age, 61.8 ± 9.9 years; 28 females and 170 males) who underwent isolated CABG surgery in a single private hospital using a restrictive transfusion strategy between April 2015 and October 2020. Pre-, intra-, and postoperative parameters were compared between patients with and without RBC transfusions. The risk factors for transfusion and transfusion probability were analyzed. Results Patients who received RBC transfusions had higher European System for Cardiac Operative Risk Evaluation values (13.60 ± 18.27%). Preoperative hematocrit (Hct) [odds ratio (OR)=0.752; 95% confidence interval (CI) 0.639-0.884; P=0.001] and female gender (OR=7.874; 95% CI 1.678-36.950; P=0.009) were significant independent risk factors for RBC transfusion in logistic regression analysis. When the preoperative Hct was 30%, the RBC transfusion probability was 61.08% in females and 16.6% in males. Patients who received RBC transfusions had longer intensive care unit (31.40 ± 25.42 hours) and hospital (11.18 ± 6.75 days) stays. Conclusion Risk factors for RBC transfusion in isolated CABG surgery with a restrictive blood transfusion strategy were preoperative anemia and female gender.
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Affiliation(s)
- Özgen Ilgaz Koçyiğit
- Department of Anaesthesiology, Acıbadem Mehmet Ali Aydınlar University, Vocational School of Health Services, İstanbul, Turkey
| | - Muharrem Koçyiğit
- Department of Anaesthesiology, Acıbadem Mehmet Ali Aydınlar University, Vocational School of Health Services, İstanbul, Turkey
| | - Ahmet Ümit Güllü
- Department of Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, İstanbul, Turkey
| | - Şahin Şenay
- Department of Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, İstanbul, Turkey
| | - Fevzi Toraman
- Department of Anaesthesiology, Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, İstanbul, Turkey
| | - Cem Alhan
- Department of Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, İstanbul, Turkey
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14
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Franke A, Bieler D, Achatz G, Suda AJ, Hoth P, Paffrath T, Friemert B. [Care of the severely injured in mass casualty incidents : What is the difference compared to emergency room management?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00113-023-01332-x. [PMID: 37270728 DOI: 10.1007/s00113-023-01332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 06/05/2023]
Abstract
The management of a severely injured patient according to the standards and principles of individualized trauma care is a well-established procedure in many hospitals. The process is structured and standardized by the content of several course formats. In contrast, a mass casualty incident (MCI, MANV) is a rare and exceptional situation. In this case the treatment priorities and approaches are changed. The main aim in this situation is to ensure the best possible chance of survival for every casualty by organizational measures to mobilize rooms, personnel and material and to temporarily abandon the standards of individualized trauma care. To be prepared for a MCl situation it is necessary to know the realistic scenarios, to update the hospital emergency plan and to adapt all treatment procedures to the transient lack of resources. This article gives an overview of this process and summarizes the current clinical concepts to cope with a MCl situation and the current principles for the care of the severely injured involving many casualties.
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Affiliation(s)
- Axel Franke
- Klinik für Unfallchirurgie, Orthopädie, Hand- und Rekonstruktive Chirurgie, Verbrennungsmedizin, BundeswehrZentralkrankenhaus Koblenz, Rübenacherstr. 170, Koblenz, Deutschland.
| | - Dan Bieler
- Klinik für Unfallchirurgie, Orthopädie, Hand- und Rekonstruktive Chirurgie, Verbrennungsmedizin, BundeswehrZentralkrankenhaus Koblenz, Rübenacherstr. 170, Koblenz, Deutschland
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Gerhard Achatz
- Klinik für Unfallchirurgie, Orthopädie, Hand- und Rekonstruktive Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Arnold J Suda
- Abteilung für Orthopädie und Traumatologie, Unfallkrankenhaus Salzburg, Salzburg, Österreich
| | - Patrick Hoth
- Klinik für Unfallchirurgie, Orthopädie, Hand- und Rekonstruktive Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Thomas Paffrath
- Klinik für Unfallchirurgie, Krankenhaus der Augustinerinnen - Severinsklösterchen, Köln, Deutschland
| | - Benedikt Friemert
- Klinik für Unfallchirurgie, Orthopädie, Hand- und Rekonstruktive Chirurgie, Verbrennungsmedizin, BundeswehrZentralkrankenhaus Koblenz, Rübenacherstr. 170, Koblenz, Deutschland
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15
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Entzel P, Nielsen M, Weiss S, Park YA, Lu R, Baskin-Miller J, Hutchinson B, Obioma P, An X, Balfanz G. How do I reduce variation in red blood cell transfusion practices in a large integrated health care system? Transfusion 2023. [PMID: 37190781 DOI: 10.1111/trf.17383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Reducing variation in transfusion practices can prevent unwarranted transfusions, an outcome that improves quality of care and patient safety, while lowering costs and eliminating waste of blood. We developed and assessed a system-wide initiative to reduce variation in red blood cell (RBC) transfusion in terms of both transfusion utilization and the number of units transfused. INTERVENTION DESIGN AND METHODS Our initiative combined a single-unit default order for RBC transfusion in hemodynamically stable, non-bleeding patients with a "Why Give 2 When 1 Will Do?" Choosing Wisely campaign, while also promoting a restrictive hemoglobin threshold (Hb <7 g/dl). This multimodal intervention was implemented across an academic medical center (AMC) with over 950 beds and 10 community hospitals. RESULTS Between our baseline (CY 2020) and intervention period (CY 2021), single-unit orders increased from 57% to 70% of all RBC transfusion orders (p < .001). The greatest change in ordering practices was at community hospitals, where single-unit orders increased from 46% to 65% (p < .001). Over the same time period, the system-wide mean (SD) Hb result prior to transfusion fell from 7.3 (0.05) to 7.2 g/dl (0.04) (p < .05). We estimate this effort saved over 4000 units of blood and over $4 million in direct and indirect costs in its first year. DISCUSSION By combining a single-unit default setting in the RBC order with a restrictive hemoglobin threshold, we significantly reduced variation in ordering practices. This effort demonstrates the value of single-unit policies and "nudges" in system-wide patient blood management initiatives.
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Affiliation(s)
- Pamela Entzel
- Care Redesign Department, UNC Health, Morrisville, North Carolina, USA
| | - Matthew Nielsen
- Department of Urology, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Susan Weiss
- Carolinas Pathology Group, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Yara A Park
- Department of Pathology and Laboratory Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Rommel Lu
- UNC Rex Hematology Oncology, Raleigh, North Carolina, USA
| | - Jacquelyn Baskin-Miller
- Department of Pediatrics, Hematology/Oncology, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Blake Hutchinson
- Department of Pathology, UNC Rex Healthcare, Raleigh, North Carolina, USA
| | - Prestige Obioma
- Care Redesign Department, UNC Health, Morrisville, North Carolina, USA
| | - Xinming An
- Department of Anesthesiology, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Greg Balfanz
- Department of Anesthesiology, UNC School of Medicine, Chapel Hill, North Carolina, USA
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16
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Stempel JM, Podoltsev NA, Dosani T. Supportive Care for Patients With Myelodysplastic Syndromes. Cancer J 2023; 29:168-178. [PMID: 37195773 DOI: 10.1097/ppo.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes are a heterogeneous group of bone marrow disorders characterized by ineffective hematopoiesis, progressive cytopenias, and an innate capability of progressing to acute myeloid leukemia. The most common causes of morbidity and mortality are complications related to myelodysplastic syndromes rather than progression to acute myeloid leukemia. Although supportive care measures are applicable to all patients with myelodysplastic syndromes, they are especially essential in patients with lower-risk disease who have a better prognosis compared with their higher-risk counterparts and require longer-term monitoring of disease and treatment-related complications. In this review, we will address the most frequent complications and supportive care interventions used in patients with myelodysplastic syndromes, including transfusion support, management of iron overload, antimicrobial prophylaxis, important considerations in the era of COVID-19 (coronavirus infectious disease 2019), role of routine immunizations, and palliative care in the myelodysplastic syndrome population.
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17
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Torkian P, Jalaeian H, Wallace S, Shrestha P, Talaie R, Golzarian J. Post-Embolization Hemoglobin Changes: When to Consider Re-intervention. Cardiovasc Intervent Radiol 2023; 46:617-625. [PMID: 36869220 DOI: 10.1007/s00270-023-03386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/05/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE Decline in hemoglobin (Hgb) levels is common post-embolization, but there is no consensus on the classification of patients based on risk for re-bleeding or re-intervention. The current study evaluated post-embolization Hgb level trends with the goal of understanding the factors predictive of re-bleeding and re-intervention. MATERIALS AND METHODS All patients who underwent embolization for gastrointestinal (GI), genitourinary, peripheral, or thoracic arterial hemorrhage from 01/2017 to 01/2022 were reviewed. Data included demographics, periprocedural pRBC transfusion (TF) or pressor requirements, and outcome. Lab data consisted of Hgb values pre-embolization, immediately post-embolization, and daily values on days 1-10 after embolization. Hgb trends were compared between patients across TF and re-bleeding outcomes. Regression model was used to examine factors predictive of re-bleeding and magnitude of Hgb reduction post-embolization. RESULTS A total of 199 patients were embolized for active arterial hemorrhage. Perioperative Hgb level trends were similar for all sites and between TF + and TF- patients, showing a decline reaching a nadir within 6 days post-embolization followed by an upward trend. Maximum Hgb drift was predicted by GI embolization (p = 0.018), TF before embolization (p = 0.001), and use of vasopressor (p = 0.000). Patients with Hgb drop > 15% within the first two days post-embolization had a higher chance of having a re-bleeding episode (p = 0.04). CONCLUSION Perioperative Hgb trends showed a consistent downward drift followed by an upward shift, irrespective of TF requirement status or site of embolization. Using a cut-off value of 15% Hgb reduction within the first two days post-embolization may be helpful to assess re-bleeding risk.
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Affiliation(s)
- Pooya Torkian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA.
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Stephanie Wallace
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Prashant Shrestha
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Reza Talaie
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Jafar Golzarian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
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18
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Kikura M, Uraoka M, Nishino J. Restrictive blood transfusion and 1-year mortality in patients undergoing open abdominal surgery: A retrospective propensity score-matched cohort study. Transfus Clin Biol 2023; 30:75-81. [PMID: 35934225 DOI: 10.1016/j.tracli.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The importance of patient blood management is increasingly recognized in surgery patients. This study aimed to examine the effect of perioperative restrictive blood transfusion on 1-year mortality and blood transfusion rate in open abdominal surgery. METHODS We retrospectively studied 452 consecutive patients who underwent open abdominal surgery before (liberal group: 233 patients) and after (restrictive group: 219 patients) implementing intraoperative restrictive transfusion of red blood cell. The trigger levels of hemoglobin were less than 9-10 g/dL in the liberal group and less than 7-8 g/dL in the restrictive group. All-cause mortality at 1-year as the primary outcome and the transfusion rate of any allogeneic blood products as secondary outcome were compared between the liberal group and the restrictive group by the propensity-score matching. RESULTS Among a total of 452 patients (69 ± 11 yr., 70.5 % men), overall mortality at 1 year was 8.4 % and the proportion of patients who received any allogeneic blood products was 19.6 %. Compared with 155 propensity-score matched patients of the liberal group, 155 matched patients of the restrictive group had significantly lower 1-year mortality (4 [2.5 %] versus 18 [11.6 %], p = 0.003, percent absolute risk reduction [%ARR]; 9.0, 95 % confidential interval [CI], 3.1-14.7) and had significantly lower proportion of patients who received any allogeneic blood products (21 [13.5 %] versus 41 [26.4 %], p = 0.006, %ARR; 12.9, 95 % CI, 3.9-21.5). CONCLUSIONS The results of this study indicate that intraoperative restrictive blood transfusion reduces 1-year mortality and the transfusion rate of allogeneic blood products.
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Affiliation(s)
- Mutsuhito Kikura
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Hamamatsu, Japan.
| | - Masahiro Uraoka
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Hamamatsu, Japan
| | - Junko Nishino
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Hamamatsu, Japan
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Jiang Y, Lin X, Wang Y, Li J, Wang G, Meng Y, Li M, Li Y, Luo Y, Gao Z, Yin P, Zhang L, Lyu H, Tang P. Preoperative Anemia and Risk of In-hospital Postoperative Complications in Patients with Hip Fracture. Clin Interv Aging 2023; 18:639-653. [PMID: 37096216 PMCID: PMC10122467 DOI: 10.2147/cia.s404211] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/07/2023] [Indexed: 04/26/2023] Open
Abstract
Purpose To evaluate the impact of preoperative anemia on postoperative complications after hip fracture surgery. Patients and Methods We conducted a retrospective study including hip fracture patients at a teaching hospital between 2005 and 2022. We defined preoperative anemia as the last hemoglobin measurement level before surgery < 130 g/L for men and < 120 g/L for women. The primary outcome was a composite of in-hospital major complications, including pneumonia, respiratory failure, gastrointestinal bleeding, urinary tract infection, incision infection, deep venous thrombosis, pulmonary embolism, angina pectoris, arrhythmia, myocardial infarction, heart failure, stroke, and death. Secondary outcomes were cardiovascular events, infection, pneumonia, and death. We used multivariate negative binomial or logistic regression to evaluate the impact of anemia and its severity, categorized as mild (90-130 g/L for men, 90-120 g/L for women) or moderate-to-severe (< 90 g/L for both) anemia on outcomes. Results Of the 3540 included patients, 1960 had preoperative anemia. 188 anemic patients experienced 324 major complications, while 63 non-anemic patients had 94 major complications. The risk of major complications was 165.3 (95% CI, 149.5-182.4) and 59.5 (95% CI, 48.9-72.3) per 1000 persons in anemic and non-anemic patients, respectively. Anemic patients were more likely to have major complications than non-anemic patients (adjusted incidence rate ratio (aIRR), 1.87; 95% CI, 1.30-2.72), which was consistent in mild (aIRR, 1.77; 95% CI, 1.22-2.59) and moderate-to-severe (aIRR, 2.97; 95% CI, 1.65-5.38) anemia. Preoperative anemia also increased the risk of cardiovascular events (aIRR, 1.96; 95% CI, 1.29-3.01), infection (aIRR, 1.68; 95% CI, 1.01-2.86), pneumonia (adjusted odds ratio (aOR), 1.91; 95% CI, 1.06-3.57), and death (aOR, 3.17; 95% CI, 1.06-11.89). Conclusion Our findings suggest that even mild preoperative anemia is associated with major postoperative complications in hip fracture patients. This finding highlights considering preoperative anemia as a risk factor in surgical decision-making for high-risk patients.
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Affiliation(s)
- Yu Jiang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Xisheng Lin
- Department of Rehabilitation, the Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Yilin Wang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Jia Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Guoqi Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People’s Republic of China
| | - Yutong Meng
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ming Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Yi Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Yan Luo
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Zefu Gao
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Pengbin Yin
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Licheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Houchen Lyu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
- Correspondence: Houchen Lyu; Peifu Tang, Department of Orthopedics, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, People’s Republic of China, Tel +86-13501149301, Email ;
| | - Peifu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
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20
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Atia J, Evison F, Gallier S, Pettler S, Garrick M, Ball S, Lester W, Morton S, Coleman J, Pankhurst T. Effectiveness of clinical decision support in controlling inappropriate red blood cell and platelet transfusions, speciality specific responses and behavioural change. BMC Med Inform Decis Mak 2022; 22:342. [PMID: 36581868 PMCID: PMC9798655 DOI: 10.1186/s12911-022-02045-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/10/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Electronic clinical decision support (CDS) within Electronic Health Records has been used to improve patient safety, including reducing unnecessary blood product transfusions. We assessed the effectiveness of CDS in controlling inappropriate red blood cell (RBC) and platelet transfusion in a large acute hospital and how speciality specific behaviours changed in response. METHODS We used segmented linear regression of interrupted time series models to analyse the instantaneous and long term effect of introducing blood product electronic warnings to prescribers. We studied the impact on transfusions for patients in critical care (CC), haematology/oncology (HO) and elsewhere. RESULTS In non-CC or HO, there was significant and sustained decrease in the numbers of RBC transfusions after introduction of alerts. In CC the alerts reduced transfusions but this was not sustained, and in HO there was no impact on RBC transfusion. For platelet transfusions outside of CC and HO, the introduction of alerts stopped a rising trend of administration of platelets above recommended targets. In CC, alerts reduced platelet transfusions, but in HO alerts had little impact on clinician prescribing. CONCLUSION The findings suggest that CDS can result in immediate change in user behaviour which is more obvious outside specialist settings of CC and HO. It is important that this is then sustained. In CC and HO, blood transfusion practices differ. CDS thus needs to take specific circumstances into account. In this case there are acceptable reasons to transfuse outside of these crude targets and CDS should take these into account.
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Affiliation(s)
- Jolene Atia
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.412563.70000 0004 0376 6589Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Felicity Evison
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.412563.70000 0004 0376 6589Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Suzy Gallier
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486PIONEER: HDR-UK Health Data Research Hub for Acute Care, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2GW UK
| | - Sophie Pettler
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486School of Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Mark Garrick
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Simon Ball
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486HDRUK Better Care Science Priority and Health Data Research UK Midlands, University of Birmingham, Birmingham, UK
| | - Will Lester
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Suzanne Morton
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Vincent Drive, Edgbaston, Birmingham, B15 2SG UK
| | - Jamie Coleman
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486School of Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Tanya Pankhurst
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
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21
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Reitz KM, Phillips AR, Tzeng E, Makaroun MS, Leeper CM, Liang NL. Characterization of immediate and early mortality after repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2022; 76:1578-1587.e5. [PMID: 35803483 PMCID: PMC10088068 DOI: 10.1016/j.jvs.2022.06.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/21/2022] [Accepted: 06/28/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND We sought to compare immediate and early mortality among patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair. Evaluation of RAAA has focused on 30-day postoperative mortality. Other emergency conditions such as trauma have demonstrated a multimodal mortality distribution within the 30-day window, expanding the pathophysiologic understanding and allowing for intervention investigations with practice changing and lifesaving results. However, the temporal distribution and risk factors of postoperative morbidity and mortality in RAAA have yet to be investigated. METHODS We evaluated factors associated with RAAA postoperative mortality in immediate (<1 day) and early (1-30 days) postoperative periods in a landmarked retrospective cohort study using data from the Vascular Quality Initiative (2010-2020). RESULTS We identified 5157 RAAA repairs (mean age, 72 ± 10 years; 77% male; 88% White; 61% endovascular). The mortality rate in the immediate period was 10.2% (528/5157) and the early mortality rate was 22.1% (918/4163). In multivariable regression analyses, signs of hemorrhagic shock (ie, hemoglobin <7 g/dL: adjusted odds ratio [aOR], 1.87 [95% confidence interval [CI], 1.14-3.06]; any preoperative systolic blood pressure <70 mm Hg: aOR, 1.40 [95% CI, 1.04-1.89]; and estimated blood loss >40%: aOR, 3.65 [95% CI, 2.29-5.83]) were associated with an increased risk of immediate mortality. Comorbid conditions (heart failure: aOR, 1.38 [95% CI, 1.00-1.92]; pulmonary disease: aOR, 1.29 [95% CI, 1.05-1.58]; elevated creatinine: aOR 1.26 [95% CI, 1.31-1.41]) were associated with increased risk of early mortality. CONCLUSIONS Immediate deaths were associated predominantly with shock from massive hemorrhage, whereas early deaths were associated with comorbid conditions predisposing patients to multisystem organ failure despite successful repair. These temporal distinctions should guide future mechanistic and intervention evaluations to improve RAAA mortality.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Amanda R Phillips
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Michel S Makaroun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nathan L Liang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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22
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Allen G. Intraoperative Transfusion Strategies: A Systematic Review and
Meta‐Analysis. AORN J 2022; 116:587-591. [DOI: 10.1002/aorn.13834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2022]
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23
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Kotani Y, Kataoka Y, Izawa J, Fujioka S, Yoshida T, Kumasawa J, Kwong JS. High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass. Cochrane Database Syst Rev 2022; 11:CD013494. [PMID: 36448514 PMCID: PMC9709767 DOI: 10.1002/14651858.cd013494.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB. OBJECTIVES To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence. MAIN RESULTS We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB. AUTHORS' CONCLUSIONS A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Junichi Izawa
- Division of Critical Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
- Department of Preventive Services, Kyoto University Graduate School of Public Health, Kyoto, Japan
| | - Shoko Fujioka
- Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Jikei University Kashiwa Hospital, Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
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24
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Cahn J. Clinical Issues-October 2022. AORN J 2022; 116:359-367. [PMID: 36165662 DOI: 10.1002/aorn.13791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 01/28/2023]
Abstract
Verifying patient identity before blood product administration Key words: patient identification, patient verification, blood transfusion, blood management, wristband. Surgical site infection risk with allogeneic blood administration Key words: patient blood management, restrictive transfusion triggers, allogeneic blood products, intraoperative blood salvage, surgical site infection. Information on topical thrombin Key words: hemostatic agents, licensed biological product, hemostasis, bovine thrombin, human thrombin. Safe use of topical thrombin Key words: severe adverse events, hemostatic agents, accidental injection, accidental intravascular uptake, product labeling.
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25
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Altaweel W, Mehmood S, Seyam R. Intraoperative cell salvage transfusion in patients undergoing posterior urethroplasty: Its efficacy of reducing allogeneic blood transfusion, safety, and cost. Urol Ann 2022; 14:377-382. [PMID: 36505990 PMCID: PMC9731203 DOI: 10.4103/ua.ua_119_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/06/2022] [Indexed: 12/15/2022] Open
Abstract
Background A significant blood loss may be encountered with complex urethroplasty surgery. Blood management aims at reducing allogeneic blood transfusion (ABT) because of limited supply, associated risks, and cost. Intraoperative cell salvage (ICS) has been used in different urological and nonurological surgeries to achieve this goal. However, no study evaluated its role in perineal urethroplasty. Objectives We set out to determine the efficacy of reducing ABT, safety, and cost of ICS in posterior urethroplasty. Methods We reviewed the charts of all patients who underwent posterior urethroplasty between 2012 and 2017. We collected data for patients' demographics, pre- and postoperative hemoglobin level, ICS volume, complications, equivalent ABT units saved, and cost. Results Seventy patients with a median age of 27.5 ± 10.2 years underwent posterior urethroplasty. Of the 70 patients, 20 (28.57%) required ICS intraoperatively with a median of 441 ml/patient, equivalent to 1.47 units per patient of allogenic blood. No patient needed intraoperative ABT, whereas two patients required transfusions postoperatively. The median pre- and postoperative hemoglobin levels were 124.2 ± 9.2 and 110.3 ± 12.6 g/dl, respectively. There were no significant complications noted while using ICS. There was a 41% cost reduction of equivalent ABT units. Conclusions ICS is safe and effective in reducing ABT during posterior urethroplasty. In our hospital, it is associated with a significant cost reduction of blood transfusion.
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Affiliation(s)
- Waleed Altaweel
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Shahbaz Mehmood
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Raouf Seyam
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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26
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Montoro M, Cucala M, Lanas Á, Villanueva C, Hervás AJ, Alcedo J, Gisbert JP, Aisa ÁP, Bujanda L, Calvet X, Mearin F, Murcia Ó, Canelles P, García López S, Martín de Argila C, Planella M, Quintana M, Jericó C, García Erce JA. Indications and hemoglobin thresholds for red blood cell transfusion and iron replacement in adults with gastrointestinal bleeding: An algorithm proposed by gastroenterologists and patient blood management experts. Front Med (Lausanne) 2022; 9:903739. [PMID: 36186804 PMCID: PMC9519983 DOI: 10.3389/fmed.2022.903739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Gastrointestinal (GI) bleeding is associated with considerable morbidity and mortality. Red blood cell (RBC) transfusion has long been the cornerstone of treatment for anemia due to GI bleeding. However, blood is not devoid of potential adverse effects, and it is also a precious resource, with limited supplies in blood banks. Nowadays, all patients should benefit from a patient blood management (PBM) program that aims to minimize blood loss, optimize hematopoiesis (mainly by using iron replacement therapy), maximize tolerance of anemia, and avoid unnecessary transfusions. Integration of PBM into healthcare management reduces patient mortality and morbidity and supports a restrictive RBC transfusion approach by reducing transfusion rates. The European Commission has outlined strategies to support hospitals with the implementation of PBM, but it is vital that these initiatives are translated into clinical practice. To help optimize management of anemia and iron deficiency in adults with acute or chronic GI bleeding, we developed a protocol under the auspices of the Spanish Association of Gastroenterology, in collaboration with healthcare professionals from 16 hospitals across Spain, including expert advice from different specialties involved in PBM strategies, such as internal medicine physicians, intensive care specialists, and hematologists. Recommendations include how to identify patients who have anemia (or iron deficiency) requiring oral/intravenous iron replacement therapy and/or RBC transfusion (using a restrictive approach to transfusion), and transfusing RBC units 1 unit at a time, with assessment of patients after each given unit (i.e., “don’t give two without review”). The advantages and limitations of oral versus intravenous iron and guidance on the safe and effective use of intravenous iron are also described. Implementation of a PBM strategy and clinical decision-making support, including early treatment of anemia with iron supplementation in patients with GI bleeding, may improve patient outcomes and lower hospital costs.
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Affiliation(s)
- Miguel Montoro
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, Huesca, Spain
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS), Zaragoza, Spain
- *Correspondence: Miguel Montoro,
| | | | - Ángel Lanas
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS), Zaragoza, Spain
- Servicio de Aparato Digestivo, Hospital Clínico Universitario “Lozano Blesa”, Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Cándido Villanueva
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servei de Digestiu, Hospital de la Santa Creu y Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Antonio José Hervás
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | - Javier Alcedo
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Javier P. Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Ángeles P. Aisa
- Servicio de Aparato Digestivo, Hospital Universitario Costa del Sol, Marbella, Spain
| | - Luis Bujanda
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Donostia, Donostia, Spain
- Instituto de Investigación Sanitaria Biodonostia, Universidad del País Vasco (UPV/EHU), Donostia, Spain
| | - Xavier Calvet
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Servei de Digestiu, Corporació Sanitaria Park Taulí, Sabadell, Spain
- Department of Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Fermín Mearin
- Servicio de Aparato Digestivo, Centro Médico Teknon, Barcelona, Spain
| | - Óscar Murcia
- Servicio de Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
| | - Pilar Canelles
- Servicio de Aparato Digestivo, Hospital General Universitario de Valencia, Valencia, Spain
| | - Santiago García López
- Departamento de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Montserrat Planella
- Servei de Digestiu, Hospital Universitario Arnau de Vilanova, Lleida, Spain
- Department of Medicine, Universidad de Lleida, Lleida, Spain
| | - Manuel Quintana
- Servicio a Medicina Intensiva, Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
- PBM Group, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Carlos Jericó
- Servicio de Medicina Interna, Complex Hospitalari Moisès Broggi, Sant Joan Despí, Barcelona, Spain
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain
| | - José Antonio García Erce
- PBM Group, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain
- Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud, Osasunbidea, Pamplona, Spain
- Instituto Aragonés de Ciencias de la Salud, Universidad de Zaragoza, Zaragoza, Spain
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27
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Tomić Mahečić T, Brooks R, Noitz M, Sarmiento I, Baronica R, Meier J. The Limits of Acute Anemia. J Clin Med 2022; 11:jcm11185279. [PMID: 36142930 PMCID: PMC9505011 DOI: 10.3390/jcm11185279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 01/28/2023] Open
Abstract
For many years, physicians’ approach to the transfusion of allogeneic red blood cells (RBC) was not individualized. It was accepted that a hemoglobin concentration (Hb) of less than 10 g/dL was a general transfusion threshold and the majority of patients were transfused immediately. In recent years, there has been increasing evidence that even significantly lower hemoglobin concentrations can be survived in the short term without sequelae. This somehow contradicts the observation that moderate or mild anemia is associated with relevant long-term morbidity and mortality. To resolve this apparent contradiction, it must be recognized that we have to avoid acute anemia or treat it by alternative methods. The aim of this article is to describe the physiological limits of acute anemia, match these considerations with clinical realities, and then present “patient blood management” (PBM) as the therapeutic concept that can prevent both anemia and unnecessary transfusion of RBC concentrates in a clinical context, especially in Intensive Care Units (ICU). This treatment concept may prove to be the key to high-quality patient care in the ICU setting in the future.
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Affiliation(s)
- Tina Tomić Mahečić
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Center Zagreb—“Rebro”, 10000 Zagreb, Croatia
| | - Roxane Brooks
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University, 4040 Linz, Austria
| | - Matthias Noitz
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University, 4040 Linz, Austria
| | - Ignacio Sarmiento
- Department of Anesthesiology, Clinica Santa Maria, Santiago 7520378, Chile
| | - Robert Baronica
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Center Zagreb—“Rebro”, 10000 Zagreb, Croatia
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University, 4040 Linz, Austria
- Correspondence:
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28
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Saporito A, La Regina D, Hofmann A, Ruinelli L, Merler A, Mongelli F, Trentino KM, Ferrari P. Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals. Front Med (Lausanne) 2022; 9:956128. [PMID: 36111110 PMCID: PMC9468475 DOI: 10.3389/fmed.2022.956128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/12/2022] [Indexed: 01/28/2023] Open
Abstract
Background Red blood cell (RBC) transfusions in surgical patients are associated with increased morbidity a hospital stay. However, little is known about how clinical and economic outcomes differ between appropriately and inappropriately transfused patients. We hypothesized that inappropriate RBC transfusions in elective surgical patients would significantly increase hospital cost. The aim of this study was to quantify the economic burden associated with inappropriate RBC transfusions. Methods We retrospectively included all adult patients admitted for elective non-cardiac surgery between January 2014 and March 2020. Patients were divided into three groups (not transfused, appropriately transfused and inappropriately transfused). The primary outcome was the excess in hospital cost in patients inappropriately transfused compared to non-transfused patients. Costs were calculated using a bottom–up approach and involving cost calculation on a granular level. According to international guidelines, transfusions were considered appropriate if administered with an ASA score of 1–2 and the last hemoglobin level measured before transfusion < 70 g/L, or with an ASA score ≥ 3 and the last hemoglobin level < 80 g/L. Cases where RBC transfusions were deemed necessary regardless of the Hb levels were reviewed by the patient blood management (PBM) board and classified accordingly. Secondary outcomes included total transfusion rate, transfusion index, and length of hospital stay. Statistical analysis was carried out by multivariable regression models. Results During the study period there were 54,922 consecutive surgical admissions, of these 1,997 received an RBC transfusion, with 1,125 considered inappropriate. The adjusted cost of each inappropriate RBC transfusions was estimated in United States dollars (USD) 9,779 (95% CI, 9,358 – 10,199; p < 0.001) and totaled USD 11,001,410 in our series. Inappropriately transfused patients stayed 1.6 times (95% CI, 1.5–1.6; p < 0.001) longer in hospital (10.6 days vs. 6.7 days) than non-transfused patients and a mean 2.35 RBC units per patient were administered. Conclusion Inappropriate RBC transfusions in elective surgical patients seem to be common and may represent a significant economic burden. In our experience, inappropriate transfusions significantly increased hospital costs by an average of USD 9,779 compared to non-transfused patients. Through specific PBM policy, hospitals may improve cost-effectiveness of their elective surgical activity by lowering inappropriate transfusions.
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Affiliation(s)
- Andrea Saporito
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Division of Anesthesiology, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Davide La Regina
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Department of Surgery, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Axel Hofmann
- Institute of Anesthesiology, University Hospital of Zurich, Zurich, Switzerland
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Lorenzo Ruinelli
- Information and Communications Technology Unit, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Alessandro Merler
- Information and Communications Technology Unit, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Francesco Mongelli
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Department of Surgery, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- *Correspondence: Francesco Mongelli,
| | - Kevin M. Trentino
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Paolo Ferrari
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Division of Nephrology, Lugano Regional Hospital, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical School, University of New South Wales, Sydney, NSW, Australia
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29
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Sertcakacilar G, Yildiz GO. Association between Anemia and New-Onset Atrial Fibrillation in Critically Ill Patients in the Intensive Care Unit: A Retrospective Cohort Analysis. Clin Pract 2022; 12:533-544. [PMID: 35892443 PMCID: PMC9326761 DOI: 10.3390/clinpract12040057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/05/2022] [Accepted: 07/09/2022] [Indexed: 01/28/2023] Open
Abstract
New-onset atrial fibrillation (NOAF) is one of the leading causes of morbidity and mortality, especially in older patients in the intensive care unit (ICU). Although many comorbidities are associated with NOAF, the effect of anemia on the onset of atrial fibrillation is still unknown. This study aimed to test the hypothesis that anemia is associated with an increased risk of developing NOAF in critically ill patients in intensive care. We performed a retrospective analysis of critically ill patients who underwent routine hemoglobin and electrocardiography monitoring in the ICU. Receiver operating characteristics analysis determined the hemoglobin (Hb) value that triggered NOAF formation. Bivariate correlation was used to determine the relationship between anemia and NOAF. The incidence of NOAF was 9.9% in the total population, and 12.8% in the patient group with anemia. Analysis of 1931 patients revealed a negative association between anemia and the development of NOAF in the ICU. The stimulatory Hb cut-off value for the formation of NOAF was determined as 9.64 g/dL. Anemia is associated with the development of NOAF in critically ill patients in intensive care.
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Affiliation(s)
- Gokhan Sertcakacilar
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anesthesiology and Reanimation, University of Health Science, Bakırköy Dr. Sadi Konuk Education and Research Hospital, 34147 Istanbul, Turkey;
- Correspondence:
| | - Gunes Ozlem Yildiz
- Department of Anesthesiology and Reanimation, University of Health Science, Bakırköy Dr. Sadi Konuk Education and Research Hospital, 34147 Istanbul, Turkey;
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30
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Characterising differences in red blood cell usage patterns between healthcare sectors in South Africa: 2014-2019. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2022; 20:299-309. [PMID: 34967724 PMCID: PMC9256512 DOI: 10.2450/2021.0209-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/19/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND South Africa aims to transition from a two-tiered healthcare system (public and private) to universal health coverage. Data on red blood cell (RBC) product usage reveal disparities between the sectors. Blood transfusion services further need to understand differing disease profiles and transfusion prescribing practices between the sectors to ensure blood security should the transition to a two-tiered health system come to fruition. MATERIALS AND METHODS Operational data for public and private healthcare RBC requests between 1 January 2014 and 31 March 2019, obtained from the South African National Blood Service (SANBS), were retrospectively analysed. Sector-specific demographic and utilisation trends were compared for the dominant clinical disciplines. Pre-transfusion haemoglobin (Hb) patterns were also delineated for 2018. RESULTS Between 2014 and 2019, 2,356,411 public and private sector RBC transfusion events resulted in the issue of 4,020,094 RBC units (1,553,159 transfusion events and 2,495,054 units within the public sector versus 803,282 transfusion events and 1,525,040 units in private). The dominant clinical disciplines within the public sector were Medical (32.9%), Gynaecology/Obstetrics (27.3%), General Surgery (13.6%), and Paediatrics (including Paediatric Surgery) (6.5%), compared to Intensive Care Units (33.2%), Medical (28.3%), General Surgery (10.4%), and Haematology/Oncology (8.3%) in the private sector. Median pre-transfusion Hb values for 2018 were lower in the public than in the private sector: 6.9 g/dL public sector versus 8 g/dL private sector. DISCUSSION Clinical drivers of RBC usage within the public and private healthcare sectors in South Africa differ significantly. Disparate pre-transfusion Hb between the sectors are likely due to differing disease profiles and severity, as well as differences in practice in prescribing transfusions. Implementation of a nationally co-ordinated Patient Blood Management programme may help to address these disparities and help ensure a sustainable blood transfusion system.
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31
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Primary Sjögren's syndrome is not associated with poor outcomes after total hip arthroplasty: a retrospective case-control study with a matched cohort of osteoarthritis patients. Clin Rheumatol 2022; 41:3075-3082. [PMID: 35763156 PMCID: PMC9243796 DOI: 10.1007/s10067-022-06256-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 01/28/2023]
Abstract
Introduction The number of patients with primary Sjögren’s syndrome (PSS) requiring total hip arthroplasty (THA) is expected to increase, but few studies have detailed their outcomes. The purpose of this study was to evaluate a THA cohort of patients with avascular necrosis of the femoral head (ANFH) who had PSS and to compare their outcomes with those of matched patients with osteoarthritis. Method A case–control study using data from a single-institution arthroplasty registry was performed. Forty-two THAs in 32 patients undergoing THA with a diagnosis of PSS were identified and were matched with 84 THAs in 64 patients with osteoarthritis (1:2 ratio). Functional and health-related quality of life (QoL) evaluations were performed, and complications were recorded at the last follow-up. Logistic regression was used to determine factors associated with reaching the transfusion trigger of hemoglobin < 8 g/dL (TT8) in PSS patients. Results After a mean 5-year follow-up, both cohorts had similar hip function and health-related QoL outcomes. The incision complications and reaching TT8 were greater in the PSS group. No differences were observed in the rate of 90-day readmission, reoperation, or overall revision. By multivariate analysis, the influencing factors for reaching TT8 in PSS patients were lower preoperative hemoglobin (OR = 0.842, 95% CI [0.741–0.958], P < 0.05). Conclusion Our study demonstrated PSS patients who received THA due to ANFH could achieve clinical outcomes similar to those of non-PSS patients. Improving preoperative Hb level can reduce the risk of transfusion.Key Points • THA significantly improved hip function and health-related quality of life in PSS patients with osteonecrosis of the femoral head. • Patients with PSS were more likely to reach the transfusion trigger and higher rates of incision complications after THA. • Improving preoperative Hb level can reduce the risk of transfusion for PSS patients who underwent THA. |
Supplementary Information The online version contains supplementary material available at 10.1007/s10067-022-06256-2.
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32
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Schoenes B, Schrezenmeier H, Welte M. [Rational therapy with erythrocyte concentrates - Update 2022]. Dtsch Med Wochenschr 2022; 147:780-796. [PMID: 35672025 DOI: 10.1055/a-1716-8148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The use of red blood cell concentrates must follow the dictates of a rational indication. To further ensure this, the "Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives" 1 of the German Medical Association, published in 2009 and last revised in part in 2014, were systematically revised in 2020. This article presents them.
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33
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Yee MY, Harrison E, Pius R, Gillies M. Changes in perioperative red cell transfusion practice over time in patients undergoing surgery for upper gastrointestinal and liver cancer: a retrospective cohort study at a single tertiary centre. BMJ Open 2022; 12:e054193. [PMID: 35534069 PMCID: PMC9086641 DOI: 10.1136/bmjopen-2021-054193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Optimum transfusion trigger for adults undergoing cancer surgery is uncertain. Published guidelines recommend restrictive transfusion strategies in hospitalised adults. We aimed to measure the red cell transfusion rate and haemoglobin trigger in patients undergoing cancer surgery and how closely practice reflected published guidelines. DESIGN Retrospective cohort study. SETTING Single tertiary centre. PARTICIPANTS Adult patients undergoing surgery for upper gastrointestinal or liver malignancy. EXPOSURE Postguideline change (2015-2017) versus preguideline change (2011-2012). OUTCOME MEASURES Primary: transfusion rate, secondary: transfusion trigger. Multivariable logistic regression was used to assess factors and adjust for confounders affecting our outcome measures. RESULTS 1578 surgical records were identified for 1520 patients. 946/1530 (62%) patients had preoperative anaemia. The transfusion rate decreased from 23% in 2011-2012 to 14% in 2015-2017. This change remained significant after adjusting for other variables associated with transfusion rates. Mean pretransfusion haemoglobin in those who were transfused was 78±13 g/L in 2011-2012 and 80±15 g/L in 2015-2017. This change in haemoglobin transfusion triggers was not significant. CONCLUSION Transfusion rate has decreased over the study period in patients undergoing surgery for malignancy and is consistent with a restrictive transfusion strategy.
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Affiliation(s)
- Mei Yi Yee
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Ewen Harrison
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Riinu Pius
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Michael Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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34
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Mandar O, Hassan B, Abdelbagi O, Eltayeb R, ALhabardi N, Adam I. Prevalence and Associated Factors for Post-Caesarean Delivery Blood Transfusion in Eastern Sudan: A Cross-Sectional Study. J Blood Med 2022; 13:219-227. [PMID: 35585876 PMCID: PMC9109909 DOI: 10.2147/jbm.s355846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/05/2022] [Indexed: 01/28/2023] Open
Abstract
Background Obstetric haemorrhage is a leading cause of maternal mortality and morbidity worldwide. Caesarean delivery (CD) is associated with significant blood loss, which may require blood transfusions. This study aimed to determine the prevalence and associated factors for post-CD transfusion. Methods A cross-sectional study was conducted in Gadarif maternity hospital, eastern Sudan, from March to September 2020. Sociodemographic, obstetric and clinical data, including pre- and postoperative haemoglobin levels, were collected. A multivariate logistic regression analysis was performed. Results A total of 539 women were enrolled in the study; the median (interquartile range) age of these women was 28.0 (8.0) years. The overall post-CD transfusion rate was 8.2%. Emergency CD (adjusted odds ratio [AOR]=2.57, 95% confidence interval [CI]=1.25‒5.28) and antepartum haemorrhage (AOR=44.70, 95% CI=11.18‒178.76) were associated with increased risk of post-CD blood transfusion. Preoperative haemoglobin (AOR=0.48, 95% CI=0.36‒0.64) and rural residence (AOR=0.45, 95% CI=0.22‒0.93) were associated with reduced risk for post-CD blood transfusion. Conclusion The overall prevalence of post-CD transfusion in this part of Sudan is 8.2%. Women with emergency CD, low preoperative haemoglobin levels and antepartum haemorrhage were at higher risk for post-CD transfusion. Risk identification and correction of antenatal anaemia can reduce the hazard of blood transfusion among CD women.
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Affiliation(s)
- Omer Mandar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gadarif University, Gadarif, Sudan
- Correspondence: Omer Mandar, Department of Obstetrics and Gynecology, Faculty of Medicine, Gadarif University, P.O Box 449, Gadarif, 32211, Sudan, Fax +249 44143162, Email
| | - Bahaeldin Hassan
- Department of Obstetrics and Gynecology, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Omer Abdelbagi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gadarif University, Gadarif, Sudan
| | - Reem Eltayeb
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gadarif University, Gadarif, Sudan
| | - Nadia ALhabardi
- Department of Obstetrics and Gynecology, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia
| | - Ishag Adam
- Department of Obstetrics and Gynecology, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia
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35
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Digging Into Past HBOC Clinical Trials. Am J Ther 2022; 29:e338-e341. [PMID: 35446268 DOI: 10.1097/mjt.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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36
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Patil A, Sephton BM, Ashdown T, Bakhshayesh P. Blood loss and transfusion rates following total hip arthroplasty: a multivariate analysis. Acta Orthop Belg 2022; 88:27-34. [PMID: 35512151 DOI: 10.52628/88.1.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study aimed to identify factors that inde- pendently predict increased rates of transfusion following total hip arthroplasty (THA) surgery. A retrospective analysis of all patients undergoing THA surgery over 12 months was performed. Electronic operative records were analysed to determine the following patient factors: American Society of Anesthesiologists (ASA) grade, body mass index (BMI), co-morbidities, indication for surgery, surgical technique, type of implant used, haematological markers, hospital length of stay (LOS) and complications. A total of 244 patients were included. There were 141 females (58%) and 103 males (42%). The median age was 65±12. The median pre-operative blood volume was 4500mls (IQR; 4000-5200). The median blood loss was 1069mls (IQR; 775-1390). The total number of patients requiring transfusion was 28 (11%), with a median of two units being transfused. Pre-operative haemoglobin (p<0.001) level, haematocrit (p<0.001) level and weight (p=0.016) were found to be predictive of transfusion requirement as well as ASA grade (p=0.005). Application of an intra-operative surgical drain was associated with higher rates of transfusion (p<0.001). Our study strengthens the evidence that pre-operative haemoglobin and haematocrit levels are valuable predictors of patients requiring transfusion. Additionally, ASA grade may be viewed as a helpful factor in predicting risk of transfusion. A strategy incorporating pre-operative optimisation of modifiable factors may reduce rates of transfusion requirement.
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Kotzerke D, Costa MW, Voigt J, Kleinhempel A, Schmidt M, Söhnlein T, Kaiser T, Henschler R. Novelle QLL 2020 – welche Auswirkungen haben die neu empfohlenen Hämoglobin-Transfusionstrigger auf die klinische Versorgung? TRANSFUSIONSMEDIZIN 2022. [DOI: 10.1055/a-1669-3918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
ZusammenfassungIn der Gesamtnovelle der Querschnittsleitlinie (QLL) Hämotherapie der Bundesärztekammer (BÄK) 2020 wurde der Hämoglobin-Transfusionstrigger (Hb-Transfusionstrigger) bei akutem Blutverlust
ohne zusätzliche Risikofaktoren aufgrund einer Neubewertung der internationalen Evidenz von 3,7 mmol/l (6 g/dl) auf 4,3 mmol/l (7 g/dl) angepasst. Ziel der vorliegenden Studie ist die
retrospektive Analyse des Transfusionsverhaltens von EK bezüglich der Maßgaben der QLL. Zu diesem Zweck analysierten wir individuelle Prä- und Posttransfusions-Hb-Werte von
Erythrozytenkonzentraten (EK), die im 4. Quartal 2019 (4946 EKs, 129 560 Hb-Werte) und 2020 (5502 EKs, 134 404 Hb-Werte) am Universitätsklinikum Leipzig (UKL) transfundiert wurden. Der
mediane Hb-Wert vor der Transfusion betrug 4,3 mmol/l (7 g/dl) (680 medizinische Fälle, die 2724 EK in 1801 Transfusionen im Jahr 2019 erhielten). Von allen Transfusionen im Jahr 2019
zeigten 899 (49,9%) Transfusionen Hb-Werte < 4,3 mmol/l (7 g/dl) vor der Transfusion, während 152 (8,4%) Hb-Werte < 3,7 mmol/l (6 g/dl) aufwiesen. 2020 wurden jeweils vergleichbare
Ergebnisse ermittelt. Wir zeigen, dass der mediane Hb-Anstieg nach der Transfusion eines EK 0,6 mmol/l (1 g/dl) betrug. 34,7% aller Transfusionen erreichten den erwarteten Anstieg von
0,6 mmol/l (1 g/dl) pro EK. Der absolute Anstieg nahm bei Transfusionen mit mehreren EK im Vergleich zu Transfusionen mit einem EK nicht linear zu. Der Grad der Hb-Erhöhung korrelierte
invers mit dem Hb-Wert vor Transfusion. Der Hb-Wert nach der Transfusion wurde bei 96,3% der Fälle innerhalb von 24 Stunden nach Hämotherapie kontrolliert. Zusammenfassend spiegelt das
Transfusionsverhalten generell die Empfehlungen der Leitlinie. Um ein optimiertes, individualisiertes und dennoch restriktives Transfusionsverhalten bei EK zu erreichen, schlagen wir die
Implementierung eines klinischen Entscheidungsunterstützungssystems (CDSS) bei Verschreibung jeder einzelnen EK-Transfusion vor, welches Ärzte bei der Einhaltung der Transfusionsleitlinie
unterstützt und über Abweichungen informiert.
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Affiliation(s)
- David Kotzerke
- Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universitätsklinikum Leipzig, Leipzig, Deutschland
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Maria Walter Costa
- Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Jenny Voigt
- Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Alisa Kleinhempel
- Institut für Transfusionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Maria Schmidt
- Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tim Söhnlein
- Institut für Transfusionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Thorsten Kaiser
- Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Reinhard Henschler
- Institut für Transfusionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
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[G-CSF for prophylaxis of neutropenia and febrile neutropenia, anemia in cancer : Guidelines on supportive treatment part 1]. Urologe A 2022; 61:537-551. [PMID: 35476110 PMCID: PMC9044390 DOI: 10.1007/s00120-022-01831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 02/01/2023]
Abstract
Infections in patients with neutropenia following chemotherapy are mostly manifested as fever (febrile neutropenia, FN). Some of the most important determinants of the risk of FN are the type of chemotherapy, the dose intensity and patient-specific factors. When the risk of FN is 20% or more granulopoiesis is prophylactically stimulated with granulocyte colony stimulating factor (G-CSF) after the treatment. Anemia should always be clarified and if necessary be treated according to the cause when symptomatic. If an absolute or functional iron deficiency is present, intravenous iron substitution is mostly necessary. Erythropoiesis-stimulating agents can be used after chemotherapy with hemoglobin (Hb) levels less than 10 g/dl (6.2 mmol/l). In cases of chronic anemia and Hb levels less than 7-8 g/dl (<4.3-5.0 mmol/l) the indications for transfusion of erythrocyte concentrates should be assessed primarily based on the individual clinical symptoms.
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Massicotte-Azarniouch D, Sood MM, Fergusson DA, Chassé M, Tinmouth A, Knoll GA. Blood transfusion and the risk for infections in kidney transplant patients. PLoS One 2021; 16:e0259270. [PMID: 34767576 PMCID: PMC8589196 DOI: 10.1371/journal.pone.0259270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/17/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Receipt of a red blood cell transfusion (RBCT) post-kidney transplantation may alter immunity which could predispose to subsequent infection. METHODS We carried out a single-center, retrospective cohort study of 1,258 adult kidney transplant recipients from 2002 to 2018 (mean age 52, 64% male). The receipt of RBCT post-transplant (468 participants transfused, total 2,373 RBCT) was analyzed as a time-varying, cumulative exposure. Adjusted cox proportional hazards models were used to calculate hazard ratios (HR) for outcomes of bacterial or viral (BK or CMV) infection. RESULTS Over a median follow-up of 3.8 years, bacterial infection occurred in 34% of participants at a median of 409 days post-transplant and viral infection occurred in 25% at a median of 154 days post-transplant. Transfusion was associated with a step-wise higher risk of bacterial infection (HR 1.35, 95%CI 0.95-1.91; HR 1.29, 95%CI 0.92-1.82; HR 2.63, 95%CI 1.94-3.56; HR 3.38, 95%CI 2.30-4.95, for 1, 2, 3-5 and >5 RBCT respectively), but not viral infection. These findings were consistent in multiple additional analyses, including accounting for reverse causality. CONCLUSION Blood transfusion after kidney transplant is associated with a higher risk for bacterial infection, emphasizing the need to use transfusions judiciously in this population already at risk for infections.
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Affiliation(s)
| | - Manish M. Sood
- Division of Nephrology, Department of Medicine, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Dean A. Fergusson
- Department of Medicine, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Michaël Chassé
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Alan Tinmouth
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Greg A. Knoll
- Division of Nephrology, Department of Medicine, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
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Caruso JP, Pernik MN, Johnson ZD, El Ahmadieh TY, Ogunnaike B, Adogwa O, Aoun SG, Bagley CA. Blood preservation techniques in complex spine surgery: Illustrative case and review of therapeutic options. Surg Neurol Int 2021; 12:515. [PMID: 34754565 PMCID: PMC8571196 DOI: 10.25259/sni_901_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/18/2021] [Indexed: 01/28/2023] Open
Abstract
Background: Complex spine surgery predisposes patients to substantial levels of blood loss, which can increase the risk of surgical morbidity and mortality. Case Description: A 29-year-old achondroplastic male required thoracolumbar deformity correction. However, he refused potential allogeneic blood transfusions for religious reasons. He, therefore, underwent pre-operative autologous blood donation and consented to the use of the intraoperative cell salvage device. Immediately prior to the incision, he underwent acute normovolemic hemodilution. Throughout the case, we additionally utilized meticulous hemostasis. Postoperatively, he was supplemented with iron and erythropoietin and recovered well. When he required a revision procedure 3 months later, similar strategies were successfully employed. Conclusion: Numerous strategies exist pre-operatively, intraoperatively, and post-operatively to optimize blood loss management for patients who refuse blood transfusions but warrant major spinal deformity surgery.
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Affiliation(s)
- James P Caruso
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Mark N Pernik
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Zachary D Johnson
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Tarek Y El Ahmadieh
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Babatunde Ogunnaike
- Department of Anesthesia and Pain Management, University of Texas Southwestern, Dallas, Texas, United States
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Salah G Aoun
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Carlos A Bagley
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
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Allard S, Cort J, Howell C, Sherliker L, Miflin G, Toh CH. Transfusion 2024: A 5-year plan for clinical and laboratory transfusion in England. Transfus Med 2021; 31:400-408. [PMID: 34693582 DOI: 10.1111/tme.12827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/30/2021] [Accepted: 10/10/2021] [Indexed: 01/28/2023]
Abstract
The Transfusion 2024 plan outlines key priorities for clinical and laboratory transfusion practice for safe patient care across the NHS for the next 5 years. It is based on the outcomes of a multi-professional symposium held in March 2019, organised by the National Blood Transfusion Committee (NBTC) and NHS Blood and Transplant (NHSBT), attended and supported by Professor Keith Willet and Dame Sue Hill on behalf of NHS England and Improvement. This best practice guidance contained within this publication will facilitate the necessary change in pathway design to meet the transfusion challenges and pressures for the restoration of a cohesive, and functional, healthcare system across the NHS following the COVID-19 pandemic.
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Affiliation(s)
- Shubha Allard
- Department of Medical, NHS Blood and Transplant, London, UK
| | - Jon Cort
- Department of Clinical, Chesterfield Royal Hospital NHS Foundation Trust, Derbyshire, UK
| | | | | | - Gail Miflin
- Department of Medical, NHS Blood and Transplant, Cambridge, UK
| | - Cheng Hock Toh
- Department of Clinical, University of Liverpool on behalf of NHSBT and NBTC, Liverpool, UK
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Xu H, Agha-Mir-Salim L, O'Brien Z, Huang DC, Li P, Gómez J, Liu X, Liu T, Yeung W, Thoral P, Elbers P, Zhang Z, Saera MB, Celi LA. Varying association of laboratory values with reference ranges and outcomes in critically ill patients: an analysis of data from five databases in four countries across Asia, Europe and North America. BMJ Health Care Inform 2021; 28:bmjhci-2021-100419. [PMID: 34642176 PMCID: PMC8513264 DOI: 10.1136/bmjhci-2021-100419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/17/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Despite wide usage across all areas of medicine, it is uncertain how useful standard reference ranges of laboratory values are for critically ill patients. OBJECTIVES The aim of this study is to assess the distributions of standard laboratory measurements in more than 330 selected intensive care units (ICUs) across the USA, Amsterdam, Beijing and Tarragona; compare differences and similarities across different geographical locations and evaluate how they may be associated with differences in length of stay (LOS) and mortality in the ICU. METHODS A multi-centre, retrospective, cross-sectional study of data from five databases for adult patients first admitted to an ICU between 2001 and 2019 was conducted. The included databases contained patient-level data regarding demographics, interventions, clinical outcomes and laboratory results. Kernel density estimation functions were applied to the distributions of laboratory tests, and the overlapping coefficient and Cohen standardised mean difference were used to quantify differences in these distributions. RESULTS The 259 382 patients studied across five databases in four countries showed a high degree of heterogeneity with regard to demographics, case mix, interventions and outcomes. A high level of divergence in the studied laboratory results (creatinine, haemoglobin, lactate, sodium) from the locally used reference ranges was observed, even when stratified by outcome. CONCLUSION Standardised reference ranges have limited relevance to ICU patients across a range of geographies. The development of context-specific reference ranges, especially as it relates to clinical outcomes like LOS and mortality, may be more useful to clinicians.
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Affiliation(s)
- Haoran Xu
- School of Medicine, Chinese PLA General Hospital, Beijing, China
| | - Louis Agha-Mir-Salim
- Laboratory for Computational Physiology, Harvard-MIT Division of Health Sciences and Technology, Cambridge, Massachusetts, USA .,Institute of Medical Informatics, Charité - Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Zachary O'Brien
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dora C Huang
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Peiyao Li
- Global Health Drug Discovery Institute, Beijing, China.,Department of Computer Science and Technology, Tsinghua University, Beijing, China
| | - Josep Gómez
- Department of Intensive Care Medicine, Joan XXIII University Hospital in Tarragona, Tarragona, Catalunya, Spain.,Pere Virgili Health Research Institute, Reus, Catalunya, Spain
| | - Xiaoli Liu
- Laboratory for Computational Physiology, Harvard-MIT Division of Health Sciences and Technology, Cambridge, Massachusetts, USA.,School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Tongbo Liu
- Information Department, Chinese PLA General Hospital, Beijing, China
| | - Wesley Yeung
- Laboratory for Computational Physiology, Harvard-MIT Division of Health Sciences and Technology, Cambridge, Massachusetts, USA.,Department of Cardiology, National University Health System, Singapore
| | - Patrick Thoral
- Department of Intensive Care Medicine, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Zhengbo Zhang
- Medical Innovation Research Department, Chinese PLA General Hospital, Beijing, China
| | - María Bodí Saera
- Department of Intensive Care Medicine, Joan XXIII University Hospital in Tarragona, Tarragona, Catalunya, Spain.,Pere Virgili Health Research Institute, Reus, Catalunya, Spain
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Harvard-MIT Division of Health Sciences and Technology, Cambridge, Massachusetts, USA.,Division of Pulmonary Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Dong S, Li W, Tang ZR, Wang H, Pei H, Yuan B. Development and validation of a novel predictive model and web calculator for evaluating transfusion risk after spinal fusion for spinal tuberculosis: a retrospective cohort study. BMC Musculoskelet Disord 2021; 22:825. [PMID: 34563170 PMCID: PMC8466716 DOI: 10.1186/s12891-021-04715-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/07/2021] [Indexed: 01/28/2023] Open
Abstract
Objectives The incidence and adverse events of postoperative blood transfusion in spinal tuberculosis (TB) have attracted increasing attention. Our purpose was to develop a prediction model to evaluate blood transfusion risk after spinal fusion (SF) for spinal TB. Methods Nomogram and machine learning algorithms, support vector machine (SVM), decision tree (DT), multilayer perceptron (MLP), Naive Bayesian (NB), k-nearest neighbors (K-NN) and random forest (RF), were constructed to identified predictors of blood transfusion from all spinal TB cases treated by SF in our department between May 2010 and April 2020. The prediction performance of the models was evaluated by 10-fold cross-validation. We calculated the average AUC and the maximum AUC, then demonstrated the ROC curve with maximum AUC. Results The collected cohort ultimately was consisted of 152 patients, where 56 required allogeneic blood transfusions. The predictors were surgical duration, preoperative Hb, preoperative ABL, preoperative MCHC, number of fused vertebrae, IBL, and anticoagulant history. We obtained the average AUC of nomogram (0.75), SVM (0.62), k-NM (0.65), DT (0.56), NB (0.74), MLP (0.56) and RF (0.72). An interactive web calculator based on this model has been provided (https://drwenleli.shinyapps.io/STTapp/). Conclusions We confirmed seven independent risk factors affecting blood transfusion and diagramed them with the nomogram and web calculator.
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Affiliation(s)
- Shengtao Dong
- Department of Spine Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian, 116021, China
| | - Wenle Li
- Department of Orthopedics, Xianyang Central Hospital, Xianyang, 712000, China
| | - Zhi-Ri Tang
- School of Physics and Technology, Wuhan University, Wuhan, 430072, China
| | - Haosheng Wang
- Department of Orthopaedics, Second Hospital of Jilin University, Changchun, 130000, China
| | - Hao Pei
- Department of Orthopaedic Trauma, Second Affiliated Hospital of Dalian Medical University, Dalian, 116021, China
| | - Bo Yuan
- Department of Reparative and Reconstructive Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian, 116021, China.
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Liu B, Pan J, Zong H, Wang Z. Establishment and Verification of a Perioperative Blood Transfusion Model After Posterior Lumbar Interbody Fusion: A Retrospective Study Based on Data From a Local Hospital. Front Surg 2021; 8:695274. [PMID: 34527694 PMCID: PMC8435709 DOI: 10.3389/fsurg.2021.695274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/27/2021] [Indexed: 01/28/2023] Open
Abstract
Objective: We aimed to analyze the related risk factors for blood transfusion and establish a blood transfusion risk model during the per-ioperative period of posterior lumbar interbody fusion (PLIF). It could provide a reference for clinical prevention and reduction of the risk of blood transfusion during the peri-operative period. Methods: We retrospectively analyzed 4,378 patients who underwent PLIF in our hospital. According to whether they were transfused blood or not, patients were divided into the non-blood transfusion group and the blood transfusion group. We collected variables of each patient, including age, sex, BMI, current medical history, past medical history, surgical indications, surgical information, and preoperative routine blood testing. We randomly divide the whole population into training group and test group according to the ratio of 4:1. We used the multivariate regression analyses get the independent predictors in the training set. The nomogram was established based on these independent predictors. Then, we used the AUC, calibration curve and DCA to evaluate the nomogram. Finally, we verified the performance of the nomogram in the validation set. Results: Three or more lumbar fusion segments, preoperative low hemoglobin, with hypertension, lower BMI, and elder people were risk factors for blood transfusion. For the training and validation sets, the AUCs of the nomogram were 0.881 (95% CI: 0.865-0.903) and 0.890 (95% CI: 0.773-0.905), respectively. The calibration curve shows that the nomogram is highly consistent with the actual observed results. The DCA shows that the nomogram has good clinical application value. The AUC of the nomogram is significantly larger than the AUCs of independent risk factors in the training and validation set. Conclusion: Three or more lumbar fusion segments, preoperative low hemoglobin, with hypertension, lower BMI, and elder people are associated with blood transfusion during the peri-operative period. Based on these factors, we established a blood transfusion nomogram and verified that it can be used to assess the risk of blood transfusion after PLIF. It could help clinicians to make clinical decisions and reduce the incidence of peri-operative blood transfusion.
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Affiliation(s)
- Bo Liu
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Junpeng Pan
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hui Zong
- Department of Neurology, The People's Hospital of Qingyun, Dezhou, China
| | - Zhijie Wang
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Perioperative red blood cell transfusion is associated with poor functional outcome and overall survival in patients with newly diagnosed glioblastoma. Neurosurg Rev 2021; 45:1327-1333. [PMID: 34480318 PMCID: PMC8976811 DOI: 10.1007/s10143-021-01633-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 06/13/2021] [Accepted: 06/21/2021] [Indexed: 01/28/2023]
Abstract
The influence of perioperative red blood cell (RBC) transfusion on prognosis of glioblastoma patients continues to be inconclusive. The aim of the present study was to evaluate the association between perioperative blood transfusion (PBT) and overall survival (OS) in patients with newly diagnosed glioblastoma. Between 2013 and 2018, 240 patients with newly diagnosed glioblastoma underwent surgical resection of intracerebral mass lesion at the authors’ institution. PBT was defined as the transfusion of RBC within 5 days from the day of surgery. The impact of PBT on overall survival was assessed using Kaplan–Meier analysis and multivariate regression analysis. Seventeen out of 240 patients (7%) with newly diagnosed glioblastoma received PBT. The overall median number of blood units transfused was 2 (95% CI 1–6). Patients who received PBT achieved a poorer median OS compared to patients without PBT (7 versus 18 months; p < 0.0001). Multivariate analysis identified “age > 65 years” (p < 0.0001, OR 6.4, 95% CI 3.3–12.3), “STR” (p = 0.001, OR 3.2, 95% CI 1.6–6.1), “unmethylated MGMT status” (p < 0.001, OR 3.3, 95% CI 1.7–6.4), and “perioperative RBC transfusion” (p = 0.01, OR 6.0, 95% CI 1.5–23.4) as significantly and independently associated with 1-year mortality. Perioperative RBC transfusion compromises survival in patients with glioblastoma indicating the need to minimize the use of transfusions at the time of surgery. Obeying evidence-based transfusion guidelines provides an opportunity to reduce transfusion rates in this population with a potentially positive effect on survival.
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Fazal MA, Shah A, Mohamed FY, Hassan R. Postoperative haemoglobin estimation in elderly hip fractures. Aging Med (Milton) 2021; 4:175-179. [PMID: 34553114 PMCID: PMC8444953 DOI: 10.1002/agm2.12172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE The purpose of our study was to analyze the effect of postoperative hemoglobin check on the day of surgery and 1 day postoperatively in elderly hip fracture patients with an aim to determine an optimum timing of postoperative hemoglobin check. MATERIAL AND METHODS A retrospective study of 253 patients. Age, Charlson morbidity index, fracture type, time from admission to surgery, type of surgery, preoperative hemoglobin, postoperative hemoglobin, hemoglobin drop, day of postoperative hemoglobin measurement, blood transfusion, length of hospital stay, and 30-day mortality were recorded. RESULTS One hundred and sixty-three patients (Group I) had postoperative hemoglobin check on the first postoperative day and 90 patients (Group II) on the day of surgery. Mean age in Group I was 82 years and 80 years in Group II. Mean Charlson morbidity index for Group I was 5.9 and Group II was 5.7. There was a significantly higher hemoglobin drop in Group I (P < 0.05) but no difference in blood transfusion requirement, length of stay, or 30-day mortality in the two groups (P > 0.05). CONCLUSION Our results suggest that postoperative hemoglobin measurement on the day of surgery is not a true reflection of hemoglobin drop and recommend estimation of hemoglobin on the first postoperative day.
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Affiliation(s)
- Muhammad Ali Fazal
- Department of Trauma and OrthopaedicsRoyal Free London NHS Foundation TrustLondonUK
| | - Anand Shah
- Department of Trauma and OrthopaedicsRoyal Free London NHS Foundation TrustLondonUK
| | - Foad Y. Mohamed
- Department of Trauma and OrthopaedicsRoyal Free London NHS Foundation TrustLondonUK
| | - Raza Hassan
- Department of Trauma and OrthopaedicsRoyal Free London NHS Foundation TrustLondonUK
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Wang X, Xu T, Wang R, Wang P, Jin S, Tong P, Lv S. Perioperative Blood Loss Can Be Reduced If Total Knee Arthroplasty Was Performed in the Si Hour-Period, Compared with the Wei Hour-Period: A Retrospective Cohort Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:9990413. [PMID: 34462644 PMCID: PMC8403044 DOI: 10.1155/2021/9990413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/17/2021] [Accepted: 08/10/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of performing primary unilateral total knee arthroplasty (TKA) in the "Si hour-period" meaning 09:00 a.m. to 11:00 a.m. (one of the 12 two-hour periods into which the day was traditionally divided, each being given the name of one of the 12 earthly branches), compared with the "Wei hour-period" (13:00-15:00). METHODS Patient documentations were studied for those who underwent a primary unilateral TKA performed by the same surgical team with a tourniquet between January 2018 and January 2021 at our medical center. Eighty-four patients were enrolled and assigned into group A (in Si hour-period) and group B (in Wei hour-period). The main outcomes were total blood cell loss (TBL), hidden blood loss (HBL), visible blood loss (VBL), maximum hemoglobin (Hb) drop, and transfusion rate. Secondary outcomes were length of hospital stay (LOS), postoperative femorotibial mechanical axis (FTMA), FTMA correction, platelet count, plasma D-dimer (D-D), prothrombin time (PT), international normalized ratio (INR), and the incidence of postoperative complications. RESULTS Group A showed statistical significance lower at the mean TBL, the mean HBL, and the maximum Hb drop (95% CI: -352.8 to -46.1,P=0.011, 95% CI: -348.0 to -40.1,P=0.014, and 95% CI: -9.5 to -0.7,P=0.023, respectively) after TKA than group B. The postoperative platelet count of group A was more significant than that of group B (95% CI:3.1 to 52.9, P=0.028). The VBL, transfusion rate, the LOS, postoperative FTMA, FTMA correction, plasma D-D, PT, INR, and the incidence of postoperative complications (wound complications, calf muscular vein thrombosis, infection, pulmonary embolism, and deep vein thrombosis) were similar between the two groups (P > 0.05, respectively). CONCLUSION Our study shows that blood loss can be reduced when TKA is performed in the "Si hour-period," which may be due to increasing platelet count, and postoperative complications did not increase, compared with the Wei hour-period. We recommend that the selective operation, such as TKA, should be performed in the "Si hour-period" in clinical practice between the two hour-period.
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Affiliation(s)
- Xiaojian Wang
- The First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Ting Xu
- The Third Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Rui Wang
- The First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Penghe Wang
- The First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Shuaijie Jin
- The First Clinical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Peijian Tong
- The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Shuaijie Lv
- The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Foster M, Presseau J, Podolsky E, McIntyre L, Papoulias M, Brehaut JC. How well do critical care audit and feedback interventions adhere to best practice? Development and application of the REFLECT-52 evaluation tool. Implement Sci 2021; 16:81. [PMID: 34404449 PMCID: PMC8369748 DOI: 10.1186/s13012-021-01145-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/24/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Healthcare Audit and Feedback (A&F) interventions have been shown to be an effective means of changing healthcare professional behavior, but work is required to optimize them, as evidence suggests that A&F interventions are not improving over time. Recent published guidance has suggested an initial set of best practices that may help to increase intervention effectiveness, which focus on the "Nature of the desired action," "Nature of the data available for feedback," "Feedback display," and "Delivering the feedback intervention." We aimed to develop a generalizable evaluation tool that can be used to assess whether A&F interventions conform to these suggestions for best practice and conducted initial testing of the tool through application to a sample of critical care A&F interventions. METHODS We used a consensus-based approach to develop an evaluation tool from published guidance and subsequently applied the tool to conduct a secondary analysis of A&F interventions. To start, the 15 suggestions for improved feedback interventions published by Brehaut et al. were deconstructed into rateable items. Items were developed through iterative consensus meetings among researchers. These items were then piloted on 12 A&F studies (two reviewers met for consensus each time after independently applying the tool to four A&F intervention studies). After each consensus meeting, items were modified to improve clarity and specificity, and to help increase the reliability between coders. We then assessed the conformity to best practices of 17 critical care A&F interventions, sourced from a systematic review of A&F interventions on provider ordering of laboratory tests and transfusions in the critical care setting. Data for each criteria item was extracted by one coder and confirmed by a second; results were then aggregated and presented graphically or in a table and described narratively. RESULTS In total, 52 criteria items were developed (38 ratable items and 14 descriptive items). Eight studies targeted lab test ordering behaviors, and 10 studies targeted blood transfusion ordering. Items focused on specifying the "Nature of the Desired Action" were adhered to most commonly-feedback was often presented in the context of an external priority (13/17), showed or described a discrepancy in performance (14/17), and in all cases it was reasonable for the recipients to be responsible for the change in behavior (17/17). Items focused on the "Nature of the Data Available for Feedback" were adhered to less often-only some interventions provided individual (5/17) or patient-level data (5/17), and few included aspirational comparators (2/17), or justifications for specificity of feedback (4/17), choice of comparator (0/9) or the interval between reports (3/13). Items focused on the "Nature of the Feedback Display" were reported poorly-just under half of interventions reported providing feedback in more than one way (8/17) and interventions rarely included pilot-testing of the feedback (1/17 unclear) or presentation of a visual display and summary message in close proximity of each other (1/13). Items focused on "Delivering the Feedback Intervention" were also poorly reported-feedback rarely reported use of barrier/enabler assessments (0/17), involved target members in the development of the feedback (0/17), or involved explicit design to be received and discussed in a social context (3/17); however, most interventions clearly indicated who was providing the feedback (11/17), involved a facilitator (8/12) or involved engaging in self-assessment around the target behavior prior to receipt of feedback (12/17). CONCLUSIONS Many of the theory-informed best practice items were not consistently applied in critical care and can suggest clear ways to improve interventions. Standardized reporting of detailed intervention descriptions and feedback templates may also help to further advance research in this field. The 52-item tool can serve as a basis for reliably assessing concordance with best practice guidance in existing A&F interventions trialed in other healthcare settings, and could be used to inform future A&F intervention development. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Madison Foster
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.,School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON, K1N 6N5, Canada
| | - Eyal Podolsky
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.,Department of Critical Care Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Maria Papoulias
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Jamie C Brehaut
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada. .,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.
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Yue R, Yang M, Deng X, Zhang P. Allogeneic Red Blood Cell Transfusion Rate and Risk Factors After Hemiarthroplasty in Elderly Patients With Femoral Neck Fracture. Front Physiol 2021; 12:701467. [PMID: 34393821 PMCID: PMC8358805 DOI: 10.3389/fphys.2021.701467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/05/2021] [Indexed: 01/28/2023] Open
Abstract
Objective This study aimed to determine the rate and risk factors of allogeneic red blood cell transfusions (ABT) after hemiarthroplasty (HA) in elderly patients with femoral neck fracture (FNF). Methods The subjects of the study were elderly patients (≥65 years old) who were admitted to the geriatric trauma orthopedics ward of Beijing Jishuitan Hospital between March 2018 and June 2019 for HA treatment due to an FNF. The perioperative data were collected retrospectively, and univariate and multivariate stepwise logistic regression analyses were performed to determine the post-operative ABT rate and its risk factors. Results There were 445 patients in the study, of whom 177 (39.8%) received ABT after surgery. Multivariate stepwise logistic regression analysis showed that preoperative low hemoglobin (Hb), high intraoperative blood loss (IBL), advanced age, and a low body mass index (BMI) are independent risk factors of ABT after HA in elderly FNF patients. Conclusion ABT after HA is a common phenomenon in elderly patients with FNF. Their post-operative ABT needs are related to preoperative low Hb, high IBL, advanced age, and low BMI. Therefore, ABT can be reduced by taking these factors into account. When the same patient had three risk factors (preoperative low hemoglobin, advanced age, and low BMI), the risk of ABT was very high (78.3%). Also, when patients have two risk factors of preoperative low hemoglobin and low BMI, the risk of ABT was also high (80.0%).
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Affiliation(s)
- Rui Yue
- Department of Cadre Health Care, Beijing Jishuitan Hospital, Beijing, China
| | - Minghui Yang
- Department of Traumatic Orthopedics, Beijing Jishuitan Hospital, Beijing, China
| | - Xiaohui Deng
- Department of Cadre Health Care, Beijing Jishuitan Hospital, Beijing, China
| | - Ping Zhang
- Department of Cadre Health Care, Beijing Jishuitan Hospital, Beijing, China
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Impact of Postoperative Complications on Long-Term Survival of Hepatocellular Carcinoma Patients After Liver Resection. Int Surg 2021. [DOI: 10.9738/intsurg-d-21-00010.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objective
The effect of postoperative complications including red blood cell transfusion (BT) on long-term survival for hepatocellular carcinoma (HCC) is unknown. The purpose of this study was to define the relationship between postoperative complications and long-term survival in patients with HCC.
Methods
Postoperative complications of 1251 patients who underwent curative liver resection for HCC were classified, and their recurrence-free survival (RFS) and cumulative overall survival (OS) were investigated.
Results
Any complications occurred in 503 patients (40%). Five-year RFS and 5-year OS in the complication group were 21% and 56%, respectively, significantly lower than the respective values of 32% (P < 0.001) and 68% (P < 0.001) in the no-complication group (n = 748). Complications related to RFS were postoperative BT [hazard ratio (HR): 1.726, 95% confidence interval (CI): 1.338–2.228, P < 0.001], pleural effusion (HR: 1.434, 95% CI: 1.200–1.713, P < 0.001) using Cox proportional-hazard model. Complications related to OS were postoperative BT (HR: 1.843, 95% CI: 1.380–2.462, P < 0.001), ascites (HR: 1.562, 95% CI: 1.066–2.290, P = 0.022), and pleural effusion (HR: 1.421, 95% CI: 1.150–1.755, P = 0.001).
Conclusions
Postoperative complications were factors associated with poor long-term survival. Postoperative BT and pleural effusion were noticeable complications that were prognostic factors for both RFS and OS.
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