801
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Lozano M, Cid J. Transfusion medicine as of 2014. F1000PRIME REPORTS 2015; 6:105. [PMID: 25580259 PMCID: PMC4229729 DOI: 10.12703/p6-105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Transfusion of blood components is one of the most common medical treatments, and in spite of the time that has evolved since we started to transfuse blood routinely in the 1930s, there are issues associated with its use that we are still trying to improve. Issues such as when to transfuse and adverse effects associated with the transfusion are fields where new evidence is being generated that ideally should help us to indicate when and what to transfuse to the patients. The recognition that the evidence generated in randomized control trials was not widely applied to guide the indication of the transfusion of blood components has provoked the development of initiatives that try to reduce its unnecessary usage. Those initiatives, grouped under the name of patient blood management, have represented a significant paradigm change, and a growing number of activities in this field are performed in health-care facilities around the world. This article tries to summarize the latest publications in those fields.
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802
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Bloom S, Kemp W, Lubel J. Portal hypertension: pathophysiology, diagnosis and management. Intern Med J 2015; 45:16-26. [DOI: 10.1111/imj.12590] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/27/2014] [Indexed: 12/19/2022]
Affiliation(s)
- S. Bloom
- Gastroenterology and Hepatology; Eastern Health; Melbourne Victoria Australia
| | - W. Kemp
- Gastroenterology and Hepatology; Alfred Health; Melbourne Victoria Australia
| | - J. Lubel
- Gastroenterology and Hepatology; Eastern Health; Melbourne Victoria Australia
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803
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Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med 2015; 10:1-7. [PMID: 25044190 DOI: 10.1002/jhm.2236] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 06/11/2014] [Accepted: 06/16/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Best practice alerts (BPAs) provide clinical decision support (CDS) at the point of care to reduce unnecessary blood product transfusions, yet substantial transfusions continue outside of recommended guidelines. OBJECTIVE To understand why providers order blood transfusions outside of recommended guidelines despite interruptive alerts. DESIGN Retrospective review. SETTING Tertiary care hospital. PARTICIPANTS Inpatient healthcare providers. INTERVENTION Provider-BPA interaction data were collected from January 2011 to August 2012 from the hospital electronic medical record. MEASUREMENTS Provider (free-text) responses to blood transfusion BPA prompts were independently reviewed and categorized by 2 licensed physicians, with agreement assessed by χ(2) analysis and kappa scoring. RESULTS Rationale for overriding blood transfusion BPAs was highly diverse, acute bleeding being the most common (>34%), followed by protocolized behaviors on specialty services (up to 26%), to "symptomatic" anemia (11%-12%). Many providers transfused in anticipation of surgical or procedural intervention (10%-15%) or imminent hospital discharge (2%-5%). Resident physicians represented the majority (55%) of providers interacting with BPAs. CONCLUSION Providers interacting with BPAs (primarily residents and midlevel providers) often do not have the negotiating power to change ordering behavior. Protocolized behaviors, unlikely to be influenced by BPAs, are among the most commonly cited reasons for transfusing outside of guidelines. Symptomatic anemia is a common, albeit subjective, indication cited for blood transfusion. With a wide swath of individually uncommon rationales for transfusion behavior, secondary use of electronic medical record databases and integrated CDS tools are important to efficiently analyze common practice behaviors.
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Affiliation(s)
- Jonathan H Chen
- Department of Medicine, Stanford University Medical Center, Stanford, California
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804
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Abstract
Liver disease is characterized by changes in all phases of hemostasis. These hemostatic alterations were long considered to predispose patients with liver disease towards a bleeding tendency, as they are associated with prolonged conventional coagulation tests. However, these patients may also suffer from thrombotic complications, and we now know that the hemostatic system in patient with liver disease is, in fact, in a rebalanced state. In this review we discuss the concept of rebalanced hemostasis and its implications for clinical management of patients with liver disease. For instance, there is no evidence that the use of prophylactic blood product transfusion prior to invasive procedures reduces bleeding risk. Clinicians should also be aware of the possibility of thrombosis occurring in patients with a liver disease, and regular thrombosis prophylaxis should not be withheld in these patients.
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Affiliation(s)
- Wilma Potze
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, BA44, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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805
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806
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Boysen SR. Gastrointestinal Hemorrhage. SMALL ANIMAL CRITICAL CARE MEDICINE 2015. [PMCID: PMC7152172 DOI: 10.1016/b978-1-4557-0306-7.00119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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807
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Hshieh TT, Kaung A, Hussain S, Curry MP, Sundaram V. The international normalized ratio does not reflect bleeding risk in esophageal variceal hemorrhage. Saudi J Gastroenterol 2015; 21:254-8. [PMID: 26228370 PMCID: PMC4542425 DOI: 10.4103/1319-3767.161646] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND/AIMS The international normalized ratio (INR) has not been validated as a predictor of bleeding risk in cirrhotics. The aim of this study was to determine whether elevation in the INR correlated with risk of esophageal variceal hemorrhage and whether correction of the INR prior to endoscopic therapy affects failure to control bleeding. PATIENTS AND METHODS Patient records were retrospectively reviewed from January 1, 2000 to December 31, 2010. Cases were cirrhotics admitted to the hospital due to bleeding esophageal varices. Controls were cirrhotics with a history of non-bleeding esophageal varices admitted with ascites or encephalopathy. All variceal bleeders were treated with octreotide, antibiotics, and band ligation. Failure to control bleeding was defined according to the Baveno V criteria. RESULTS We analyzed 74 cases and 74 controls. The mean INR at presentation was lower in those with bleeding varices compared to non-bleeders (1.61 vs 1.74, P = 0.03). Those with bleeding varices had higher serum sodium (136.1 vs 133.8, P = 0.02), lower hemoglobin (9.59 vs 11.0, P < 0.001), and lower total bilirubin (2.47 vs 5.50, P < 0.001). Multivariable logistic regression showed total bilirubin to inversely correlate with bleeding (OR = 0.74). Bleeders received a mean of 1.14 units of fresh frozen plasma (FFP) prior to endoscopy (range 0-11 units). Of the 14 patients (20%) with failure to control bleeding, median INR (1.8 vs 1.5, P = 0.02) and median units of FFP transfused (2 vs 0, P = 0.01) were higher than those with hemostasis after the initial endoscopy. CONCLUSIONS The INR reflects liver dysfunction, not bleeding risk. Correction of INR with FFP has little effect on hemostasis.
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Affiliation(s)
- Tammy T. Hshieh
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Aung Kaung
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US
| | - Syed Hussain
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| | - Michael P. Curry
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Vinay Sundaram
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US,Address for correspondence: Dr. Vinay Sundaram, 8900 Beverly Boulevard, Los Angeles, CA 90048. E-mail:
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808
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809
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Transfusion of Blood and Blood Products. EVIDENCE-BASED CRITICAL CARE 2015. [PMCID: PMC7124112 DOI: 10.1007/978-3-319-11020-2_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In transfusion medicine, several blood products can be prepared and used as replacement therapy; however, four of these products are more commonly used in general practice: RBCs, fresh frozen plasma (FFP), platelets and cryoprecipitate. RBC transfusions are mainly administered to improve tissue oxygenation in cases of anaemia or acute blood loss due to trauma or surgery. FFP, platelets and cryoprecipitate are used for the prevention and treatment of bleeding.
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810
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Park WG, Shaheen NJ, Cohen J, Pike IM, Adler DG, Inadomi JM, Laine LA, Lieb JG, Rizk MK, Sawhney MS, Wani S. Quality indicators for EGD. Gastrointest Endosc 2015; 81:17-30. [PMID: 25480101 DOI: 10.1016/j.gie.2014.07.057] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 02/07/2023]
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811
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Transfusion de concentrés globulaires en réanimation : moins, c’est mieux ! MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-014-1015-5] [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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812
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Kujovich JL. Coagulopathy in liver disease: a balancing act. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:243-9. [PMID: 26637729 DOI: 10.1182/asheducation-2015.1.243] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Liver disease results in complex alterations of all 3 phases of hemostasis. It is now recognized that hemostasis is rebalanced in chronic liver disease. The fall in clotting factor levels is accompanied by a parallel fall in anticoagulant proteins. High von Willebrand factor levels counteract defects in primary hemostasis. Conventional coagulation tests do not fully reflect the derangement in hemostasis and do not accurately predict the risk of bleeding. Global coagulation assays (thrombin generation, thromboelastography) reflect the interaction between procoagulant factors, anticoagulant factors, platelets, and the fibrinolytic system and show promise for assessing bleeding risk and guiding therapy. These assays are not yet commercially approved or validated. Prevention of bleeding should not be aimed at correcting conventional coagulation tests. Thrombopoietin receptor agonists were shown to increase the platelet count in cirrhotic patients undergoing invasive procedures but may increase the risk of thrombosis. Rebalanced hemostasis in liver disease is precarious and may be tipped toward hemorrhage or thrombosis depending on coexisting circumstantial risk factors. Bacterial infection may impair hemostasis in cirrhosis by triggering the release of endogenous heparinoids. There are no evidence-based guidelines for hemostatic therapy of acute hemorrhage in liver disease. There is currently inadequate evidence to support the use of recombinant FVIIa, prothrombin complex concentrates, or tranexamic acid in acute variceal or other hemorrhage.
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Affiliation(s)
- Jody L Kujovich
- Oregon Health & Science University, Pediatric Hematology/Oncology, Oregon Hemophilia Center, Portland, OR
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813
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Iyer SS, Shah J. Red blood cell transfusion strategies and Maximum surgical blood ordering schedule. Indian J Anaesth 2014; 58:581-9. [PMID: 25535420 PMCID: PMC4260304 DOI: 10.4103/0019-5049.144660] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Blood transfusion is one of the practices that is in vogue because it expands blood volume and purportedly improves the oxygen carrying capacity. Despite this supposed physiological benefit, paradoxically, both anaemia and transfusion are independently associated with organ injury and increased morbidity. Historically, transfusion was used to maintain blood haemoglobin concentration above 10 g/dL and a haematocrit above 30%. There is now a greater emphasis on interventions to reduce the use of transfusion as it is a scarce and expensive resource with many serious adverse effects. Institutional maximum surgical blood ordering schedule algorithm developed with data analysis and consensus of surgeons, anaesthesiologists and blood banks can reduce the overuse of blood. A PubMed search was performed with search words/combination of words 'erythrocyte transfusion, adverse effects, economics, mortality, therapy, therapeutic use and utilisation'. Search yielded a total of 1541 articles that were screened for clinical relevance for the purpose of this review.
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Affiliation(s)
- Shivakumar S Iyer
- Department of Critical Care, Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
| | - Jignesh Shah
- Department of Critical Care, Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
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814
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Affiliation(s)
- Jv Divatia
- Section Editor (Critical Care), IJA, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India. E-mail:
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815
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Abstract
Transfusion of blood products carries certain inherent risks and hence it should be undertaken only if it improves patient outcome. A review of the literature was carried out to find the indications and effects of transfusion on morbidity and mortality of patients. There is high-quality evidence showing that restrictive blood transfusion with a transfusion trigger of haemoglobin of 7-8 g/dl or the presence of symptoms of anaemia is safe and not associated with increased mortality compared with liberal transfusion. Thus, restrictive strategy is strongly recommended in surgical and critically ill-patients. There is moderate evidence for the use of plasma and platelet transfusion in patients receiving massive blood transfusion. There is not enough evidence to support the use of plasma, platelets and cryoprecipitate in any other clinical setting. Retrospective studies show improved survival after high plasma and platelet to red blood cell ratio of 1:1:1, but this has not been confirmed in randomised trials.
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Affiliation(s)
| | - Ln Yaddanapudi
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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816
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Yazer MH, Triulzi DJ. Things aren't always as they seem: what the randomized trials of red blood cell transfusion tell us about adverse outcomes (CME). Transfusion 2014; 54:3243-6; quiz 3242. [DOI: 10.1111/trf.12706] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/08/2014] [Accepted: 03/14/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Mark H. Yazer
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
- Department of Pathology; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Darrell J. Triulzi
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
- Department of Pathology; University of Pittsburgh; Pittsburgh Pennsylvania
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817
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Trentino KM, Farmer SL, Swain SG, Burrows SA, Hofmann A, Ienco R, Pavey W, Daly FFS, Van Niekerk A, Webb SAR, Towler S, Leahy MF. Increased hospital costs associated with red blood cell transfusion. Transfusion 2014; 55:1082-9. [PMID: 25488623 DOI: 10.1111/trf.12958] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 08/26/2014] [Accepted: 10/17/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusion is independently associated in a dose-dependent manner with increased intensive care unit stay, total hospital length of stay, and hospital-acquired complications. Since little is known of the cost of these transfusion-associated adverse outcomes our aim was to determine the total hospital cost associated with RBC transfusion and to assess any dose-dependent relationship. STUDY DESIGN AND METHODS A retrospective cohort study of all multiday acute care inpatients discharged from a five hospital health service in Western Australia between July 2011 and June 2012 was conducted. Main outcome measures were incidence of RBC transfusion and mean inpatient hospital costs. RESULTS Of 89,996 multiday, acute care inpatient discharges, 4805 (5.3%) were transfused at least 1 unit of RBCs. After potential confounders were adjusted for, the mean inpatient cost was 1.83 times higher in the transfused group compared with the nontransfused group (95% confidence interval, 1.78-1.89; p < 0.001). The estimated total hospital-associated cost of RBC transfusion in this study was AUD $77 million (US $72 million), representing 7.8% of total hospital expenditure on acute care inpatients. There was a significant dose-dependent association between the number of RBC units transfused and increased costs after adjusting for confounders. CONCLUSION RBC transfusions were independently associated with significantly higher hospital costs. The financial implication to hospital budgets will assist in prioritizing areas to reduce the rate of RBC transfusions and in implementing patient blood management programs.
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Affiliation(s)
- Kevin M Trentino
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia
| | - Shannon L Farmer
- School of Surgery, University of Western Australia, Perth, Western Australia.,Centre for Population Health Research, Curtin University, Perth, Western Australia
| | - Stuart G Swain
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia
| | - Sally A Burrows
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - Axel Hofmann
- School of Surgery, University of Western Australia, Perth, Western Australia.,Centre for Population Health Research, Curtin University, Perth, Western Australia
| | - Rinaldo Ienco
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia
| | - Warren Pavey
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia
| | - Frank F S Daly
- Royal Perth Group, South Metropolitan Health Service, Perth, Western Australia.,Center for Clinical Research in Emergency Medicine, University of Western Australia, Perth, Western Australia
| | - Anton Van Niekerk
- Department of Anaesthesiology, Fremantle Hospital, Fremantle, Western Australia
| | - Steven A R Webb
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria
| | - Simon Towler
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia.,Service 4, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Michael F Leahy
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia.,Department of Haematology, PathWest, Fremantle Hospital, Fremantle, Western Australia
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818
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Abstract
Abstract
Substantial progress has been made in our understanding of the risks and benefits of RBC transfusion through the performance of large clinical trials. More than 7000 patients have been enrolled in trials randomly allocating patients to higher transfusion thresholds (∼9-10 g/dL), referred to as liberal transfusion, or lower transfusion thresholds (∼7-8 g/dL), referred to as restrictive transfusion. The results of most of the trials suggest that a restrictive transfusion strategy is safe and, in some cases, superior to a liberal transfusion strategy. However, in patients with myocardial infarction, brain injury, stroke, or hematological disorders, more large trials are needed because preliminary evidence suggests that liberal transfusion might be beneficial or trials have not been performed at all.
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819
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Upper gastrointestinal bleeding: patient presentation, risk stratification, and early management. Gastroenterol Clin North Am 2014; 43:665-75. [PMID: 25440918 DOI: 10.1016/j.gtc.2014.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The established quality indicators for early management of upper gastrointestinal (GI) hemorrhage are based on rapid diagnosis, risk stratification, and early management. Effective preendoscopic treatment may improve survivability of critically ill patients and improve resource allocation for all patients. Accurate risk stratification helps determine the need for hospital admission, hemodynamic monitoring, blood transfusion, and endoscopic hemostasis before esophagogastroduodenoscopy (EGD) via indirect measures such as laboratory studies, physiologic data, and comorbidities. Early management before the definitive EGD is essential to improving outcomes for patients with upper GI bleeding.
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820
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Liver: Can we identify failure to control acute variceal bleeding? Nat Rev Gastroenterol Hepatol 2014; 11:705-6. [PMID: 25331633 DOI: 10.1038/nrgastro.2014.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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821
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Joubert J, Joubert S, Raubenheimer J, Louw V. The long-term effects of training interventions on transfusion practice: A follow-up audit of red cell concentrate utilisation at Kimberley Hospital, South Africa. Transfus Apher Sci 2014; 51:25-32. [DOI: 10.1016/j.transci.2014.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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822
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Yeh DD. Packed red blood cell transfusions in the intensive care unit: treating the patient or the doctor? ANZ J Surg 2014; 84:202-3. [PMID: 24812705 DOI: 10.1111/ans.12529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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823
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Teng W, Chen WT, Ho YP, Jeng WJ, Huang CH, Chen YC, Lin SM, Chiu CT, Lin CY, Sheen IS. Predictors of mortality within 6 weeks after treatment of gastric variceal bleeding in cirrhotic patients. Medicine (Baltimore) 2014; 93:e321. [PMID: 25546678 PMCID: PMC4602601 DOI: 10.1097/md.0000000000000321] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Acute gastric variceal bleeding (GVB) is a catastrophic problem and accounts for one of the major causes of death in cirrhotic patients. Although, N-butyl cyanoacrylate (NBC) has been shown to control bleeding effectively, it still carries up high mortality rate. This study aimed to find the predictors of mortality within 6 weeks after emergent endoscopic treatment with NBC injection. This retrospective study recruited patients with acute GVB after emergent endoscopic NBC injection between January 2011 and June 2013 in Linkou Medical Center, Chang Gung Memorial Hospital, Linkou, Taiwan. Logistic regression analysis was applied for predictors of mortality within 6 weeks. Statistical significance was set as P < 0.05. There were 132 patients with acute GVB (83.3% men, median age 51.3 years) with endoscopic NBC injection treatments recruited. Mortality within 6 weeks was noted in 16.7% patients. By multivariate analysis, renal function impairment (odds ratio [OR]: 21.1, 95% confidence interval [CI]: 3.06-146.0, P = 0.002), higher Child-Turcotte-Pugh (CTP) score (OR: 2.49, 95% CI: 1.41-4.38, P = 0.002), higher model for end-stage liver disease (MELD) score (OR: 1.18, 95% CI: 1.03-1.35, P = 0.013), rebleeding within 5 days (OR: 16.4, 95% CI: 3.36-79.7, P = 0.001), and acute on chronic liver failure (ACLF) (OR: 4.67, 95% CI: 1.62-13.33, P = 0.004) were independent predictors of mortality within 6 weeks. A MELD score of ≥ 18 was associated with Area Under the Receiver Operating Characteristic (AUROC) of 0.79 (P < 0.001, 95% CI: 0.69-0.90) and a CTP score of ≥ 9 with AUROC of 0.85 (P < 0.001, 95% CI: 0.76-0.94) for determining 6 weeks mortality. Impaired renal function, deteriorated liver function with CTP score ≥ 9 as well as MELD score ≥ 18, rebleeding within 5 days, and ACLF are independent predictors of mortality.
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Affiliation(s)
- Wei Teng
- From the Department of Gastroenterology and Hepatology (WT, W-TC, Y-PH, W-JJ, C-HH, Y-CC, S-ML, C-TC, C-YL, I-SS); Division of Hepatology (W-TC, W-JJ, C-HH, Y-CC, S-ML, C-YL, I-SS), Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou; and Chang Gung University (Y-PH, S-ML, C-TC, C-YL), Taoyuan, Taiwan
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824
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825
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Goodnough LT, Shah N. The next chapter in patient blood management: real-time clinical decision support. Am J Clin Pathol 2014; 142:741-7. [PMID: 25389326 DOI: 10.1309/ajcp4w5ccfozujfu] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Blood transfusion was identified by the American Medical Association as one of the top five most frequently overused therapies. Utilization review has been required by accreditation agencies, but retrospective review has been ineffective due to labor-intense resources applied to only a sampling of transfusion events. Electronic medical records have allowed clinical decision support (CDS) to occur via a best practices alert at the critical decision point concurrently with physician order entry. METHODS We review emerging strategies for improving blood utilization. RESULTS Implementation of CDS at our institution decreased the percentage of transfusions in patients with a hemoglobin level of more than 8 g/dL from 60% to less than 30%. Annual RBC transfusions were reduced by 24%, despite concurrent increases in patient discharge volumes and case mix complexity. This resulted in acquisition costs savings (direct blood product purchase costs) of $6.4 million over 4 years. CONCLUSIONS We have been able to significantly reduce inappropriate blood transfusions and related costs through an educational initiative coupled with real-time CDS. In deriving increased value out of health care, CDS can be applied to a number of overuse measures in laboratory testing, radiology, and therapy such as antibiotics, as outlined by the American Board of Internal Medicine's Choosing Wisely campaign.
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Affiliation(s)
- Lawrence Tim Goodnough
- Department of Pathology, Stanford University, Stanford, CA
- Department of Medicine, Stanford University, Stanford, CA
| | - Neil Shah
- Department of Pathology, Stanford University, Stanford, CA
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826
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827
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Pathak R, Bhatt VR, Karmacharya P, Aryal MR, Alweis R. Trends in blood-product transfusion among inpatients in the United States from 2002 to 2011: data from the Nationwide Inpatient Sample. J Hosp Med 2014; 9:800-1. [PMID: 25100306 DOI: 10.1002/jhm.2248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/17/2014] [Accepted: 07/22/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Ranjan Pathak
- Department of Internal Medicine, Reading Health System, West Reading, Pennsylvania
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828
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Shah A, Stanworth SJ, McKechnie S. Evidence and triggers for the transfusion of blood and blood products. Anaesthesia 2014; 70 Suppl 1:10-9, e3-5. [DOI: 10.1111/anae.12893] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 01/28/2023]
Affiliation(s)
- A. Shah
- Adult Intensive Care Unit; John Radcliffe Hospital; Oxford UK
| | - S. J. Stanworth
- Department of Haematology; John Radcliffe Hospital; Oxford UK
| | - S. McKechnie
- Department of Anaesthesia and Intensive Care; John Radcliffe Hospital; Oxford UK
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829
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Abstract
Acute variceal bleeding (AVB) is a milestone event for patients with portal hypertension. Esophageal varices bleed because of an increase in portal pressure that causes the variceal wall to rupture. AVB in a patient with cirrhosis and portal hypertension is associated with significant morbidity and mortality. The initial management of these patients includes proper resuscitation, antibiotic prophylaxis, pharmacologic therapy with vasoconstrictors, and endoscopic therapy. Intravascular fluid management, timing of endoscopy, and endoscopic technique are key in managing these patients. This article reviews the current endoscopic hemostatic strategies for patients with AVB.
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830
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Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage. Gastroenterol Clin North Am 2014; 43:765-82. [PMID: 25440924 DOI: 10.1016/j.gtc.2014.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute variceal bleeding (AVB) is a potentially life-threatening complication of cirrhosis and portal hypertension. Combination therapy with vasoactive drugs and endoscopic variceal ligation is the first-line treatment in the management of AVB after adequate hemodynamic resuscitation. Short-term antibiotic prophylaxis, early resuscitation, early use of lactulose for prevention of hepatic encephalopathy, targeting of conservative goals for blood transfusion, and application of early transjugular intrahepatic portosystemic shunts in patients with AVB have further improved the prognosis of AVB. This article discusses the epidemiology, diagnosis, and nonendoscopic management of AVB.
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831
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832
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Chin JL, Hisamuddin SH, O'Sullivan A, Chan G, McCormick PA. Thrombocytopenia, Platelet Transfusion, and Outcome Following Liver Transplantation. Clin Appl Thromb Hemost 2014; 22:351-60. [PMID: 25430936 DOI: 10.1177/1076029614559771] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Thrombocytopenia affects patients undergoing liver transplantation. Intraoperative platelet transfusion has been shown to independently influence survival after liver transplantation at 1 and 5 years. We examined the impact of thrombocytopenia and intraoperative platelet transfusion on short-term graft and overall survival after orthotopic liver transplantation (OLT). A total of 399 patients undergoing first OLT were studied. Graft and overall survival in patients with different degrees of thrombocytopenia and with or without intraoperative platelet transfusion were described. The degree of thrombocytopenia prior to OLT did not affect graft or overall survival after transplant. However, graft survival in patients receiving platelets was significantly reduced at 1 year (P= .023) but not at 90 days (P= .093). Overall survival was significantly reduced at both 90 days (P= .040) and 1 year (P= .037) in patients receiving platelets. We conclude that a consistently lower graft and overall survival were observed in patients receiving intraoperative platelet transfusion.
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Affiliation(s)
- Jun Liong Chin
- Liver Unit, St Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | | | - Aoife O'Sullivan
- Blood bank, St Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Grace Chan
- Liver Unit, St Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - P Aiden McCormick
- Liver Unit, St Vincent's University Hospital, University College Dublin, Dublin, Ireland
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833
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Kahan BC, Cro S, Doré CJ, Bratton DJ, Rehal S, Maskell NA, Rahman N, Jairath V. Reducing bias in open-label trials where blinded outcome assessment is not feasible: strategies from two randomised trials. Trials 2014; 15:456. [PMID: 25416527 PMCID: PMC4247637 DOI: 10.1186/1745-6215-15-456] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 11/06/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Blinded outcome assessment is recommended in open-label trials to reduce bias, however it is not always feasible. It is therefore important to find other means of reducing bias in these scenarios. METHODS We describe two randomised trials where blinded outcome assessment was not possible, and discuss the strategies used to reduce the possibility of bias. RESULTS TRIGGER was an open-label cluster randomised trial whose primary outcome was further bleeding. Because of the cluster randomisation, all researchers in a hospital were aware of treatment allocation and so could not perform a blinded assessment. A blinded adjudication committee was also not feasible as it was impossible to compile relevant information to send to the committee in a blinded manner. Therefore, the definition of further bleeding was modified to exclude subjective aspects (such as whether symptoms like vomiting blood were severe enough to indicate the outcome had been met), leaving only objective aspects (the presence versus absence of active bleeding in the upper gastrointestinal tract confirmed by an internal examination).TAPPS was an open-label trial whose primary outcome was whether the patient was referred for a pleural drainage procedure. Allowing a blinded assessor to decide whether to refer the patient for a procedure was not feasible as many clinicians may be reluctant to enrol patients into the trial if they cannot be involved in their care during follow-up. Assessment by an adjudication committee was not possible, as the outcome either occurred or did not. Therefore, the decision pathway for procedure referral was modified. If a chest x-ray indicated that more than a third of the pleural space filled with fluid, the patient could be referred for a procedure; otherwise, the unblinded clinician was required to reach a consensus on referral with a blinded assessor. This process allowed the unblinded clinician to be involved in the patient's care, while reducing the potential for bias. CONCLUSIONS When blinded outcome assessment is not possible, it may be useful to modify the outcome definition or method of assessment to reduce the risk of bias. TRIAL REGISTRATION TRIGGER ISRCTN85757829. Registered 26 July 2012.TAPPS: ISRCTN47845793. Registered 28 May 2012.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, E1 2AB London, UK.
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834
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Abstract
PURPOSE OF REVIEW To provide an update on the recent publications for the management and prognostication of critically ill cirrhotic patients before and after liver transplant. RECENT FINDINGS The CLIF Acute-oN-ChrONicLIver Failure in Cirrhosis (CANONIC) study recently derived an evidence-based definition of acute-on-chronic liver failure (ACLF): hepatic decompensation; organ failure [predefined by the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA)]; and high 28-day mortality rate. Although Sequential Organ Failure Assessment (SOFA) appears to be more accurate in predicting ICU and hospital mortality in ACLF patients, CLIF-SOFA has been derived specifically for critically ill cirrhotic patients, including those not receiving mechanical ventilation. Recent data suggest that a lower transfusion target in esophageal variceal bleeding (<7 g/l) is safe. Newly defined 'cirrhosis-associated acute kidney injury (AKI)' correlates with mortality, organ failure and length of hospital stay. Although the SOFA score appears to perform better than liver-specific scoring systems [Model for End-stage Liver Disease (MELD) and Child-Pugh scores], neither MELD nor SOFA appears to independently predict posttransplant survival; however, correlated with lengths of ICU and hospital stay. For patients declined for liver transplant, palliative care referral and appropriate goals of care are rarely achieved. SUMMARY New definitions for ACLF, cirrhosis-associated AKI and the CLIF-SOFA may improve the discrimination between survivors and nonsurvivors with ACLF. Predicting futility postliver transplant based on preliver transplant severity of illness still poses significant challenges.
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835
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Perioperative blood transfusion in gynecologic oncology surgery: analysis of the National Surgical Quality Improvement Program Database. Gynecol Oncol 2014; 136:65-70. [PMID: 25451693 DOI: 10.1016/j.ygyno.2014.11.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/04/2014] [Accepted: 11/07/2014] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To use a large-scale multi-institutional dataset to quantify the prevalence of packed red blood cell transfusions and examine the associations between transfusion and perioperative outcomes in gynecologic cancer surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant use file was queried for all gynecologic cancer cases between 2010 and 2012. Demographic, preoperative and intraoperative variables were compared between transfusion and non-transfusion groups using chi-squared, Fisher's exact and Wilcoxon rank-sum tests. The primary endpoint was 30-day composite morbidity. Secondary endpoints included composite surgical site infections, mortality and length of stay. RESULTS A total of 8519 patients were analyzed, and 13.8% received a packed red blood cell transfusion. In the multivariate analysis, after adjusting for key clinical and perioperative factors, including preoperative anemia and case magnitude, transfusion was associated with higher composite morbidity (OR = 1.85, 95% CI 1.5-2.24), surgical site infections (OR 1.80, 95% CI 1.39-2.35), mortality (OR 3.38, 95% CI 1.80-6.36) and length of hospital stay (3.02 days v. 7.17 days, P < 0.001). CONCLUSIONS Blood transfusions are associated with increased surgical wound infections, composite morbidity and mortality. Based on our analysis of the NSQIP database, transfusion practices in gynecologic cancer should be scrutinized. Examination of institutional practices and creation of transfusion guidelines for gynecologic malignancies could potentially result in better utilization of blood bank resources and clinical outcomes among patients.
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836
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Squara P. Central venous oxygenation: when physiology explains apparent discrepancies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:579. [PMID: 25407250 PMCID: PMC4282012 DOI: 10.1186/s13054-014-0579-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Central venous oxygen saturation (ScvO2) >70% or mixed venous oxygen saturation (SvO2) >65% is recommended for both septic and non-septic patients. Although it is the task of experts to suggest clear and simple guidelines, there is a risk of reducing critical care to these simple recommendations. This article reviews the basic physiological and pathological features as well as the metrological issues that provide clear evidence that SvO2 and ScvO2 are adaptative variables with large inter-patient variability. This variability is exemplified in a modeled population of 1,000 standard ICU patients and in a real population of 100 patients including 15,860 measurements. In these populations, it can be seen how optimizing one to three of the four S(c)vO2 components homogenized the patients and yields a clear dependency with the fourth one. This explains the discordant results observed in large studies where cardiac output was increased up to predetermined S(c)vO2 thresholds following arterial oxygen hemoglobin saturation, total body oxygen consumption needs and hemoglobin optimization. Although a systematic S(c)vO2 goal-oriented protocol can be statistically profitable before ICU admission, appropriate intensive care mandates determination of the best compromise between S(c)vO2 and its four components, taking into account the specific constraints of each individual patient.
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837
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Abstract
Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.
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838
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Abstract
Patients with portal hypertension and esophageal varices are at risk of bleeding due to a progressive increase in portal pressure that may rupture the variceal wall. Appropriate treatment with initial general measures, such as resuscitation, a restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy with vasoconstrictors, and endoscopic therapy with endoscopic band ligation are mandatory. However, 10% to 15% of patients fail initial endoscopic therapy and thus rescue therapies are needed. This article reviews the current endoscopic strategies with band ligation and esophageal stents for patients with acute variceal bleeding.
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839
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Rudler M, Cluzel P, Corvec TL, Benosman H, Rousseau G, Poynard T, Thabut D. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther 2014; 40:1074-80. [PMID: 25230051 DOI: 10.1111/apt.12934] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 06/25/2014] [Accepted: 08/04/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Early-TIPSS (transjugular intrahepatic portosystemic shunt) placement may improve rebleeding and reduce 1-year mortality, compared to standard management in high-risk patients with cirrhosis and variceal bleeding. AIM To obtain external validation of this therapeutic approach. METHODS We performed a prospective study including all consecutive patients with Child-Pugh C 10-13 cirrhosis or Child-Pugh B with active bleeding at endoscopy admitted to our ICU between March 2011 and February 2013 for variceal bleeding. TIPSS were placed within 72 h after stabilisation. Patients were matched for gender, age, Child-Pugh score, MELD score and to patients from a historical cohort hospitalised before March 2011. RESULTS 31/128 patients with cirrhosis (77.4% men, mean age 53.2 ± 9.0 years old, MELD score 20.9 ± 6.9, Child-Pugh C: 77.4%) admitted for acute variceal bleeding between March 2011 and February 2013 (TIPSS+ group) were matched to 31 historical patients (TIPSS- group). Uncontrolled bleeding occurred in 1/31 patients in the TIPSS+ group vs. 2/31 patients in TIPSS- group (P = 0.55). The 1-year probability of being free of rebleeding was higher in the TIPSS+ group (97% vs. 51%, P < 0.001). Actuarial 1-year survival was not different between the two groups (66.8 ± 9.4% vs. 74.2 ± 7.8%, P = 0.78). Acute cardiac failure occurred more frequently in the TIPSS+ group (25.8% vs. 6.4%, P = 0.03). CONCLUSIONS Early-TIPSS placement effectively prevents rebleeding in high-risk patients with variceal bleeding but does not significantly improve survival. This might be due to the high proportion of patients with Child-Pugh C cirrhosis in our series. Cardiac failure may play a role and must be investigated before the procedure, when possible.
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Affiliation(s)
- M Rudler
- Department of Hepatogastroenterology, La Pitié-Salpêtrière Hospital, 47-80 boulevard de l'Hôpital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
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840
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841
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Abstract
PURPOSE OF REVIEW Acute upper gastrointestinal bleeding is one of the most common medical emergencies. It is important to recognize potential etiologies of upper gastrointestinal bleeding and understand therapeutic modalities available in achieving hemostasis. This article summarizes guidelines in management of acute nonvariceal upper gastrointestinal bleeding and reviews recent advances in the field. RECENT FINDINGS Recent study showed that patients who received blood transfusion with threshold hemoglobin below 7 g/dl rather than below 9 g/dl had significantly lower mortality at 45 days. Endoscopic therapy should be performed on actively bleeding ulcers and ulcers with visible vessel or adherent clot. An over-the-scope clip is a novel device that can be used to achieve hemostasis. It may be a useful tool for achieving hemostasis for patients who failed endoscopic therapy with epinephrine injection, clip, or thermal therapy. Doppler ultrasound probe can evaluate arterial flow to the ulcer and identify ulcers that are at high risk of rebleeding. SUMMARY Upper gastrointestinal bleeding from peptic ulcer disease is not a new clinical problem. Yet, the approach to management continues to evolve with the accumulation of data and well designed studies on the subject.
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842
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Bydon M, Abt NB, Macki M, Brem H, Huang J, Bydon A, Tamargo RJ. Preoperative anemia increases postoperative morbidity in elective cranial neurosurgery. Surg Neurol Int 2014; 5:156. [PMID: 25422784 PMCID: PMC4235129 DOI: 10.4103/2152-7806.143754] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 09/19/2014] [Indexed: 01/26/2023] Open
Abstract
Background: Preoperative anemia may affect postoperative mortality and morbidity following elective cranial operations. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify elective cranial neurosurgical cases (2006-2012). Morbidity was defined as wound infection, systemic infection, cardiac, respiratory, renal, neurologic, and thromboembolic events, and unplanned returns to the operating room. For 30-day postoperative mortality and morbidity, adjusted odds ratios (ORs) were estimated with multivariable logistic regression. Results: Of 8015 patients who underwent elective cranial neurosurgery, 1710 patients (21.4%) were anemic. Anemic patients had an increased 30-day mortality of 4.1% versus 1.3% in non-anemic patients (P < 0.001) and an increased 30-day morbidity rate of 25.9% versus 14.14% in non-anemic patients (P < 0.001). The 30-day morbidity rates for all patients undergoing cranial procedures were stratified by diagnosis: 26.5% aneurysm, 24.7% sellar tumor, 19.7% extra-axial tumor, 14.8% intra-axial tumor, 14.4% arteriovenous malformation, and 5.6% pain. Following multivariable regression, the 30-day mortality in anemic patients was threefold higher than in non-anemic patients (4.1% vs 1.3%; OR = 2.77; 95% CI: 1.65-4.66). The odds of postoperative morbidity in anemic patients were significantly higher than in non-anemic patients (OR = 1.29; 95% CI: 1.03-1.61). There was a significant difference in postoperative morbidity event odds with a hematocrit level above (OR = 1.07; 95% CI: 0.78-1.48) and below (OR = 2.30; 95% CI: 1.55-3.42) 33% [hemoglobin (Hgb) 11 g/dl]. Conclusions: Preoperative anemia in elective cranial neurosurgery was independently associated with an increased risk of 30-day postoperative mortality and morbidity when compared to non-anemic patients. A hematocrit level below 33% (Hgb 11 g/dl) was associated with a significant increase in postoperative morbidity.
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Affiliation(s)
- Mohamad Bydon
- Johns Hopkins, Department of Neurosurgery, 600 N Wolfe Street, Sheik Zayed Tower Room 6115G, Baltimore, Maryland, 21287, USA
| | - Nicholas B Abt
- Johns Hopkins, Department of Neurosurgery, 600 N Wolfe Street, Sheik Zayed Tower Room 6115G, Baltimore, Maryland, 21287, USA
| | - Mohamed Macki
- Johns Hopkins, Department of Neurosurgery, 600 N Wolfe Street, Sheik Zayed Tower Room 6115G, Baltimore, Maryland, 21287, USA
| | - Henry Brem
- Johns Hopkins, Department of Neurosurgery, 600 N Wolfe Street, Sheik Zayed Tower Room 6115G, Baltimore, Maryland, 21287, USA
| | - Judy Huang
- Johns Hopkins, Department of Neurosurgery, 600 N Wolfe Street, Sheik Zayed Tower Room 6115G, Baltimore, Maryland, 21287, USA
| | - Ali Bydon
- Johns Hopkins, Department of Neurosurgery, 600 N Wolfe Street, Sheik Zayed Tower Room 6115G, Baltimore, Maryland, 21287, USA
| | - Rafael J Tamargo
- Johns Hopkins, Department of Neurosurgery, 600 N Wolfe Street, Sheik Zayed Tower Room 6115G, Baltimore, Maryland, 21287, USA
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843
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Seiffert M, Conradi L, Terstesse AC, Koschyk D, Schirmer J, Schnabel RB, Wilde S, Ojeda FM, Reichenspurner H, Blankenberg S, Schäfer U, Treede H, Diemert P. Blood transfusion is associated with impaired outcome after transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2014; 85:460-7. [DOI: 10.1002/ccd.25691] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 07/17/2014] [Accepted: 10/01/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Moritz Seiffert
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery; University Heart Center Hamburg; Germany
| | | | - Dietmar Koschyk
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
| | - Johannes Schirmer
- Department of Cardiovascular Surgery; University Heart Center Hamburg; Germany
| | - Renate B. Schnabel
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
| | - Sandra Wilde
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
| | - Francisco M. Ojeda
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
| | | | - Stefan Blankenberg
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
| | - Ulrich Schäfer
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
| | - Hendrik Treede
- Department of Cardiovascular Surgery; University Heart Center Hamburg; Germany
| | - Patrick Diemert
- Department of General and Interventional Cardiology; University Heart Center Hamburg; Germany
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844
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Affiliation(s)
- Juan G. Abraldes
- Cirrhosis Care Clinic (CCC) (JGA and PT), Liver Unit, Division of Gastroenterology and the Division of Pediatric Gastroenterology and Nutrition (JY)University of AlbertaEdmontonAlbertaCanada.
| | - Puneeta Tandon
- Cirrhosis Care Clinic (CCC) (JGA and PT), Liver Unit, Division of Gastroenterology and the Division of Pediatric Gastroenterology and Nutrition (JY)University of AlbertaEdmontonAlbertaCanada.
| | - Jason Yap
- Cirrhosis Care Clinic (CCC) (JGA and PT), Liver Unit, Division of Gastroenterology and the Division of Pediatric Gastroenterology and Nutrition (JY)University of AlbertaEdmontonAlbertaCanada.
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845
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Can old dogs learn new "transfusion requirements in critical care": a survey of packed red blood cell transfusion practices among members of The American Association for the Surgery of Trauma. Am J Surg 2014; 210:45-51. [PMID: 26025750 DOI: 10.1016/j.amjsurg.2014.08.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 07/30/2014] [Accepted: 08/08/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND The objective of this study was to characterize variations in packed red blood cell (PRBC) transfusion practices in critically ill patients and to identify which factors influence such practices. We hypothesized that significant variation in transfusion triggers exists among acute care surgeons. METHODS A survey of PRBC transfusion practices was administered to the American Association for the Surgery of Trauma members. The scenarios examined hemoglobin thresholds for which participants would transfuse PRBCs. RESULTS A hemoglobin threshold of less than or equal to 7 g/dL was adopted by 45% of respondents in gastrointestinal bleeding, 75% in penetrating trauma, 66% in sepsis, and 62% in blunt trauma. Acute care surgeons modified their transfusion trigger significantly in the majority of the modifications of these scenarios, often inappropriately so. CONCLUSIONS This study documents continued evidence-practice gaps and wide variations in the PRBC transfusion practices of acute care surgeons. Numerous clinical factors altered such patterns despite a lack of supporting evidence (for or against).
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846
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Carson JL, Patel MS. Red blood cell transfusion thresholds: can we go even lower? Transfusion 2014; 54:2593-4. [DOI: 10.1111/trf.12812] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Jeffrey L. Carson
- Division of General Internal Medicine; Rutgers Robert Wood Johnson Medical School; Rutgers Biomedical and Health Sciences; Rutgers, The State University of New Jersey; New Brunswick NJ
| | - Manish S. Patel
- Division of General Internal Medicine; Rutgers Robert Wood Johnson Medical School; Rutgers Biomedical and Health Sciences; Rutgers, The State University of New Jersey; New Brunswick NJ
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847
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Affiliation(s)
- Paul C Hébert
- From the Canadian Critical Care Trials Group, Department of Medicine and Centre de Recherche, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal (P.C.H.); and the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.)
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848
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Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, Johansson PI, Aneman A, Vang ML, Winding R, Nebrich L, Nibro HL, Rasmussen BS, Lauridsen JRM, Nielsen JS, Oldner A, Pettilä V, Cronhjort MB, Andersen LH, Pedersen UG, Reiter N, Wiis J, White JO, Russell L, Thornberg KJ, Hjortrup PB, Müller RG, Møller MH, Steensen M, Tjäder I, Kilsand K, Odeberg-Wernerman S, Sjøbø B, Bundgaard H, Thyø MA, Lodahl D, Mærkedahl R, Albeck C, Illum D, Kruse M, Winkel P, Perner A. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014; 371:1381-91. [PMID: 25270275 DOI: 10.1056/nejmoa1406617] [Citation(s) in RCA: 545] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. METHODS In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization. RESULTS We analyzed data from 998 of 1005 patients (99.3%) who underwent randomization. The two intervention groups had similar baseline characteristics. In the ICU, the lower-threshold group received a median of 1 unit of blood (interquartile range, 0 to 3) and the higher-threshold group received a median of 4 units (interquartile range, 2 to 7). At 90 days after randomization, 216 of 502 patients (43.0%) assigned to the lower-threshold group, as compared with 223 of 496 (45.0%) assigned to the higher-threshold group, had died (relative risk, 0.94; 95% confidence interval, 0.78 to 1.09; P=0.44). The results were similar in analyses adjusted for risk factors at baseline and in analyses of the per-protocol populations. The numbers of patients who had ischemic events, who had severe adverse reactions, and who required life support were similar in the two intervention groups. CONCLUSIONS Among patients with septic shock, mortality at 90 days and rates of ischemic events and use of life support were similar among those assigned to blood transfusion at a higher hemoglobin threshold and those assigned to blood transfusion at a lower threshold; the latter group received fewer transfusions. (Funded by the Danish Strategic Research Council and others; TRISS ClinicalTrials.gov number, NCT01485315.).
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Affiliation(s)
- Lars B Holst
- From the Department of Intensive Care (L.B.H., N.H., L.H.A., U.G.P., N.R., J. Wiis, J.O.W., L.R., K.J.T., P.B.H., R.G.M., M.H.M., M.S., A.P.), Copenhagen Trial Unit, Center for Clinical Intervention Research (J. Wetterslev, P.W.), and Section for Transfusion Medicine (P.I.J.), Rigshospitalet and University of Copenhagen, Copenhagen, Randers Hospital, Randers (M.L.V., H.B., M.A.T.), Herning Hospital, Herning (R.W., D.L., R.M.), Hvidovre Hospital, Hvidovre (L.N., C.A.), Aarhus University Hospital, Aarhus (H.L.N., D.I.), Aalborg University Hospital, Aalborg (B.S.R.), Holbæk Hospital, Holbæk (J.R.M.L.), Kolding Hospital, Kolding (J.S.N.), and Hjørring Hospital, Hjørring (M.K.) - all in Denmark; Karolinska University Hospital, Huddinge, Stockholm (J. Wernerman, I.T., K.K., S.O.-W.), Karolinska University Hospital, Solna (A.O.), and Södersjukhuset, Stockholm (M.B.C.) - all in Sweden; Haukeland University Hospital and University of Bergen, Bergen, Norway (A.B.G., B.S.); Tampere University Hospital, Tampere (S.K.), and Helsinki University Hospital and University of Helsinki, Helsinki (V.P.) - all in Finland; and Liverpool Hospital, Sydney (A.Å.)
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849
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Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM. An Official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine Policy Statement: The Choosing Wisely® Top 5 List in Critical Care Medicine. Am J Respir Crit Care Med 2014; 190:818-26. [DOI: 10.1164/rccm.201407-1317st] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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850
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Adherence to guidelines: a national audit of the management of acute upper gastrointestinal bleeding. The REASON registry. Can J Gastroenterol Hepatol 2014; 28:495-501. [PMID: 25314356 PMCID: PMC4205906 DOI: 10.1155/2014/252307] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To assess process of care in nonvariceal upper gastrointestinal bleeding (NVUGIB) using a national cohort, and to identify predictors of adherence to 'best practice' standards. METHODS Consecutive charts of patients hospitalized for acute upper gastrointestinal bleeding across 21 Canadian hospitals were reviewed. Data regarding initial presentation, endoscopic management and outcomes were collected. Results were compared with 'best practice' using established guidelines on NVUGIB. Adherence was quantified and independent predictors were evaluated using multivariable analysis. RESULTS Overall, 2020 patients (89.4% NVUGIB, variceal in 10.6%) were included (mean [± SD] age 66.3±16.4 years; 38.4% female). Endoscopy was performed in 1612 patients: 1533 with NVUGIB had endoscopic lesions (63.1% ulcers; high-risk stigmata in 47.8%). Early endoscopy was performed in 65.6% and an assistant was present in 83.5%. Only 64.5% of patients with high-risk stigmata received endoscopic hemostasis; 9.8% of patients exhibiting low-risk stigmata also did. Intravenous proton pump inhibitor was administered after endoscopic hemostasis in 95.7%. Rebleeding and mortality rates were 10.5% and 9.4%, respectively. Multivariable analysis revealed that low American Society of Anesthesiologists score patients had fewer assistants present during endoscopy (OR 0.63 [95% CI 0.48 to 0.83), a hemoglobin level <70 g⁄L predicted inappropriate high-dose intravenous proton pump inhibitor use in patients with low-risk stigmata, and endoscopies performed during regular hours were associated with longer delays from presentation (OR 0.33 [95% CI 0.24 to 0.47]). CONCLUSION There was variability between the process of care and 'best practice' in NVUGIB. Certain patient and situational characteristics may influence guideline adherence. Dissemination initiatives must identify and focus on such considerations to improve quality of care.
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