901
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Fortinsky KJ, Stall NM, Barkun AN. A 77-year-old man with nonvariceal upper gastrointestinal bleeding. CMAJ 2014; 186:363-5. [PMID: 24396097 DOI: 10.1503/cmaj.131288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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902
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Weeder PD, Porte RJ, Lisman T. Hemostasis in liver disease: implications of new concepts for perioperative management. Transfus Med Rev 2014; 28:107-13. [PMID: 24721432 DOI: 10.1016/j.tmrv.2014.03.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/09/2014] [Accepted: 03/10/2014] [Indexed: 02/08/2023]
Abstract
The hemostatic profile of patients with liver diseases is frequently profoundly different from that of healthy individuals. These complex alterations lead to abnormal results from routine laboratory tests, but because of the nature of these assays, they fail to accurately represent the patient's hemostatic state. Nevertheless, based on abnormal laboratory coagulation values, it has long been assumed that patients with liver disease have a natural bleeding tendency and are protected from thrombosis. This assumption is false; the average patient with liver disease is actually in a state of "rebalanced hemostasis" that can relatively easily be tipped toward both bleeding and thrombosis. The new paradigm of rebalanced hemostasis has strong implications for the clinic, which are presented in this review. There is no evidence that prophylactic transfusion of plasma helps to prevent procedure-related bleeding. In addition, the presence of independent risk factors such as poor kidney status or infections should be carefully assessed before invasive procedures. Furthermore, central venous pressure plays an important role in the risk of bleeding in patients with liver diseases, so during procedures, a restrictive infusion policy should be applied. Finally, thrombosis prophylaxis should not be withheld from patients with cirrhosis or acute liver failure, and clinicians should be alert to the possibility of thrombosis occurring in these patients.
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Affiliation(s)
- Pepijn D Weeder
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.
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903
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[Diverticular bleeding. Diagnostics, non-surgical treatment, indications for surgery]. Chirurg 2014; 85:314-9. [PMID: 24610007 DOI: 10.1007/s00104-013-2622-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Diverticular bleeding is the most common cause of acute severe lower gastrointestinal bleeding. Diagnostic and therapeutic approaches have not been standardized. OBJECTIVE Development of an evidence-based management algorithm. MATERIALS AND METHODS A systematic search of the literature (PubMed 1998-2013) was carried out and a review with consideration of current guidelines is given. RESULTS The lifetime risk of clinically relevant bleeding is estimated to be 5 % in persons with colonic diverticula. Patients with clinically suspected diverticular hemorrhage should be admitted to hospital. Diverticular bleeding will cease spontaneously in around 70-90 % of the cases. In patients with severe lower gastrointestinal tract bleeding, defined as instability of the circulation, persistent bleeding after 24 h, drop of the hemoglobin level to ≥ 2 g/dl or the necessity for transfusion, endoscopy of the upper and lower gastrointestinal tract within the first 12-24 h is recommended. In patients with active diverticular bleeding or signs of recent hemorrhage (e.g. visible vessel or adherent clot) endoscopic therapy is strongly recommended because it significantly decreases the rate of early and late rebleeding. Angiography with superselective embolization is a therapeutic option in patients where endoscopy failed. Surgery should be considered in patients with ongoing bleeding and failure of interventional treatment and in patients who suffered from recurrent severe diverticular bleeding. CONCLUSIONS Diverticulosis coli remains the most common cause of lower gastrointestinal bleeding. Colonoscopy is recommended as first-line diagnostic and therapeutic approach. In the vast majority of patients diverticular hemorrhage can be readily managed either conventionally or by interventional therapy.
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904
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Abstract
Anemia is extremely common following hip fracture. Consistent data from randomized trials show that transfusion of less blood, with a transfusion threshold around 8 g/dL hemoglobin concentration, is preferable to a traditional threshold of 10 g/dL. Adoption of a lower threshold leads to at least equivalent clinical outcomes, with much less exposure to transfusion costs and risks. The most common complication of transfusion is circulatory overload. Future research may elucidate the optimal transfusion threshold for these elderly patients and address the specific needs of subgroups of patients, including those with acute coronary syndrome or chronic kidney disease.
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Affiliation(s)
- Laura Rees Willett
- Division of Education, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, MEB-486, New Brunswick, NJ 08903, USA.
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, New Brunswick, NJ 08901, USA.
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905
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906
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Molina-Infante J, Calvet X, Gisbert JP. Letter: the irony of oral iron - not an underdog for post-gastrointestinal bleeding anaemia. Aliment Pharmacol Ther 2014; 39:550-1. [PMID: 24494851 DOI: 10.1111/apt.12617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 12/30/2022]
Affiliation(s)
- J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcántara, Cáceres, Spain.
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907
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Alan N, Seicean A, Seicean S, Neuhauser D, Weil RJ. Impact of preoperative anemia on outcomes in patients undergoing elective cranial surgery. J Neurosurg 2014; 120:764-72. [DOI: 10.3171/2013.10.jns131028] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The objective of this study was to assess whether preoperative anemia in patients undergoing elective cranial surgery influences outcomes in the immediate perioperative period (≤ 30 days).
Methods
The National Surgical Quality Improvement Program (NSQIP) was used to identify 6576 patients undergoing elective cranial surgery between 2006 and 2011. Propensity scores were used to match patients with moderate to severe anemia (moderate-severe) or mild anemia with patients without anemia. Logistic regression analysis was used to predict the outcomes of interest. Sensitivity analyses were used to limit the sample to patients without perioperative transfusion as well as those who underwent craniotomy for definitive resection of a malignant brain tumor.
Results
A total of 6576 patients underwent elective cranial surgery, of whom 175 had moderate-severe anemia and 1868 had mild anemia. Patients with moderate-severe (odds ratio 1.8, 95% CI 1.1–2.8) and mild (odds ratio 1.5, 95% CI 1.3–1.7) anemia were more likely to have prolonged length of stay (LOS) in the hospital compared to those with no anemia. Similarly, in patients who underwent craniotomy for a malignant tumor resection (n = 2537), anemia of any severity was associated with prolonged LOS, but not postoperative complications nor death.
Conclusions
Anemia is not associated with an overall increased risk for adverse outcomes in patients undergoing elective cranial surgery. However, patients with anemia are more likely to experience prolonged hospitalization postoperatively, resulting in increased resource utilization.
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Affiliation(s)
- Nima Alan
- 1Case Western Reserve University School of Medicine
| | - Andreea Seicean
- 1Case Western Reserve University School of Medicine
- 2Department of Epidemiology and Biostatistics, Case Western Reserve University
| | - Sinziana Seicean
- 3Departments of Pulmonary, Critical Care and Sleep Medicine, University Hospitals
- 4Heart and Vascular Institute, Cleveland Clinic
| | - Duncan Neuhauser
- 2Department of Epidemiology and Biostatistics, Case Western Reserve University
| | - Robert J. Weil
- 5The Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, and Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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908
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Affiliation(s)
- Beverley J Hunt
- From King's College London and Guy's and St. Thomas' Trust - both in London
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909
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Rosland RG, Hagen MU, Haase N, Holst LB, Plambech M, Madsen KR, Søe-Jensen P, Poulsen LM, Bestle M, Perner A. Red blood cell transfusion in septic shock - clinical characteristics and outcome of unselected patients in a prospective, multicentre cohort. Scand J Trauma Resusc Emerg Med 2014; 22:14. [PMID: 24571858 PMCID: PMC3938972 DOI: 10.1186/1757-7241-22-14] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 02/24/2014] [Indexed: 12/20/2022] Open
Abstract
Background Treating anaemia with red blood cell (RBC) transfusion is frequent, but controversial, in patients with septic shock. Therefore we assessed characteristics and outcome associated with RBC transfusion in this group of high risk patients. Methods We did a prospective cohort study at 7 general intensive care units (ICUs) including all adult patients with septic shock in a 5-month period. Results Ninety-five of the 213 included patients (45%) received median 3 (interquartile range 2–5) RBC units during shock. The median pre-transfusion haemoglobin level was 8.1 (7.4–8.9) g/dl and independent of shock day and bleeding. Patients with cardiovascular disease were transfused at higher haemoglobin levels. Transfused patients had higher Simplified Acute Physiology Score (SAPS) II (56 (45-69) vs. 48 (37-61), p = 0.0005), more bleeding episodes, lower haemoglobin levels days 1 to 5, higher Sepsis-related Organ Failure Assessment (SOFA) scores (days 1 and 5), more days in shock (5 (3-10) vs. 2 (2-4), p = 0.0001), more days in ICU (10 (4-19) vs. 4 (2-8), p = 0.0001) and higher 90-day mortality (66 vs. 43%, p = 0.001). The latter association was lost after adjustment for admission category and SAPS II and SOFA-score on day 1. Conclusions The decision to transfuse patients with septic shock was likely affected by disease severity and bleeding, but haemoglobin level was the only measure that consistently differed between transfused and non-transfused patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark.
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910
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Stonemetz JL, Allen PX, Wasey J, Rivers RJ, Ness PM, Frank SM. Development of a risk-adjusted blood utilization metric. Transfusion 2014; 54:2716-23. [PMID: 24611645 DOI: 10.1111/trf.12548] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 11/24/2013] [Accepted: 11/25/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Blood utilization has become an important outcome measure for surgical patients because of the recognized risks and costs associated with transfusion. However, comparisons of blood utilization between providers or institutions are difficult, because there is no standard method for risk adjustment when assessing surgical blood requirements. We examined whether accepted diagnosis-related group (DRG) case mix indexes can be used for this purpose. STUDY DESIGN AND METHODS We retrospectively analyzed electronic medical record data from 37,403 surgical inpatients to assess the relationship between intraoperative blood component transfusion requirements and the case mix indexes: weighted Medicare severity DRG and weighted all-patient refined DRG. Thirty-one surgeons from the general surgery service were compared to determine correlations between blood component utilization and case mix index in both a risk unadjusted and an adjusted fashion. RESULTS Case mix indexes and transfusion requirements were directly correlated for red blood cells (RBCs), plasma, and platelet (PLT) transfusions (p < 0.0001 for all three blood components, for both indexes). Surgeons with greater case mix index values had greater transfusion requirements, and adjustment for case mix index resulted in less variation among surgeons (p < 0.0001, p = 0.0003, and p < 0.0001 for unadjusted vs. adjusted utilization of RBCs, plasma, and PLTs, respectively). CONCLUSIONS The standard DRG-based case mix indexes used to determine hospital reimbursement were strongly correlated with intraoperative transfusion requirements. We propose that these methods can be used as a risk-adjusted blood utilization metric for surgical patients.
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Affiliation(s)
- Jerry L Stonemetz
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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911
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Fortune B, Garcia-Tsao G. Current Management Strategies for Acute Esophageal Variceal Hemorrhage. ACTA ACUST UNITED AC 2014; 13:35-42. [PMID: 24955303 DOI: 10.1007/s11901-014-0221-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute esophageal variceal hemorrhage is one of the clinical events that define decompensated cirrhosis and is associated with high rates of morbidity and mortality. Although recent treatment strategies have led to improved outcomes, variceal hemorrhage still carries a 6-week mortality rate of 15-20%. Current standards in its treatment include antibiotic prophylaxis, infusion of a vasoactive drug and endoscopic variceal ligation. The placement of a transjugular intrahepatic portosystemic shunt (TIPS) is considered for patients that have treatment failure or recurrent bleeding. Recurrent hemorrhage is prevented with the combination of a non-selective beta-blocker and endoscopic variceal ligation. These recommendations however assume that all patients with cirrhosis are equal. Based on a review of recent evidence, a strategy in which patients are stratified by Child class, the main predictor of outcomes, is proposed.
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Affiliation(s)
- Brett Fortune
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT ; Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT
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912
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Gombotz H, Hofmann A. [Patient Blood Management : three pillar strategy to improve outcome through avoidance of allogeneic blood products]. Anaesthesist 2014; 62:519-27. [PMID: 23836145 DOI: 10.1007/s00101-013-2199-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Blood transfusions are commonly viewed as life-saving interventions; however, current evidence shows that blood transfusions are associated with a significant increase of morbidity and mortality in a dose-dependent relationship. Not only explanatory models of basic research but also the results from randomized controlled trials suggest a causal relationship between blood transfusion and adverse outcome. Therefore, it can be claimed that the current state of science debunks the long held belief in the so-called life-saving blood transfusion by exposing the potential for promoting disease and death. Adherence to the precautionary principle and also the fact that blood transfusions are more costly than previously assumed require novel approaches in the treatment of anemia and bleeding. Patient Blood Management (PBM) allows transfusion rates to be dramatically reduced through correcting anemia by stimulating erythropoiesis, minimization of perioperative blood loss and harnessing and optimizing the physiological tolerance of anemia. A resolution of the World Health Assembly has endorsed PBM and therefore morbidity and mortality should be significantly reduced by lowering of the currently high blood utilization rate of allogeneic blood products in Austria, Germany and Switzerland.
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Affiliation(s)
- H Gombotz
- Abteilung für Anästhesiologie und Intensivmedizin, Allgemeines Krankenhaus der Stadt Linz, Krankenhausstr. 9, 4020, Linz, Österreich.
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913
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Kiamanesh D, Rumley J, Moitra VK. Monitoring and managing hepatic disease in anaesthesia. Br J Anaesth 2014; 111 Suppl 1:i50-61. [PMID: 24335399 DOI: 10.1093/bja/aet378] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with liver disease have multisystem organ dysfunction that leads to physiological perturbations ranging from hyperbilirubinaemia of no clinical consequence to severe coagulopathy and metabolic disarray. Patient-specific risk factors, clinical scoring systems, and surgical procedures stratify perioperative risk for these patients. The anaesthetic management of patients with hepatic dysfunction involves consideration of impaired drug metabolism, hyperdynamic circulation, perioperative hypoxaemia, bleeding, thrombosis, and hepatic encephalopathy.
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Affiliation(s)
- D Kiamanesh
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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914
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Astin R, Puthucheary Z. Anaemia secondary to critical illness: an unexplained phenomenon. EXTREME PHYSIOLOGY & MEDICINE 2014; 3:4. [PMID: 24507552 PMCID: PMC3917528 DOI: 10.1186/2046-7648-3-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 01/23/2014] [Indexed: 12/12/2022]
Abstract
Almost all patients suffering critical illness become anaemic during their time in intensive care. The cause of this anaemia and its management has been a topic of debate in critical care medicine for the last two decades. Packed red cell transfusion has an associated cost and morbidity such that decreasing the number of units transfused would be of great benefit. Our understanding of the aetiology and importance of this anaemia is improving with recent and ongoing work to establish the cause, effect and best treatment options. This review aims to describe the current literature whilst suggesting that the nature of the anaemia should be considered with reference to the time point in critical illness. Finally, we suggest that using haemoglobin concentration as a measure of oxygen-carrying capacity has limitations and that ways of measuring haemoglobin mass should be explored.
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Affiliation(s)
- Ronan Astin
- Department of Medicine, UCL Institute for Human Health and Performance, University College London, 4th Floor, Rockefeller Building, 21 University Street, London WC1E 6DB, UK.
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915
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Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med 2014; 127:124-131.e3. [PMID: 24331453 DOI: 10.1016/j.amjmed.2013.09.017] [Citation(s) in RCA: 164] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 09/10/2013] [Accepted: 09/14/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is accumulating evidence that restricting blood transfusions improves outcomes, with newer trials showing greater benefit from more restrictive strategies. We systematically evaluated the impact of various transfusion triggers on clinical outcomes. METHODS The MEDLINE database was searched from 1966 to April 2013 to find randomized trials evaluating a restrictive hemoglobin transfusion trigger of <7 g/dL, compared with a more liberal trigger. Two investigators independently extracted data from the trials. Outcomes evaluated included mortality, acute coronary syndrome, pulmonary edema, infections, rebleeding, number of patients transfused, and units of blood transfused per patient. Extracted data also included information on study setting, design, participant characteristics, and risk for bias of the included trials. A secondary analysis evaluated trials using less restrictive transfusion triggers, and a systematic review of observational studies evaluated more restrictive triggers. RESULTS In the primary analysis, pooled results from 3 trials with 2364 participants showed that a restrictive hemoglobin transfusion trigger of <7 g/dL resulted in reduced in-hospital mortality (risk ratio [RR], 0.74; confidence interval [CI], 0.60-0.92), total mortality (RR, 0.80; CI, 0.65-0.98), rebleeding (RR, 0.64; CI, 0.45-0.90), acute coronary syndrome (RR, 0.44; CI, 0.22-0.89), pulmonary edema (RR, 0.48; CI, 0.33-0.72), and bacterial infections (RR, 0.86; CI, 0.73-1.00), compared with a more liberal strategy. The number needed to treat with a restrictive strategy to prevent 1 death was 33. Pooled data from randomized trials with less restrictive transfusion strategies showed no significant effect on outcomes. CONCLUSIONS In patients with critical illness or bleed, restricting blood transfusions by using a hemoglobin trigger of <7 g/dL significantly reduces cardiac events, rebleeding, bacterial infections, and total mortality. A less restrictive transfusion strategy was not effective.
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916
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Rudler M, Thabut D. Transfusion strategy in gastrointestinal bleeding: less is best? J Hepatol 2014; 60:453-4. [PMID: 24055549 DOI: 10.1016/j.jhep.2013.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 09/02/2013] [Accepted: 09/03/2013] [Indexed: 12/04/2022]
Affiliation(s)
- Marika Rudler
- AP-HP, UPMC, Department of Hepatogastroenterology La Pitié-Salpêtrière Hospital, 47-80 boulevard de l'Hôpital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, 75013 Paris, France
| | - Dominique Thabut
- AP-HP, UPMC, Department of Hepatogastroenterology La Pitié-Salpêtrière Hospital, 47-80 boulevard de l'Hôpital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, 75013 Paris, France.
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917
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Röhrig G, Klossok W, Becker I, Benzing T, Schulz R. Prevalence of anemia among elderly patients in an emergency room setting. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2013.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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918
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Carson JL, Hebert PC. Should we universally adopt a restrictive approach to blood transfusion? It's all about the number. Am J Med 2014; 127:103-4. [PMID: 24269656 DOI: 10.1016/j.amjmed.2013.10.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 10/29/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Paul C Hebert
- Department of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Hôpital Notre-Dame, Montréal, Quebec, Canada
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919
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Tavares MM, Diquattro PJ, Sweeney JD. Reduction in red blood cell transfusion associated with engagement of the ordering physician. Transfusion 2014; 54:2625-30. [PMID: 24472040 DOI: 10.1111/trf.12552] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/24/2013] [Accepted: 12/04/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Data on red blood cell (RBC) transfusion in the United States show variation in practice and overprescribing or overdosing is considered to be prevalent. Education or restrictive interventions could modify practice. STUDY DESIGN AND METHODS RBC transfusion and mortality rates were recorded in a single institution over a 15-year period. The first 3 years were used as a baseline. Education measures were used to influence practice for 3 years followed by a 9-year period when questionable RBC orders in nonbleeding inpatients resulted in prospective physician notification for potential modification. Physician notification was done by blood bank technologists with transfusion medicine physician support, if needed. Pretransfusion hemoglobin levels of more than 9 g/dL were recommended for cancellation and levels between 8 and 9 g/dL advised for a single unit, if 2 or more units were requested. RBC transfusion rates were described as inpatient units per 1000 discharges to allow for interyear comparison. RESULTS A downward trend in RBC transfusion was noted for the intervention period. Comparison of the baseline period with the past 3 years of the intervention period showed an approximate 33% decrease, which was highly significant (508 ± 66 vs. 341 ± 32, p < 0.01). Inpatient mortality rates declined over this period. CONCLUSION Physician education in appropriate transfusion practice is desirable but may not greatly impact RBC use. Engagement of physicians who prescribe RBCs that appear inappropriate for indication or dose was associated with a significant decline in RBC use without evidence of a change in mortality.
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Affiliation(s)
- Maria M Tavares
- Blood Bank, Roger Williams Hospital, Providence, Rhode Island
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920
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Economic considerations on transfusion medicine and patient blood management. Best Pract Res Clin Anaesthesiol 2014; 27:59-68. [PMID: 23590916 DOI: 10.1016/j.bpa.2013.02.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/06/2013] [Indexed: 01/23/2023]
Abstract
In times of escalating health-care cost, it is of great importance to carefully assess the cost-effectiveness and appropriateness of the most resource-consuming health interventions. A long-standing and common clinical practice that has been underestimated in cost and overestimated in effectiveness is the transfusion of allogeneic blood products. Studies show that this intervention comes with largely underestimated service cost and unacceptably high utilisation variability for matched patients, thus adding billions of unnecessary dollars to the health-care expenditure each year. Moreover, a large and increasing body of literature points to a dose-dependent increase of morbidity and mortality and adverse long-term outcomes associated with transfusion whereas published evidence for benefit is extremely limited. This means that transfusion may be a generator for increased hospital stay and possible re-admissions, resulting in additional billions in unnecessary expenditure for the health system. In contrast to this, there are evidence-based and cost-effective treatment options available to pre-empt and reduce allogeneic transfusions. The patient-specific rather than a product-centred application of these multiple modalities is termed patient blood management (PBM). From a health-economic perspective, the expeditious implementation of PBM programmes is clearly indicated. Both patients and payers could benefit from this concept that has recently been endorsed through the World Health Assembly resolution WHA63.12.
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921
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Abstract
Upper gastrointestinal (GI) bleeding remains a commonly encountered diagnosis for acute care surgeons. Initial stabilization and resuscitation of patients is imperative. Stable patients can have initiation of medical therapy and localization of the bleeding, whereas persistently unstable patients require emergent endoscopic or operative intervention. Minimally invasive techniques have surpassed surgery as the treatment of choice for most upper GI bleeding.
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922
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Prick BW, Jansen AJG, Steegers EAP, Hop WCJ, Essink-Bot ML, Uyl-de Groot CA, Akerboom BMC, van Alphen M, Bloemenkamp KWM, Boers KE, Bremer HA, Kwee A, van Loon AJ, Metz GCH, Papatsonis DNM, van der Post JAM, Porath MM, Rijnders RJP, Roumen FJME, Scheepers HCJ, Schippers DH, Schuitemaker NWE, Stigter RH, Woiski MD, Mol BWJ, van Rhenen DJ, Duvekot JJ. Transfusion policy after severe postpartum haemorrhage: a randomised non-inferiority trial. BJOG 2014; 121:1005-14. [DOI: 10.1111/1471-0528.12531] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2013] [Indexed: 01/22/2023]
Affiliation(s)
- BW Prick
- Department of Obstetrics and Gynaecology; Erasmus Medical Centre; Rotterdam the Netherlands
- Department of Obstetrics and Gynaecology; Maasstad Hospital; Rotterdam the Netherlands
| | - AJG Jansen
- Sanquin Blood Supply Foundation; Rotterdam the Netherlands
| | - EAP Steegers
- Department of Obstetrics and Gynaecology; Erasmus Medical Centre; Rotterdam the Netherlands
| | - WCJ Hop
- Department of Biostatistics; Erasmus Medical Centre; Rotterdam the Netherlands
| | - ML Essink-Bot
- Department of Public Health; Academic Medical Centre; Amsterdam the Netherlands
| | - CA Uyl-de Groot
- Institute for Medical Technology Assessment; Erasmus University; Rotterdam the Netherlands
| | - BMC Akerboom
- Department of Obstetrics and Gynaecology; Albert Schweitzer Hospital; Dordrecht the Netherlands
| | - M van Alphen
- Department of Obstetrics and Gynaecology; Flevo Hospital; Almere the Netherlands
| | - KWM Bloemenkamp
- Department of Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - KE Boers
- Department of Obstetrics and Gynaecology; Bronovo Hospital; the Hague the Netherlands
| | - HA Bremer
- Department of Obstetrics and Gynaecology; Reinier de Graaf Gasthuis; Delft the Netherlands
| | - A Kwee
- Department of Obstetrics and Gynaecology; University Medical Centre Utrecht; Utrecht the Netherlands
| | - AJ van Loon
- Department of Obstetrics and Gynaecology; Martini Hospital; Groningen the Netherlands
| | - GCH Metz
- Department of Obstetrics and Gynaecology; Ikazia Hospital; Rotterdam the Netherlands
| | - DNM Papatsonis
- Department of Obstetrics and Gynaecology; Amphia Hospital; Breda the Netherlands
| | - JAM van der Post
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - MM Porath
- Department of Obstetrics and Gynaecology; Maxima Medical Centre; Veldhoven the Netherlands
| | - RJP Rijnders
- Department of Obstetrics and Gynaecology; Jeroen Bosch Hospital; ‘s-Hertogenbosch the Netherlands
| | - FJME Roumen
- Department of Obstetrics and Gynaecology; Atrium Medical Centre; Heerlen the Netherlands
| | - HCJ Scheepers
- Department of Obstetrics and Gynaecology; Maastricht University Medical Centre; Maastricht the Netherlands
| | - DH Schippers
- Department of Obstetrics and Gynaecology; Canisius Wilhelmina Hospital; Nijmegen the Netherlands
| | - NWE Schuitemaker
- Department of Obstetrics and Gynaecology; Diakonessen Hospital; Utrecht the Netherlands
| | - RH Stigter
- Department of Obstetrics and Gynaecology; Deventer Hospital; Deventer the Netherlands
| | - MD Woiski
- Department of Obstetrics and Gynaecology; Radboud University Nijmegen Medical Centre; Nijmegen the Netherlands
| | - BWJ Mol
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - DJ van Rhenen
- Sanquin Blood Supply Foundation; Rotterdam the Netherlands
| | - JJ Duvekot
- Department of Obstetrics and Gynaecology; Erasmus Medical Centre; Rotterdam the Netherlands
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923
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Refaai MA, Blumberg N. Transfusion immunomodulation from a clinical perspective: an update. Expert Rev Hematol 2014; 6:653-63. [DOI: 10.1586/17474086.2013.850026] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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924
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Ozsoylu S. Congenital diaphragmatic hernia and iron deficiency anemia. TURKISH JOURNAL OF HAEMATOLOGY : OFFICIAL JOURNAL OF TURKISH SOCIETY OF HAEMATOLOGY 2014; 30:225. [PMID: 24385795 PMCID: PMC3878455 DOI: 10.4274/tjh.2013.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 02/18/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Sinasi Ozsoylu
- Fatih University School of Medicine, Department of Hematology, Ankara, Turkey
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925
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Yates SG, Sarode R. Is platelet transfusion necessary in cirrhotic patients with splenomegaly? Liver Int 2014; 34:164-5. [PMID: 24102873 DOI: 10.1111/liv.12332] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 09/06/2013] [Indexed: 12/14/2022]
Affiliation(s)
- Sean G Yates
- Pathology Division of Transfusion and Hemostasis, UT Southwestern Medical Center, Dallas, TX, USA
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926
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Hohmuth B, Ozawa S, Ashton M, Melseth RL. Patient-centered blood management. J Hosp Med 2014; 9:60-5. [PMID: 24282018 DOI: 10.1002/jhm.2116] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/18/2013] [Accepted: 10/25/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transfusions are common in hospitalized patients but carry significant risk, with associated morbidity and mortality that increases with each unit of blood received. Clinical trials consistently support a conservative over a liberal approach to transfusion. Yet there remains wide variation in practice, and more than half of red cell transfusions may be inappropriate. Adopting a more comprehensive approach to the bleeding, coagulopathic, or anemic patient has the potential to improve patient care. METHODS We present a patient-centered blood management (PBM) paradigm. The 4 guiding principles of effective PBM that we present include anemia management, coagulation optimization, blood conservation, and patient-centered decision making. RESULTS PBM has the potential to decrease transfusion rates, decrease practice variation, and improve patient outcomes. CONCLUSION PBM's value proposition is highly aligned with that of hospital medicine. Hospitalists' dual role as front-line care providers and quality improvement leaders make them the ideal candidates to develop, implement, and practice PBM.
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Affiliation(s)
- Benjamin Hohmuth
- Department of Hospital Medicine, Geisinger Medical Center, Danville, Pennsylvania
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927
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Bager P, Dahlerup JF. Randomised clinical trial: oral vs. intravenous iron after upper gastrointestinal haemorrhage--a placebo-controlled study. Aliment Pharmacol Ther 2014; 39:176-87. [PMID: 24251969 DOI: 10.1111/apt.12556] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 08/22/2013] [Accepted: 10/29/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonvariceal acute upper gastrointestinal bleeding (AUGIB) is often accompanied by post-discharge anaemia. AIM To investigate whether iron treatment can effectively treat anaemia and to compare a 3-month regimen of oral iron treatment with a single administration of intravenous iron prior to discharge. METHODS Ninety-seven patients with nonvariceal AUGIB and anaemia were enrolled in a double-blind, placebo-controlled, randomised study. The patients were allocated to one of three groups, receiving a single intravenous administration of 1000 mg of iron; oral iron treatment, 200 mg daily for 3 months; or placebo, respectively. The patients were followed up for 3 months. RESULTS From week 4 onwards, patients receiving treatment had significantly higher haemoglobin levels compared with patients who received placebo only. At the end of treatment, the proportion of patients with anaemia was significantly higher in the placebo group (P < 0.01) than in the treatment groups. Intravenous iron appeared to be more effective than oral iron in ensuring sufficient iron stores. CONCLUSIONS Iron treatment is effective and essential for treating anaemia after nonvariceal acute upper gastrointestinal bleeding. The route of iron supplementation is less important in terms of the increase in haemoglobin levels. Iron stores are filled most effectively if intravenous iron supplementation is administered (ClinicalTrials.gov identifier: NCT00978575).
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Affiliation(s)
- P Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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928
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Goodnough LT, Schrier SL. Evaluation and management of anemia in the elderly. Am J Hematol 2014; 89:88-96. [PMID: 24122955 DOI: 10.1002/ajh.23598] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/21/2013] [Indexed: 12/14/2022]
Abstract
Anemia is now recognized as a risk factor for a number of adverse outcomes in the elderly, including hospitalization, morbidity, and mortality. What constitutes appropriate evaluation and management for an elderly patient with anemia, and when to initiate a referral to a hematologist, are significant issues. Attempts to identify suggested hemoglobin levels for blood transfusion therapy have been confounded for elderly patients with their co-morbidities. Since no specific recommended hemoglobin threshold has stood the test of time, prudent transfusion practices to maintain hemoglobin thresholds of 9-10 g/dL in the elderly are indicated, unless or until evidence emerges to indicate otherwise.
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Affiliation(s)
- Lawrence Tim Goodnough
- Department of Pathology and Medicine; Stanford University School of Medicine; Stanford California
- Department of Medicine; Stanford University School of Medicine; Stanford California
- Division of Hematology; Stanford University School of Medicine; Stanford California
| | - Stanley L. Schrier
- Department of Medicine; Stanford University School of Medicine; Stanford California
- Division of Hematology; Stanford University School of Medicine; Stanford California
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929
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Martin R, Esper A, Martin GS. Hematologic Complications. NON-PULMONARY COMPLICATIONS OF CRITICAL CARE 2014. [PMCID: PMC7121187 DOI: 10.1007/978-1-4939-0873-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Critically ill patients are at high risk of developing various hematologic complications that may be present on admission or occur during their stay in the Intensive Care Unit (ICU). Often times the etiology of specific hematologic abnormalities is unclear and the diagnosis may be challenging due to the complexity of critically ill patients. This chapter will focus on diagnosis and management of the most commonly encountered hematologic problems in the critically ill such as anemia, neutropenia, thrombocytopenia, coagulopathy and thrombotic complications, with specific focus on diagnosis and management of these conditions.
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930
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Abstract
Patients with cirrhosis who experience hepatic decompensation, such as the development of ascites, SBP, variceal hemorrhage, or hepatic encephalopathy, or who develop HCC, are at a higher risk of mortality. Management should be focused on the prevention of recurrence of complications, and these patients should be referred for consideration of liver transplantation.
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Affiliation(s)
- Iris W Liou
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Box 356175, Seattle, WA 98195-6175, USA.
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931
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Karam O, Tucci M, Combescure C, Lacroix J, Rimensberger PC. Plasma transfusion strategies for critically ill patients. Cochrane Database Syst Rev 2013:CD010654. [PMID: 24374651 DOI: 10.1002/14651858.cd010654.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although plasma transfusions are frequently prescribed for critically ill patients, most clinical uses of plasma are not supported by evidence. Plasma transfusions do not seem to correct mild coagulation abnormalities based on international normalised ratio (INR) testing, but they seem to be independently associated with worse clinical outcomes in non-massively bleeding patients. Current recommendations on plasma transfusion strategies advocate limiting plasma transfusions to patients who are actively bleeding or who are at risk of bleeding and concomitantly have moderately abnormal coagulation tests. OBJECTIVES To determine whether use of a restrictive versus a liberal plasma transfusion threshold affects mortality or morbidity in critically ill patients, and to assess the clinical effects of different plasma transfusion thresholds in critically ill patients. SEARCH METHODS A search for studies was run on 15 August 2013. We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE(R) Ovid, MEDLINE(R) Ovid In-Process & Other Non-Indexed Citations, MEDLINE(R) Ovid Daily and OLDMEDLINE(R) Ovid, EMBASE Classic + EMBASE (Ovid SP), reference lists, related websites and trial registries and checked lists of references. SELECTION CRITERIA Randomised clinical trials that assessed the effects of two plasma transfusion strategies, using a restrictive and a liberal threshold of at least one coagulation test, in critically ill participants. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality using the standard methods of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS Of 843 references identified by our search, none of the trials satisfied our predefined inclusion criteria. No studies are included in this review. AUTHORS' CONCLUSIONS This review highlights the lack of evidence that is available to guide plasma transfusions in critically ill patients. Randomised controlled trials are needed to determine the appropriate plasma transfusion strategy in critically ill patients.
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Affiliation(s)
- Oliver Karam
- Pediatric Critical Care Unit, Geneva University Hospital, 6 rue Willy Donzé, Geneva, Switzerland, 1211
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932
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Kilic A, Whitman GJR. Blood transfusions in cardiac surgery: indications, risks, and conservation strategies. Ann Thorac Surg 2013; 97:726-34. [PMID: 24359936 DOI: 10.1016/j.athoracsur.2013.08.016] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 07/31/2013] [Accepted: 08/07/2013] [Indexed: 10/25/2022]
Abstract
Although red blood cell (RBC) transfusions are frequently used in cardiac operations, an increasing amount of data has demonstrated deleterious consequences. Consequently, the appropriate use of this limited resource is unclear. In this review, we discuss the relationship between anemia and the outcomes of cardiac surgical procedures, the risks associated with RBC transfusion, and the impact of blood transfusions on mortality and morbidity after cardiac operations. The review concludes with a discussion of randomized trials comparing restrictive versus liberal transfusion strategies and a consideration of blood conservation techniques.
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Affiliation(s)
- Arman Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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933
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Rao SV, Sherwood MW. Isn't it about time we learned how to use blood transfusion in patients with ischemic heart disease? J Am Coll Cardiol 2013; 63:1297-1299. [PMID: 24361316 DOI: 10.1016/j.jacc.2013.11.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 11/19/2013] [Indexed: 01/28/2023]
Affiliation(s)
- Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina.
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934
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Finkelmeier F, Bettinger D, Köberle V, Schultheiß M, Zeuzem S, Kronenberger B, Piiper A, Waidmann O. Single measurement of hemoglobin predicts outcome of HCC patients. Med Oncol 2013; 31:806. [PMID: 24326985 DOI: 10.1007/s12032-013-0806-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 12/04/2013] [Indexed: 12/29/2022]
Abstract
Anemia is a common complication in several types of cancer including hepatocellular carcinoma (HCC). The prognostic potential of hemoglobin (Hb) levels has not yet been investigated in HCC patients. One hundred and ninety-nine patients were prospectively recruited and Hb levels were determined. Hb levels were compared to the stages of liver cirrhosis and HCC stages. The association of the Hb levels and overall survival (OS) was assessed by univariate and multivariate Cox regression models. The relation of Hb levels and OS was further validated in an independent cohort of 87 HCC patients. Hb levels negatively correlated with the stage of liver cirrhosis (model of end stage liver disease score and Child-Pugh stage) and differed between stages of HCC. Low Hb levels (≤ 13 g/dl) were associated with higher mortality in the test [hazard ratio (HR) 2.422, 95 % confidence interval (CI) 1.357-4.322, P = 0.003] as well in the validation cohort (HR 2.486, 95 % CI 1.097-5.632, P = 0.029) in univariate Cox regression model. Low Hb levels were associated with mortality independently from the tumor stage, age, gender and the C-reactive protein levels in a multivariate Cox regression model. Anemia should be considered as a risk factor for mortality in HCC patients.
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Affiliation(s)
- Fabian Finkelmeier
- Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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935
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Affiliation(s)
- Michael F. Murphy
- NHS Blood & Transplant; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre; Oxford University Hospitals; University of Oxford; Oxford UK
| | - Mark H. Yazer
- Institute for Transfusion Medicine; Department of Pathology; University of Pittsburgh; Pittsburgh PA
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936
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Abstract
Abstract
Transfusion of blood and blood components has been a routine practice for more than half a century. The rationale supporting this practice is that replacement of blood loss should be beneficial for the patient. This assumption has constituted the underpinning of transfusion medicine for many decades. Only over the past 20 years, we have seen a more concerted effort to answer very basic questions regarding the value of transfusion therapy. An assessment of the value of transfusion based on well-designed and appropriately powered randomized, controlled trials is the first step in optimizing transfusion practices. Systematic reviews provide the second step by building the knowledge base necessary to assess the impact of transfusion practice on patient outcomes. The third step is the development of clinical practice guidelines, and this occurs when systematic reviews are interpreted by individuals with expertise in transfusion medicine. Such guidelines are typically supported by professional organizations and/or health authorities. Implementation of clinical practice guidelines can be challenging, especially in an area as heterogeneous as transfusion medicine. However, clinical practice guidelines are necessary for the practice of evidence-based medicine, which optimizes patient care and improves patient outcomes. This review focuses on clinical practice guidelines for transfusion of three blood components: RBCs, platelets and plasma. In addition, we provide the approach used to implement clinical practice guidelines at our own institution.
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937
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Cohen B, Matot I. Aged erythrocytes: a fine wine or sour grapes? Br J Anaesth 2013; 111 Suppl 1:i62-70. [DOI: 10.1093/bja/aet405] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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938
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Abstract
Gastrointestinal (GI) bleeding from the colon is a common reason for hospitalization and is becoming more common in the elderly. While most cases will cease spontaneously, patients with ongoing bleeding or major stigmata of hemorrhage require urgent diagnosis and intervention to achieve definitive hemostasis. Colonoscopy is the primary modality for establishing a diagnosis, risk stratification, and treating some of the most common causes of colonic bleeding, including diverticular hemorrhage which is the etiology in 30% of cases. Other interventions, including angiography and surgery, are usually reserved for instances of bleeding that cannot be stabilized or allow for adequate bowel preparation for colonoscopy. We discuss the colonoscopic diagnosis, risk stratification, and definitive treatment of colonic hemorrhage in patients presenting with severe hematochezia.
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939
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Lu Y, Loffroy R, Lau JYW, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2013; 101:e34-50. [PMID: 24277160 DOI: 10.1002/bjs.9351] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed. METHODS A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding. RESULTS Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding. CONCLUSION An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Y Lu
- Division of Gastroenterology and
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940
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Grant MC, Whitman GJ, Savage WJ, Ness PM, Frank SM. Clinical predictors of postoperative hemoglobin drift. Transfusion 2013; 54:1460-8. [DOI: 10.1111/trf.12491] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/23/2013] [Accepted: 09/30/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Michael C. Grant
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Glen J. Whitman
- Department of Surgery; Division of Cardiac Surgery; The Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Will J. Savage
- Department of Pathology (Transfusion Medicine); The Brigham and Women's Hospital; Boston Massachusetts
| | - Paul M. Ness
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Steven M. Frank
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore Maryland
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941
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Predictors of early rebleeding after endoscopic therapy in patients with nonvariceal upper gastrointestinal bleeding secondary to high-risk lesions. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 27:454-8. [PMID: 23936874 DOI: 10.1155/2013/128760] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In an era of increasingly shortened admissions, data regarding predictors of early rebleeding among patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) exhibiting high-risk stigmata (HRS) having undergone endoscopic hemostasis are lacking. OBJECTIVES To determine predictors of early rebleeding, defined as rebleeding before completion of recommended 72 h intravenous proton pump inhibitor infusion postendoscopic hemostasis. METHODS Data from a national registry of patients with upper gastrointestinal bleeding (the REASON registry) were accessed. Univariable and multivariable analyses were sequentially performed to identify significant independent predictors among a comprehensive list of clinical and laboratory characteristics. RESULTS Overall, 393 patients underwent endoscopic hemostasis for NVUGIB with HRS. Forty patients rebled ≤72 h thereafter (32.5% female, mean [± SD] age 70.2 ± 11.8 years, 2.88 ± 2.11 comorbidities), while 21 rebled later (38.1% female, mean 70.5 ± 14.1 years of age, 2.62 ± 2.06 comorbidities). Hematemesis or bright red blood per nasogastric tube aspirate was identified as the sole independent significant predictor of early rebleeding versus later among both NVUGIB and, more specifically, patients with peptic ulcer bleeding (OR 7.94 [95% CI 1.80 to 35.01]; P<0.01, and OR 8.41 [95% CI 1.54 to 46.10]; P=0.014, respectively). CONCLUSIONS When attempting to determine the optimal duration of pharmacotherapy and timing of discharge for patients following endoscopic hemostasis for NVUGIB with HRS, it is noteworthy that individuals who present with hematemesis or bright red blood per nasogastric tube aspirate are at particularly high risk for rebleeding within the first 72 h.
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942
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Hogshire LC, Patel MS, Rivera E, Carson JL. Evidence review: periprocedural use of blood products. J Hosp Med 2013; 8:647-52. [PMID: 24124069 DOI: 10.1002/jhm.2089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 08/19/2013] [Accepted: 08/26/2013] [Indexed: 11/07/2022]
Abstract
Blood product transfusion has not been subject to rigorous clinical study, and great practice variations exist. Of particular concern to hospitalists is the use of red blood cells, plasma, and platelets prior to invasive procedures to correct anemia or perceived bleeding risk. We summarize the known risks associated with periprocedural anemia, prolonged international normalized ratio (INR), and thrombocytopenia, as well as the effects of blood product administration on clinical outcomes. Clinical trial evidence argues for a restrictive red blood cell transfusion threshold (a hemoglobin level of 7-8 g/dL or symptomatic anemia) for most perioperative patients. There are no high-quality data to guide plasma and platelet transfusions around the time of procedures. Available data do not support the use of prothrombin time/INR to guide prophylactic administration of plasma, and there are scarce data to guide platelet use around the time of an invasive procedure. Therefore, we rely on current consensus expert opinion, which recommends administration of plasma in moderate- to high-risk procedures when INR is >1.5. We recommend platelet transfusion in low-risk procedures when platelet count is <20,000/μL, for average-risk procedures when platelet count is <50,000/μL, and for procedures involving the central nervous system when the platelet count is <100,000/μL.
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Affiliation(s)
- Lauren C Hogshire
- Hospitalist Program, Division of General Internal Medicine, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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943
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Wang J, Bao YX, Bai M, Zhang YG, Xu WD, Qi XS. Restrictive vs liberal transfusion for upper gastrointestinal bleeding: A meta-analysis of randomized controlled trials. World J Gastroenterol 2013; 19:6919-6927. [PMID: 24187470 PMCID: PMC3812494 DOI: 10.3748/wjg.v19.i40.6919] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 08/16/2013] [Accepted: 09/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcome of upper gastrointestinal bleeding (UGIB) between patients receiving restrictive and liberal transfusion.
METHODS: PubMed, EMBASE, and Cochrane Library databases were employed to identify all relevant randomized controlled trials regarding the outcome of UGIB after restrictive or liberal transfusion. Primary outcomes were death and rebleeding. Secondary outcomes were length of hospitalization, amount of blood transfused, and hematocrit and hemoglobin at discharge or after expansion.
RESULTS: Overall, 4 papers were included in this meta-analysis. The incidence of death was significantly lower in patients receiving restrictive transfusion than those receiving liberal transfusion (OR: 0.52, 95%CI: 0.31-0.87, P = 0.01). The incidence of rebleeding was lower in patients receiving restrictive transfusion than those receiving liberal transfusion, but this difference did not reach any statistical significance (OR: 0.26, 95%CI: 0.03-2.10, P = 0.21). Compared with those receiving liberal transfusion, patients receiving restrictive transfusion had a significantly shorter length of hospitalization (standard mean difference: -0.17, 95%CI: -0.30--0.04, P = 0.009) and a significantly smaller amount of blood transfused (standard mean difference: -0.74, 95%CI: -1.15--0.32, P = 0.0005) with a lower hematocrit and hemoglobin level at discharge or after expansion.
CONCLUSION: Restrictive transfusion should be employed in patients with UGIB.
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944
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Andrzejewski C, Casey MA, Popovsky MA. How we view and approach transfusion-associated circulatory overload: pathogenesis, diagnosis, management, mitigation, and prevention. Transfusion 2013; 53:3037-47. [DOI: 10.1111/trf.12454] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/27/2013] [Accepted: 08/27/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Chester Andrzejewski
- Transfusion Medicine Services; Department of Pathology; Baystate Health; Springfield Massachusetts
| | - Mark A. Casey
- Department of Medicine; Cardiology Division; Baystate Medical Center; Baystate Health; Springfield Massachusetts
- Department of Medicine; Cooley Dickinson Hospital; Northampton Massachusetts
| | - Mark A. Popovsky
- Haemonetics Corporation; Braintree Massachusetts
- Beth Israel Deaconess Medical Center; Boston Massachusetts
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945
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Braun G, Messmann H. Gastrointestinale Blutungen beim kardiologischen Patienten. Med Klin Intensivmed Notfmed 2013; 108:628-33. [DOI: 10.1007/s00063-013-0257-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 09/05/2013] [Indexed: 12/23/2022]
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946
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Madisch A. [Restrictive transfusion strategy in upper gastrointestinal hemorrhage]. MMW Fortschr Med 2013; 155:34. [PMID: 24288916 DOI: 10.1007/s15006-013-2273-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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947
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Current Management of Iron Deficiency Anemia in Inflammatory Bowel Diseases: A Practical Guide. Drugs 2013; 73:1761-70. [DOI: 10.1007/s40265-013-0131-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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948
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Wong SH, Sung JJY. Management of GI emergencies: peptic ulcer acute bleeding. Best Pract Res Clin Gastroenterol 2013; 27:639-47. [PMID: 24160924 DOI: 10.1016/j.bpg.2013.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/18/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Peptic ulcer bleeding is a common medical emergency. Management of acute ulcer bleeding requires prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy and treatment of co-morbid diseases. Tremendous advances in endoscopic technique and pharmacotherapy in the past few decades have reduced recurrent bleeding, the need for surgery and mortality of the disease. Strategies to minimize recurrence have been defined for various types of peptic ulcers. This article reviews the current management of acute peptic ulcer bleeding.
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Affiliation(s)
- Sunny H Wong
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong.
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Bolton-Maggs PHB. Blood transfusion safety: patients at risk from human errors. Br J Hosp Med (Lond) 2013; 74:544-5. [PMID: 24105304 DOI: 10.12968/hmed.2013.74.10.544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Paula HB Bolton-Maggs
- University of Manchester, Medical Director of the Serious Hazards of Transfusion UK National Haemovigilance Scheme, SHOT Office, Manchester Blood Centre, Manchester M13 9LL
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950
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Manejo de la hemorragia digestiva baja aguda: documento de posicionamiento de la Societat Catalana de Digestologia. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:534-45. [DOI: 10.1016/j.gastrohep.2013.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/11/2013] [Indexed: 12/16/2022]
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