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Granholm A, Perner A, Krag M, Marker S, Hjortrup PB, Haase N, Holst LB, Collet MO, Jensen AKG, Møller MH. External validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). Acta Anaesthesiol Scand 2019; 63:1216-1224. [PMID: 31273763 DOI: 10.1111/aas.13422] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Simplified Mortality Score for the Intensive Care Unit (SMS-ICU) is a clinical prediction model, which estimates the risk of 90-day mortality in acutely ill adult ICU patients using 7 readily available variables. We aimed to externally validate the SMS-ICU and compare its discrimination with existing prediction models used with 90-day mortality as the outcome. METHODS We externally validated the SMS-ICU using data from 3282 patients included in the Stress Ulcer Prophylaxis in the Intensive Care Unit trial, which randomised acutely ill adult ICU patients with risk factors for gastrointestinal bleeding to prophylactic pantoprazole or placebo in 33 ICUs in Europe. We assessed discrimination, calibration and overall performance of the SMS-ICU and compared discrimination with the commonly used and more complex SAPS II and SOFA scores. RESULTS Mortality at day 90 was 30.7%. The discrimination (area under the receiver operating characteristic curve) for the SMS-ICU was 0.67 (95% CI: 0.65-0.69), as compared with 0.68 (95% CI: 0.66-0.70, P = 0.35) for SAPS II and 0.63 (95% CI: 0.61-0.65, P < 0.001) for the SOFA score. Calibration (intercept and slope) was 0.001 and 0.786, respectively, and Nagelkerke's R2 (overall performance) was 0.06. The proportions of missing data for the SMS-ICU, SAPS II and SOFA scores were 0.2%, 8.5% and 6.8%, respectively. CONCLUSIONS Discrimination for 90-day mortality of the SMS-ICU in this cohort was poor, but similar to SAPS II and better than that of the SOFA score with markedly less missing data.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Mette Krag
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Søren Marker
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Peter Buhl Hjortrup
- Centre for Research in Intensive Care Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Zealand University Hospital Køge Denmark
| | - Nicolai Haase
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Lars Broksø Holst
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Marie Oxenbøll Collet
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Aksel Karl Georg Jensen
- Centre for Research in Intensive Care Copenhagen Denmark
- Section of Biostatistics University of Copenhagen Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
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Granholm A, Christiansen CF, Christensen S, Perner A, Møller MH. Performance of SAPS II according to ICU length of stay: A Danish nationwide cohort study. Acta Anaesthesiol Scand 2019; 63:1200-1209. [PMID: 31197823 DOI: 10.1111/aas.13415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/26/2019] [Accepted: 05/02/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Intensive care unit (ICU) severity scores use data available at admission or shortly thereafter. There are limited contemporary data on how the prognostic performance of these scores is affected by ICU length of stay (LOS). METHODS We conducted a nationwide cohort study using routinely collected health data from the Danish Intensive Care Database. We included adults with ICU admissions ≥24 hours between 1 January 2012 and 30 June 2016, who survived to ICU discharge and had valid ICU LOS and vital status data registered. We assessed discrimination of the Simplified Acute Physiology Score (SAPS) II for predicting mortality 90 days after ICU discharge, followed by recalibration of the model and assessment of standardized mortality ratios (SMRs) and calibration. Performance was assessed in the entire cohort and stratified by ICU LOS quartiles. RESULTS We included 44 523 patients. Increasing SAPS II was associated with increasing ICU LOS. Overall discrimination (area under the receiver-operating characteristics curve) of SAPS II was 0.70 (95% CI: 0.70-0.71), with decreasing discrimination from the first (0.75, 95% CI: 0.73-0.76) to the last (0.64, 95% CI: 0.63-0.65) ICU LOS quartile. SMRs were lower (less deaths) than expected in the first ICU LOS quartile and higher (more deaths) than expected in the last two ICU LOS quartiles. Calibration decreased with increasing ICU LOS. CONCLUSIONS We observed that discrimination and calibration of SAPS II decreased with increasing ICU LOS, and that this affected SMRs. These findings should be acknowledged when using SAPS II for clinical, research and administrative purposes.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | | | | | - Anders Perner
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131 Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen Denmark
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Chang WK, Tai YH, Lin SP, Wu HL, Chan MY, Chang KY. Perioperative blood transfusions are not associated with overall survival in elderly patients receiving surgery for fractured hips. J Chin Med Assoc 2019; 82:787-790. [PMID: 31356570 DOI: 10.1097/jcma.0000000000000163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Whether perioperative blood transfusions are associated with long-term outcomes remains controversial. This study aimed to evaluate the effect of blood transfusions on overall survival in hip fracture patients. METHODS This retrospective survey was conducted at a single medical center and enrolled patients aged ≥ 70 years who received hip fracture surgery between 2013 and 2015. Multivariate Cox regression analysis was used to estimate the effect of blood transfusions on overall survival after surgery. Furthermore, patients who received a blood transfusion were further matched to those who did not receive a blood transfusion by patient characteristics. Stratified Cox regression analysis was used to assess the effect of transfusions on overall survival after matching. RESULTS A total of 718 patients with a median follow-up period of 25.9 months were included in the analysis, of whom 495 (68.9%) received a blood transfusion. Four independent risk factors for mortality were identified, including male sex (hazard ratio [HR], 1.48; 95% CI, 1.01-2.17), aging (HR, 1.03; 95% CI, 1.0-1.06), general anesthesia (HR, 1.61; 95% CI, 1.11-2.31), and anemia status (mild vs no anemia: HR, 1.67; 95% CI, 0.96-2.90 and moderate versus no anemia: HR, 4.14; 95% CI, 2.35-7.3). The effect of blood transfusions on overall survival was nonsignificant after adjusting for the selected risk factors (HR, 1.44; 95% CI, 0.87-2.36). After matching, the effect of blood transfusions on overall survival remained nonsignificant (HR, 1.7; 95% CI, 0.78-3.71). CONCLUSION No association was found between blood transfusions and overall survival among elderly patients undergoing hip fracture surgery. More prospective studies are necessary to elucidate the association between blood transfusions and long-term outcomes in patients receiving hip fracture surgery.
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Affiliation(s)
- Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan, ROC
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsiang-Ling Wu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Min-Ya Chan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Technology Application and Human Resource Development, National Taiwan Normal University, Taipei, Taiwan, ROC
| | - Kuang-Yi Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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Jonsson AB, Granholm A, Rygård SL, Holst LB, Møller MH, Perner A. Lower vs higher transfusion threshold in septic shock patients of different ages: A study protocol. Acta Anaesthesiol Scand 2019; 63:1247-1250. [PMID: 31281958 DOI: 10.1111/aas.13437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Current evidence indicates that it is safe to use a lower haemoglobin (Hb) threshold for red blood cell (RBC) transfusion as compared to a higher Hb-threshold. However, the recent Transfusion Requirements in Cardiac Surgery (TRICS-3) trial reported a significant interaction between patient age and the effect of lower vs higher Hb-thresholds for RBC transfusion. The interaction between patient age and transfusion strategy appears to differ between trials. METHODS This is the protocol and statistical analysis plan for a post hoc analysis of the Transfusion Requirements in Septic Shock (TRISS) trial. We will assess the effect of a lower vs a higher Hb-threshold for RBC transfusion in patients of different ages with septic shock. The primary and secondary outcomes are 1-year mortality and 90-day mortality respectively. We will assess age divided into six age groups and as a continuous variable and present baseline characteristics and odds ratios derived from both simple and adjusted (for the Sequential Organ Failure Assessment score, haematological malignancy, age and trial site) logistic regression models and P-values for the test-of-interaction. Furthermore, we will compare outcomes according to Hb-threshold in each age group using Kaplan-Meier curves and log-rank tests. DISCUSSION The outlined study will make a detailed assessment of potential interaction of patient age with transfusion strategy in patients with septic shock. This may inform future trials on the benefits and harms of RBC transfusion.
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Affiliation(s)
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
| | - Sofie Louise Rygård
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
| | - Lars Broksø Holst
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
| | | | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
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Meyhoff TS, Hjortrup PB, Møller MH, Wetterslev J, Lange T, Kjær MN, Jonsson AB, Hjortsø CJS, Cronhjort M, Laake JH, Jakob SM, Nalos M, Pettilä V, Horst I, Ostermann M, Mouncey P, Rowan K, Cecconi M, Ferrer R, Malbrain MLNG, Ahlstedt C, Hoffmann S, Bestle MH, Nebrich L, Russell L, Vang M, Rasmussen ML, Sølling C, Rasmussen BS, Brøchner AC, Perner A. Conservative vs liberal fluid therapy in septic shock (CLASSIC) trial-Protocol and statistical analysis plan. Acta Anaesthesiol Scand 2019; 63:1262-1271. [PMID: 31276193 DOI: 10.1111/aas.13434] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/01/2019] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Intravenous (IV) fluid is a key intervention in the management of septic shock. The benefits and harms of lower versus higher fluid volumes are unknown and thus clinical equipoise exists. We describe the protocol and detailed statistical analysis plan for the conservative versus liberal approach to fluid therapy of septic shock in the Intensive Care (CLASSIC) trial. The aim of the CLASSIC trial is to assess benefits and harms of IV fluid restriction versus standard care in adult intensive care unit (ICU) patients with septic shock. METHODS CLASSIC trial is an investigator-initiated, international, randomised, stratified, and analyst-blinded trial. We will allocate 1554 adult patients with septic shock, who are planned to be or are admitted to an ICU, to IV fluid restriction versus standard care. The primary outcome is mortality at day 90. Secondary outcomes are serious adverse events (SAEs), serious adverse reactions (SARs), days alive at day 90 without life support, days alive and out of the hospital at day 90 and mortality, health-related quality of life (HRQoL), and cognitive function at 1 year. We will conduct the statistical analyses according to a pre-defined statistical analysis plan, including three interim analyses. For the primary analysis, we will use logistic regression adjusted for the stratification variables comparing the two interventions in the intention-to-treat (ITT) population. DISCUSSION The CLASSIC trial results will provide important evidence to guide clinicians' choice regarding the IV fluid therapy in adults with septic shock.
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Affiliation(s)
- Tine Sylvest Meyhoff
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Peter Buhl Hjortrup
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics University of Copenhagen Copenhagen Denmark
| | - Maj‐Brit Nørregaard Kjær
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Andreas Bender Jonsson
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | | | - Maria Cronhjort
- Department of Clinical Science and Education, Section of Anaesthesia and Intensive Care Karolinska Institutet, Södersjukhuset Stockholm Sweden
| | - Jon Henrik Laake
- Department of Anaesthesiology, Division of Emergencies and Critical Care Rikshospitalet, Oslo University Hospital Oslo Norway
| | - Stephan M. Jakob
- Department of Intensive Care Medicine University Hospital Bern (Inselspital), University of Bern Bern Switzerland
| | - Marek Nalos
- Medical Intensive Care Unit Interni klinika, Fakultni Nemocnice Plzen Czech Republic
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Iwan Horst
- Department of Intensive Care University Medical Centre Groningen Groningen The Netherlands
| | - Marlies Ostermann
- Department of Intensive Care Guy’s and St Thomas’ Hospital London UK
| | - Paul Mouncey
- Intensive Care National Audit & Research Centre (ICNARC) London UK
| | - Kathy Rowan
- Intensive Care National Audit & Research Centre (ICNARC) London UK
| | - Maurizio Cecconi
- Department of Intensive Care Medicine Humanitas Research Hospital Milan Italy
| | - Ricard Ferrer
- Department of Intensive Care Hospital Vall d'Hebron Barcelona Spain
| | - Manu L. N. G. Malbrain
- Department of Intensive Care Medicine University Hospital Brussels (UZB) Jette Belgium
- Faculty of Medicine and Pharmacy Vrije Universiteit Brussel (VUB) Brussels Belgium
| | - Christian Ahlstedt
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Huddinge Stockholm Sweden
| | - Søren Hoffmann
- Department of Anaesthesia and Intensive Care Copenhagen University Hospital, Bispebjerg Copenhagen Denmark
| | - Morten Heiberg Bestle
- Department of Anaesthesia and Intensive Care Nordsjællands Hospital, University Hospital of Copenhagen Hillerød Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Lars Nebrich
- Department of Anaesthesia and Intensive Care Zealand University Hospital Køge Denmark
| | - Lene Russell
- Department of Anaesthesia and Intensive Care Zealand University Hospital Roskilde Denmark
- Copenhagen Academy for Medical Education and Simulation, Rigshospitalet Copenhagen Denmark
| | - Marianne Vang
- Department of Anaesthesia and Intensive Care Randers Hospital Randers Denmark
| | | | | | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
| | | | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
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To transfuse or not transfuse: an intensive appraisal of red blood cell transfusions in the ICU. Curr Opin Hematol 2019; 25:468-472. [PMID: 30281035 DOI: 10.1097/moh.0000000000000460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW This review is a critical appraisal of the current data comparing restrictive vs. liberal transfusion strategies for patients who are critically ill in ICUs. We focus on four subsets of critically ill patients: pediatric patients, patients with gastrointestinal bleeds, septic patients and patients undergoing cardiac surgery. RECENT FINDINGS Almost a decade after the TRICC trial, a randomized trial showing the safety of a restrictive transfusion threshold in critically ill patients, four large randomized controlled trials have shown that a restrictive transfusion strategy is safe in pediatric critically ill patients, patients with acute upper gastrointestinal bleeds, patients with septic shock and patients undergoing cardiac surgery. A large multicenter randomized trial is underway to determine the safety of a restrictive strategy in myocardial infarction. SUMMARY A restrictive transfusion threshold is recommended in nearly all critically ill patients. This is at least noninferior to more liberal transfusion practice; in addition, a restrictive threshold has shown improved outcomes in some patients and decreased chances of adverse events in patients. Judicious use of red cells improves patient outcome and protects the blood supply, a limited resource. More data are needed to determine appropriate transfusion threshold recommendations for patients with traumatic brain injury and acute coronary syndrome.
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207
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Vincent JL, De Backer D. From Early Goal-Directed Therapy to Late(r) Scvo 2 Checks. Chest 2019; 154:1267-1269. [PMID: 30526962 DOI: 10.1016/j.chest.2018.07.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium.
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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209
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Abstract
PURPOSE OF REVIEW To outline key points for perioperative ICU optimization of nutrition, airway management, blood product preparation and transfusion, antibiotic prophylaxis and transport. RECENT FINDINGS Optimization entails glycemic control for all, with specific attention to type-1 diabetic patients. Transport-related adverse events may be averted with surgery in the ICU. If moving the patient is unavoidable, transport guidelines should be followed and hemodynamic optimization, airway control, and stabilization of mechanical ventilation ensured before transport. Preinduction preparation includes assessment of the airway and the provision of high-flow oxygen to prolong apneic oxygenation. Postintubation, a protective positive ventilation strategy should be employed. Ideal transfusion thresholds are 7 g/dl for hemodynamically stable adult patients, 8 g/dl in orthopedic or cardiac surgery patients as well as those with underlying cardiovascular disease. Higher transfusions thresholds may be required in specific disease states. Antimicrobial prophylaxis within 120 min of incision prevents most surgical site infections. Antibiotic therapy depends on the antibiotics being received in the ICU, the time elapsed since ICU admission, local epidemiology and the type of surgery. Tailored antimicrobial regimens may be continued periprocedurally. If more than 70% of the nutritional requirement cannot be met enterally, parenteral nutrition should be initiated within 5-7 days of surgery or earlier if the patient is malnourished. SUMMARY ICU patients who require surgery may benefit from appropriate perioperative management.
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210
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de Bruin S, Scheeren TWL, Bakker J, van Bruggen R, Vlaar APJ. Transfusion practice in the non-bleeding critically ill: an international online survey-the TRACE survey. Crit Care 2019; 23:309. [PMID: 31511083 PMCID: PMC6737617 DOI: 10.1186/s13054-019-2591-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/29/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Over the last decade, multiple large randomized controlled trials have studied alternative transfusion strategies in critically ill patients, demonstrating the safety of restrictive transfusion strategies. Due to the lack of international guidelines specific for the intensive care unit (ICU), we hypothesized that a large heterogeneity in transfusion practice in this patient population exists. The aims of this study were to describe the current transfusion practices and identify the knowledge gaps. METHODS An online, anonymous, worldwide survey among ICU physicians was performed evaluating red blood cell, platelet and plasma transfusion practices. Furthermore, the presence of a hospital- or ICU-specific transfusion guideline was asked. Only completed surveys were analysed. RESULTS Nine hundred forty-seven respondents filled in the survey of which 725 could be analysed. Hospital transfusion protocol available in their ICU was reported by 53% of the respondents. Only 29% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin (Hb) threshold for the general ICU population was 7 g/dL (7-7). The highest reported variation in transfusion threshold was in patients on extracorporeal membrane oxygenation or with brain injury (8 g/dL (7.0-9.0)). Platelets were transfused at a median count of 20 × 109 cells/L IQR (10-25) in asymptomatic patients, but at a higher count prior to invasive procedures (p < 0.001). In patients with an international normalized ratio (INR) > 3, 43% and 57% of the respondents would consider plasma transfusion without any upcoming procedures or prior to a planned invasive procedure, respectively. Finally, doctors with base specialty in anaesthesiology transfused critically ill patients more liberally compared to internal medicine physicians. CONCLUSION Red blood cell transfusion practice for the general ICU population is restrictive, while for different subpopulations, higher Hb thresholds are applied. Furthermore, practice in plasma and platelet transfusion is heterogeneous, and local transfusion guidelines are lacking in the majority of the ICUs.
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Affiliation(s)
- Sanne de Bruin
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research, and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas W L Scheeren
- Department of Anaesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Bakker
- Department of Intensive Care Medicine, Erasmus MC University Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care Medicine, New York University Medical Center and Columbia University Medical Center New York, New York City, USA
- Ponfificia Universidad Católica de Chile, Santiago, Chile
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research, and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Sullivan HC, Roback JD. The pillars of patient blood management: key to successful implementation
(Article, p. 2840). Transfusion 2019; 59:2763-2767. [DOI: 10.1111/trf.15464] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/15/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | - John D. Roback
- Pathology and Laboratory MedicineEmory University Atlanta Georgia
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Kofoed A, Perner A, Marker S, Haase N, Holst LB, Møller MH. Effects of simulated sample sizes on mortality estimates-Protocol for a study in 3 randomised ICU trials. Acta Anaesthesiol Scand 2019; 63:1098-1101. [PMID: 31032881 DOI: 10.1111/aas.13381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/19/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND An increasing number of trials are stopped earlier than originally planned. It has been suggested that trials stopped pre-maturely overestimate the treatment effect. With the outlined observational study, we aim to simulate the results of stopping trials before they reach their planned sample size to assess the effects on mortality estimates. METHODS AND STATISTICS Based on 3 international, randomised clinical trials (RCTs) in critical care: Scandinavian Starch for Severe Sepsis and Septic Shock (6S) trial, the Transfusion Requirements in Septic Shock (TRISS) trial and the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial, we will estimate relative risks with 95% confidence intervals for the primary outcome 90-day mortality after the inclusion of each individual patient in each RCT. This will be presented graphically with the primary outcome as a function of the number of included patients. DISCUSSION The outlined study will provide important knowledge about the effects of stopping critical care trials early. This may have important implications for patients, relatives, clinicians, researchers, guideline committee members and policy makers. ETHICS AND DISSEMINATION We will use data from consenting patients enrolled in RCTs approved by the relevant ethical committees; this study requires no further permissions. We will report the results in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and submit the final approved manuscript to a peer-reviewed journal.
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Affiliation(s)
- A. Kofoed
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - A. Perner
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - S. Marker
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - N. Haase
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - L. B. Holst
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - M. H. Møller
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
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Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery. Anesthesiology 2019; 129:1082-1091. [PMID: 30124488 DOI: 10.1097/aln.0000000000002397] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes. METHODS After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index. RESULTS After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016). CONCLUSIONS In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.
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Ayling OGS, Ibrahim GM, Alotaibi NM, Gooderham PA, Macdonald RL. Anemia After Aneurysmal Subarachnoid Hemorrhage Is Associated With Poor Outcome and Death. Stroke 2019; 49:1859-1865. [PMID: 29946013 DOI: 10.1161/strokeaha.117.020260] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Anemia after aneurysmal subarachnoid hemorrhage is common and potentially modifiable. Here, we first evaluate the effect of anemia on neurological outcome and death and second, study the effects of packed red blood cell transfusion on outcome. Methods- A secondary analysis on 413 subjects in the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage). Multivariable logistic regression identified independent risk factors for anemia and determined the effect of anemia on neurological outcome and death, while adjusting for selected covariates. Optimal predictive thresholds for hemoglobin levels were determined using receiver operating characteristic curve analysis. Finally, patients were pseudorandomized to transfusion using propensity score matching to study the effect of transfusions on outcome. Results- Anemia, defined as hemoglobin <10 g/dL, was present in 5% of patients at presentation, in 29% of patients after aneurysm securing (days 1-3), and in 32% of patients during the peak delayed cerebral ischemia risk period (days 5-9). Anemia after aneurysm securing (odds ratio, 1.96; 95% confidence interval, 1.07-3.59; P=0.03) and during the delayed cerebral ischemia window (odds ratio, 2.63; 95% confidence interval, 1.46-4.76; P=0.0014) was independently associated with poor neurological outcome. Anemia postaneurysm securing (odds ratio, 3.50; 95% confidence interval, 1.15-10.62; P=0.027) but not during the delayed cerebral ischemia window was associated with death. Using propensity score-matched cohorts, we found that transfusion of anemic patients did not improve long-term outcome (P=0.8) or mortality rates (P=0.9). Transfusion of patients with a hemoglobin concentration >10 g/dL was associated with improved neurological outcomes (odds ratio, 0.09; 95% confidence interval, 0.002-0.72; P=0.015), with no differences in mortality. Conclusions- Anemia after aneurysmal subarachnoid hemorrhage is associated with poor long-term neurological outcome and death. Transfusion of packed red blood cells is beneficial for patients who are not considerably anemic beforehand, suggesting further work needs to define the threshold but also the time period of anemia that is sufficient and necessary to contribute to poor outcomes. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00111085.
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Affiliation(s)
- Oliver G S Ayling
- From the Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G.)
| | | | - Naif M Alotaibi
- Department of Surgery, Li Ka Shing Knowledge Institute (N.M.A., R.L.M.).,Institute of Medical Science (N.M.A.), University of Toronto, Canada.,Division of Neurosurgery, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, St. Michael's Hospital, Toronto, Canada (N.M.A., R.L.M.)
| | - Peter A Gooderham
- From the Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G.)
| | - R Loch Macdonald
- Department of Surgery, Li Ka Shing Knowledge Institute (N.M.A., R.L.M.).,Division of Neurosurgery, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, St. Michael's Hospital, Toronto, Canada (N.M.A., R.L.M.)
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215
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Slovinski AP, Hajjar LA, Ince C. Microcirculation in Cardiovascular Diseases. J Cardiothorac Vasc Anesth 2019; 33:3458-3468. [PMID: 31521493 DOI: 10.1053/j.jvca.2019.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022]
Abstract
Microcirculation is a system composed of interconnected microvessels, which is responsible for the distribution of oxygenated blood among and within organs according to regional metabolic demand. Critical medical conditions, e. g., sepsis, and heart failure are known triggers of microcirculatory disturbance, which usually develops early in such clinical pictures and represents an independent risk factor for mortality. Therefore, hemodynamic resuscitation aiming at restoring microcirculatory perfusion is of paramount importance. Until recently, however, resuscitation protocols were based on macrohemodynamic variables, which increases the risk of under or over resuscitation. The introduction of hand-held video-microscopy (HVM) into clinical practice has allowed real-time analysis of microcirculatory variables at the bedside and, hence, favored a more individualized approach. In the cardiac intensive care unit scenario, HVM provides essential information on patients' hemodynamic status, e. g., to classify the type of shock, to adequate the dosage of vasopressors or inotropes according to demand and define safer limits, to guide fluid therapy and red blood cell transfusion, to evaluate response to treatment, among others. Nevertheless, several drawbacks have to be addressed before HVM becomes a standard of care.
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Affiliation(s)
| | | | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands
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216
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Boshuizen M, van Bruggen R, Zaat SA, Schultz MJ, Aguilera E, Motos A, Senussi T, Idone FA, Pelosi P, Torres A, Bassi GL, Juffermans NP. Development of a model for anemia of inflammation that is relevant to critical care. Intensive Care Med Exp 2019; 7:47. [PMID: 31346819 PMCID: PMC6658638 DOI: 10.1186/s40635-019-0261-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Anemia of inflammation (AI) is common in critically ill patients. Although this syndrome negatively impacts the outcome of critical illness, understanding of its pathophysiology is limited. Also, new therapies that increase iron availability for erythropoiesis during AI are upcoming. A model of AI induced by bacterial infections that are relevant for the critically ill is currently not available. This paper describes the development of an animal model for AI that is relevant for critical care research. RESULTS In experiments with rats, the rats were inoculated either repeatedly or with a slow release of Streptococcus pneumoniae or Pseudomonas aeruginosa. Rats became ill, but their hemoglobin levels remained stable. The use of a higher dose of bacteria resulted in a lethal model. Then, we turned to a model with longer disease duration, using pigs that were supported by mechanical ventilation after inoculation with P. aeruginosa. The pigs became septic 12 to 24 h after inoculation, with a statistically significant decrease in mean arterial pressure and base excess, while heart rate tended to increase. Pigs needed resuscitation and vasopressor therapy to maintain a mean arterial pressure > 60 mmHg. After 72 h, the pigs developed anemia (baseline 9.9 g/dl vs. 72 h, 7.6 g/dl, p = 0.01), characterized by statistically significant decreased iron levels, decreased transferrin saturation, and increased ferritin. Hepcidin levels tended to increase and transferrin levels tended to decrease. CONCLUSIONS Using pathogens commonly involved in pulmonary sepsis, AI could not be induced in rats. Conversely, in pigs, P. aeruginosa induced pulmonary sepsis with concomitant AI. This AI model can be applied to study the pathophysiology of AI in the critically ill and to investigate the effectivity and toxicity of new therapies that aim to increase iron availability.
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Affiliation(s)
- Margit Boshuizen
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, 1066, CX, The Netherlands.
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, 1066, CX, The Netherlands
| | - Sebastian A Zaat
- Department of Microbiology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, 1105, AZ, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Eli Aguilera
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, 08036, Barcelona, Spain
| | - Ana Motos
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, 08036, Barcelona, Spain
| | - Tarek Senussi
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, 08036, Barcelona, Spain
- Department of Surgical Sciences and Integrated Diagnostics (DISC), San Martino Policlinico Hospital - IRCCS for Oncology, 16132, Genova, Italy
| | - Francesco Antonio Idone
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, 08036, Barcelona, Spain
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), San Martino Policlinico Hospital - IRCCS for Oncology, 16132, Genova, Italy
| | - Antonio Torres
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, 08036, Barcelona, Spain
| | - Gianluigi Li Bassi
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, 08036, Barcelona, Spain
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
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217
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Hamarneh Z, Robinson K, Andrews J, Hunt R, Fraser R. Transfusion strategies in upper gastrointestinal bleeding management: a review of South Australian hospital practice. Intern Med J 2019; 50:582-589. [PMID: 31336018 DOI: 10.1111/imj.14440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a common cause of hospital admission and red cell transfusion is frequently required. A large single-centre randomised study from 2013 showed that a restrictive transfusion strategy in UGIB management was associated with better outcomes compared to a liberal strategy. Subsequently multiple international guidelines favour a restrictive transfusion strategy. However, given the multiple exclusion criteria in the study, generalisation to everyday practice was unclear. AIMS To assess applicability of the data to a non-trial UGIB population and determine how often restrictive thresholds are used in clinical practice. METHODS A retrospective case note review of patients with an UGIB admission during 2014 in three tertiary hospitals was undertaken. Information collected included demographics, comorbidities and factors associated with transfusion, such as apparent haemoglobin triggers and units transfused. The proportion of patients who would have met inclusion criteria of the study was calculated. RESULTS Of 89 UGIB admissions reviewed, up to 70% would be suitable for a restrictive approach. Use of this approach was evident in only 26% of transfusion episodes in patients meeting inclusion criteria. However, assessment was, limited by rapidly changing clinical status and potential for overestimation of true haemoglobin level with fluid resuscitation and equilibration. CONCLUSION A restrictive transfusion strategy may be suitable for many patients presenting with UGIB; however, important exclusions were not uncommon. Opportunities for increased uptake of restrictive thresholds were identified. Ongoing improvement initiatives should address the risks of both over and under-transfusion.
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Affiliation(s)
- Zaki Hamarneh
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Kathryn Robinson
- BloodSafe Program, Department for Health and Wellbeing, Government of South Australia, Adelaide, South Australia, Australia
| | - Jane Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Russell Hunt
- BloodSafe Program, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Robert Fraser
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
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218
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Hirano Y, Miyoshi Y, Kondo Y, Okamoto K, Tanaka H. Liberal versus restrictive red blood cell transfusion strategy in sepsis or septic shock: a systematic review and meta-analysis of randomized trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:262. [PMID: 31345236 PMCID: PMC6659290 DOI: 10.1186/s13054-019-2543-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023]
Abstract
Background We assessed the effect of liberal versus restrictive red blood cell transfusion strategy on survival outcome in sepsis or septic shock by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). Methods We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases. We included RCTs that compared mortality between a liberal transfusion strategy with a hemoglobin threshold of 9 or 10 g/dL and a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL in adults with sepsis or septic shock. Two investigators independently screened citations and conducted data extraction. The primary outcome was 28- or 30-day mortality. Secondary outcomes were 60- and 90-day mortality, use of life support at 28 days of admission, and number of patients transfused during their intensive care unit stay. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs). Results A total of 1516 patients from three RCTs were included; 749 were randomly assigned to the liberal transfusion group and 767 to the restrictive strategy group. Within 28–30 days, 273 patients (36.4%) died in the liberal transfusion group, while 278 (36.2%) died in the restrictive transfusion group (pooled OR, 0.99; 95% confidence interval [CI], 0.67–1.46). For the primary outcome, heterogeneity was observed among the studies (I2 = 61.0%, χ2 = 5.13, p = 0.08). For secondary outcomes, only two RCTs were included. There were no significant differences in secondary outcomes between the two groups. Conclusions We could not show any difference in 28- or 30-day mortality between the liberal and restrictive transfusion strategies in sepsis or septic shock patients by meta-analysis of RCTs. Our results should be interpreted with caution due to the existence of heterogeneity. As sepsis complicates a potentially wide range of underlying diseases, further trials in carefully selected populations are anticipated. Trial registration This present study was registered in the PROSPERO database (CRD42018108578). Electronic supplementary material The online version of this article (10.1186/s13054-019-2543-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Yukari Miyoshi
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Ken Okamoto
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
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219
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Vincent JL, Sakr Y. Clinical trial design for unmet clinical needs: a spotlight on sepsis. Expert Rev Clin Pharmacol 2019; 12:893-900. [DOI: 10.1080/17512433.2019.1643235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jean-Louis Vincent
- Dept of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
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220
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Should Transfusion Trigger Thresholds Differ for Critical Care Versus Perioperative Patients? A Meta-Analysis of Randomized Trials. Crit Care Med 2019; 46:252-263. [PMID: 29189348 PMCID: PMC5770109 DOI: 10.1097/ccm.0000000000002873] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Supplemental Digital Content is available in the text. Objective: To address the significant uncertainty as to whether transfusion thresholds for critical care versus surgical patients should differ. Design: Meta-analysis of randomized controlled trials. Setting: Medline, EMBASE, and Cochrane Library searches were performed up to 15 June 2016. Patients: Trials had to enroll adult surgical or critically ill patients for inclusion. Interventions: Studies had to compare a liberal versus restrictive threshold for the transfusion of allogeneic packed RBCs. Measurements and Main Results: The primary outcome was 30-day all-cause mortality, sub-grouped by surgical and critical care patients. Secondary outcomes included myocardial infarction, stroke, renal failure, allogeneic blood exposure, and length of stay. Odds ratios and weighted mean differences were calculated using random effects meta-analysis. To assess whether subgroups were significantly different, tests for subgroup interaction were used. Subgroup analysis by trials enrolling critically ill versus surgical patients was performed. Twenty-seven randomized controlled trials (10,797 patients) were included. In critical care patients, restrictive transfusion resulted in significantly reduced 30-day mortality compared with liberal transfusion (odds ratio, 0.82; 95% CI, 0.70–0.97). In surgical patients, a restrictive transfusion strategy led to the opposite direction of effect for mortality (odds ratio, 1.31; 95% CI, 0.94–1.82). The subgroup interaction test was significant (p = 0.04), suggesting that the effect of restrictive transfusion on mortality is statistically different for critical care (decreased risk) versus surgical patients (potentially increased risk or no difference). Regarding secondary outcomes, for critically ill patients, a restrictive strategy resulted in reduced risk of stroke/transient ischemic attack, packed RBC exposure, transfusion reactions, and hospital length of stay. In surgical patients, restrictive transfusion resulted in reduced packed RBC exposure. Conclusions: The safety of restrictive transfusion strategies likely differs for critically ill patients versus perioperative patients. Further trials investigating transfusion strategies in the perioperative setting are necessary.
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221
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Pelavski AD, de Miguel M, Villarino L, Alcaraz G, Buendía P, Rochera MI, Lacasta A, Señas L, Colomina MJ. Audit of transfusion among the oldest old: treading the fine line between undertransfusion and optimum trigger. Transfusion 2019; 59:2812-2819. [PMID: 31259421 DOI: 10.1111/trf.15428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/27/2019] [Accepted: 06/02/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recent research has questioned restrictive transfusion policies in vulnerable elderly populations. Our audit assesses the prevalence and postoperative outcomes of extremely elderly patients undergoing the stress of surgery with perioperative hemoglobin (Hb) less than 9 g/dL. STUDY DESIGN AND METHODS This retrospective analysis of prospectively collected data addressed patients aged 85+ undergoing elective surgery. Demographic data and baseline characteristics were recorded, as well as Hb and transfused red blood cell (RBC) units. The main endpoint was the prevalence of perioperative Hb less than 9 g/dL, that is, patients with baseline Hb <9 g/dL without preoperative transfusions (defined as Group A). Patients with perioperative Hb of 9 g/dL or greater (with or without transfusion) were designated as Group B. Secondary outcomes included morbidity, length of hospital stay, and mortality 30 days and 6 months after surgery. A bivariate analysis was performed followed by logistic regression to determine whether undergoing the stress of surgery with perioperative Hb less than 9 g/dL was an independent risk factor for postoperative outcomes. RESULTS A total of 148 patients were included. The prevalence of perioperative Hb less than 9 g/dL was 25%. It was associated with increased morbidity and mortality -both 30 days and 6 months after surgery- and a prolonged length of hospital stay. Anemia-associated complications were higher among patients from Group A, whereas transfusion-associated ones were evenly distributed. In all the regression models, perioperative Hb less than 9 g/dL was an independent risk factor for worse postoperative outcomes. CONCLUSION Perioperative Hb less than 9 g/dL was common among patients aged 85+, and it was associated with increased risk of adverse postoperative outcomes. The tolerance to anemia might decrease perioperatively when Hb is less than 9 g/dL. Thus, less restrictive thresholds deserve further evaluation.
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Affiliation(s)
- Andrés D Pelavski
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcos de Miguel
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Villarino
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gabriela Alcaraz
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paloma Buendía
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María I Rochera
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Albert Lacasta
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lucía Señas
- Department of Anaesthesia, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María J Colomina
- Department of Anaesthesia, Hospital de Bellvitge, Universitat de Barcelona, Barcelona, Spain
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222
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Hippensteel JA, Schmidt EP. Sequestering Damage-associated Molecular Patterns in Critical Illness. A Novel Homeostatic Role for the Erythrocyte. Am J Respir Crit Care Med 2019; 197:416-418. [PMID: 29120664 DOI: 10.1164/rccm.201710-2094ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Eric P Schmidt
- 1 Department of Medicine University of Colorado Denver Aurora, Colorado
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223
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[Mortality after high-risk surgery in Jehovah's Witness patients]. Anaesthesist 2019; 68:444-455. [PMID: 31236704 DOI: 10.1007/s00101-019-0617-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/21/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Jehovah's Witness (JW) patients strictly refuse allogeneic blood transfusion for religious reasons. Nevertheless, JW also wish to benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The Northwest Hospital in Frankfurt am Main Germany is a confidential clinic of JW and performs approximately 100 surgical interventions per year on this patient group. MATERIAL AND METHODS A retrospective analysis of closed medical cases performed in the years 2008-2018 at the Northwest Hospital aimed to clarify (1) the frequency of surgical procedures in JW patients associated with a statistical allogeneic transfusion risk (presence of preoperative anemia and/or in-house transfusion probability >10%) during this time period, (2) the degree of acceptance of strategies avoiding blood transfusion by JW and (3) the anemia-related postoperative mortality rate in JW patients. RESULTS In the 11- year observation period 123 surgical procedures with a relevant allogeneic transfusion risk were performed in 105 JW patients. Anemia according to World Health Organization (WHO) criteria was present in 44% of cases on the day of surgery. Synthetic and recombinant drugs (tranexamic acid, desmopressin, erythropoetin, rFVIIa) were generally accepted, acute normovolemic hemodilution (ANH) in 92% and cell salvage in 96%. Coagulation factor concentrates extracted from human plasma and therefore generally refused by JW so far, were accepted by 83% of patients following detailed elucidation. Out of 105 JW patients 7 (6.6%) died during the postoperative hospital stay. In 4 of the 7 fatal cases the cause of death could be traced back to severe postoperative anemia. CONCLUSION Given optimal management JW patients can undergo major surgery without an excessive risk of death. The 6.6% in-hospital mortality observed in this institution was in the range of the 4% generally observed after surgery in Europe. The majority of JW patients accepted a variety of blood conservation strategies following appropriate elucidation. This also included coagulation factor concentrates extracted from human plasma enabling an effective treatment of even severe bleeding complications. In this analysis postoperative hemoglobin concentrations below 6 g/dl in older JW patients were associated with a high mortality risk due to anemia.
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224
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Camou F, Didier M, Leguay T, Milpied N, Daste A, Ravaud A, Mourissoux G, Guisset O, Issa N. Long-term prognosis of septic shock in cancer patients. Support Care Cancer 2019; 28:1325-1333. [PMID: 31243586 DOI: 10.1007/s00520-019-04937-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/11/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES In the last decades, the number of cancer patients admitted in intensive care units (ICUs) for septic shock has dramatically increased. However, prognosis data remain scarce. METHODS To assess the 180-day mortality rate in cancer patients admitted to the ICU for septic shock, a 5-year prospective study was performed. All adult patients admitted for septic shock were included and categorized into the following two groups and four subgroups: cancer patients (solid tumor or hematological malignancy) and non-cancer patients (immunocompromised or not). Data were collected and compared between the groups. Upon early ICU admission, the decision to forgo life-sustaining therapy (DFLST) or not was made by consultation among hematologists, oncologists, and the patients or their relatives. RESULTS During the study period, 496 patients were admitted for septic shock: 252 cancer patients (119 hematological malignancies and 133 solid tumors) and 244 non-cancer patients. A DFLST was made for 39% of the non-cancer patients and 52% of the cancer patients. The 180-day mortality rate among the cancer patients was 51% and 68% for those with hematological malignancies and solid cancers, respectively. The mortality rate among the non-cancer patients was 44%. In a multivariate analysis, the performance status, Charlson comorbidity index, simplified acute physiology score 2, sequential organ failure assessment score, and DFLST were independent predictors of 180-day mortality. CONCLUSIONS Despite early admission to the ICU, the 180-day mortality rate due to septic shock was higher in cancer patients compared with non-cancer patients, due to excess mortality in the patients with solid tumors. The long-term prognosis of cancer patients with septic shock is modulated by their general state, severity of organ failure, and DFLST.
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Affiliation(s)
- Fabrice Camou
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | - Marion Didier
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | | | - Noël Milpied
- Hematology, CHU Bordeaux, 33000, Bordeaux, France
| | | | | | - Gaëlle Mourissoux
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | - Olivier Guisset
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | - Nahéma Issa
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France. .,Hôpital Saint-André, 1 rue Jean Burguet, 33075, Bordeaux, France.
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225
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Ukken J, Froehlich M, Kioka M, Romero A, Lee YJ, Liu X, Liu C, Yoo JW. Effects of Advanced Care Planning on Reduced Mortality, Implications of Blood Transfusion Use by ICU sites, and Further Statistical Considerations. Chest 2019; 153:284-285. [PMID: 29307423 DOI: 10.1016/j.chest.2017.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 09/27/2017] [Indexed: 01/28/2023] Open
Affiliation(s)
- Johnson Ukken
- University of Nevada Reno School of Medicine, Reno, NV
| | | | - Mutsumi Kioka
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV
| | - Arthur Romero
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV
| | - Yong Jae Lee
- Department of Family Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Xibei Liu
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Caroline Liu
- Department of Science, Northeastern University, Boston, MA
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV.
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Jung SM, Kim YJ, Ryoo SM, Kim WY. Relationship between low hemoglobin levels and mortality in patients with septic shock. Acute Crit Care 2019; 34:141-147. [PMID: 31723919 PMCID: PMC6786672 DOI: 10.4266/acc.2019.00465] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/19/2019] [Accepted: 05/20/2019] [Indexed: 01/01/2023] Open
Abstract
Background Hemoglobin levels are a critical parameter for oxygen delivery in patients with shock. On comparing target hemoglobin levels upon transfusion initiation, the correlation between the severity of decrease in hemoglobin levels and patient outcomes remains unclear. We evaluated the association between initial hemoglobin levels and mortality in patients with septic shock treated with protocol-driven resuscitation bundle therapy at an emergency department. Methods Data of adult patients diagnosed with septic shock between June 2012 and December 2016 were extracted from a prospectively compiled septic shock registry at a single academic medical center. Patients were classified into four groups according to initial hemoglobin levels: ≥9.0 g/dl, 8.0-8.9 g/dl, 7.0-7.9 g/dl, and <7.0 g/dl. The primary endpoint was 90-day mortality. Results In total, 2,265 patients (male, 58.3%; median age, 70.0 years [interquartile range, 60 to 78 years]) with septic shock were included. For the four groups, 90-day mortality rates were as follows: 29.1%, 43.0%, 46.5%, and 46.9% for ≥9.0 g/dl (n=1,808), 8.0-8.9 g/dl (n=217), 7.0-7.9 g/dl (n=135), and <7.0 g/dl (n=105), respectively (P<0.001). Multivariate logistic regression showed that initial hemoglobin levels were an independent factor associated with 90-day mortality and mortality proportionally increased with decreasing hemoglobin levels (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.36 to 2.61 for 8.0-8.9 g/dl; OR, 1.97; 95% CI, 1.31 to 2.95 for 7.0-7.9 g/dl; and OR, 2.35; 95% CI, 1.52 to 3.63 for <7.0 g/dl). Conclusions Low hemoglobin levels (<9.0 g/dl) were observed in approximately 20% of patients with septic shock, and the severity of decrease in these levels correlated with mortality.
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Affiliation(s)
- Sung Min Jung
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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228
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Abstract
Sepsis is still associated with very high morbidity and mortality. Continuous improvements in the early recognition and management of this syndrome are thus necessary. The 2016 Surviving Sepsis Campaign sepsis guideline presents current evidence and consequences in the management of sepsis. This new guideline came at the beginning of the paradigm shift in sepsis definition, whereby the influence of the current sepsis definition on the management of sepsis is yet to be seen. Despite tremendous research efforts, several recommendations in the new sepsis guideline have a weak to moderate evidence grade. Several issues, such as the effect of the Sepsis-3 definition on the early recognition of sepsis, the selection of appropriate fluid and antibiotic therapy, as well as individualizing sepsis management are yet to be addressed. Therefore, the current guideline is also a call for the intensive care community for more and better research on sepsis treatment.
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Affiliation(s)
- S Petros
- Interdisziplinäre Internistische Intensivmedizin, Zentrum für Hämostaseologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - S John
- Medizinische Klinik 4, Intensivmedizin, Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
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229
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Extracorporeal Membrane Oxygenation Is Not First-Line Therapy for the Acute Respiratory Distress Syndrome. Crit Care Med 2019; 45:2074-2077. [PMID: 28991831 DOI: 10.1097/ccm.0000000000002748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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230
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Metcalf RA, White SK, Potter S, Barney R, Hunter C, White M, Enniss T, Galaviz C, Reddy S, Wanner N, Schmidt RL, Blaylock R. The association of inpatient blood utilization and diagnosis-related group weight: implications for risk-adjusted benchmarking. Transfusion 2019; 59:2316-2323. [PMID: 31106447 DOI: 10.1111/trf.15343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 04/05/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Risk-adjusted benchmarking could be useful to compare blood utilization between hospitals or individual groups, such as physicians, while accounting for differences in patient complexity. The aim of this study was to analyze the association of red blood cell (RBC) use and diagnosis-related group (DRG) weights across all inpatient hospital stays to determine the suitability of using DRGs for between-hospital risk-adjusted benchmarking. Specific hierarchical organizational units (surgical vs. nonsurgical patients, departments, and physicians) were also evaluated. STUDY DESIGN AND METHODS We studied blood use among all adult inpatients, and within organizational units, over 4 years (May 2014 to March 2018) at an academic center. Number of RBCs transfused, all patient refined (APR)-DRGs, and other variables were captured over entire hospital stays. We used multilevel generalized linear modeling (zero-inflated negative binomial) to study the relationship between RBC utilization and APR-DRG. RESULTS A total of 97,955 hospital stays were evaluated and the median APR-DRG weight was 1.2. The association of RBCs transfused and APR-DRG weight was statistically significant at all hierarchical levels (incidence rate ratio = 1.22; p < 0.001). The impact of APR-DRG on blood use, measured by the incidence rate ratio, demonstrated an association at the all-patient and surgical levels, at several department and physician levels, but not at the medical patient level. The relationship between RBCs transfused and APR-DRG varied across organizational units. CONCLUSION Number of RBCs transfused was associated with APR-DRG weight at multiple hierarchical levels and could be used for risk-adjusted benchmarking in those contexts. The relationship between RBC use and APR-DRG varied across organizational units.
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Affiliation(s)
- Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City, Utah.,ARUP Laboratories, Salt Lake City, Utah
| | - Sandra K White
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Scott Potter
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Reed Barney
- Enterprise Data Warehouse, University of Utah, Salt Lake City, Utah
| | - Cheri Hunter
- Enterprise Data Warehouse, University of Utah, Salt Lake City, Utah
| | - Michael White
- Enterprise Data Warehouse, University of Utah, Salt Lake City, Utah
| | - Toby Enniss
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Charles Galaviz
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Santosh Reddy
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Nathan Wanner
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Robert L Schmidt
- Department of Pathology, University of Utah, Salt Lake City, Utah.,ARUP Laboratories, Salt Lake City, Utah
| | - Robert Blaylock
- Department of Pathology, University of Utah, Salt Lake City, Utah.,ARUP Laboratories, Salt Lake City, Utah
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231
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Is A Hemoglobin Concentration As Low As 7 g/dL Adequate For All Critically Ill Patients With Sepsis? Legitimate Doubts Remain! Crit Care Med 2019; 45:2101-2102. [PMID: 29148987 DOI: 10.1097/ccm.0000000000002739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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232
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Obonyo NG, Byrne L, Tung JP, Simonova G, Diab SD, Dunster KR, Passmore MR, Boon AC, See Hoe L, Engkilde-Pedersen S, Esguerra-Lallen A, Fauzi MH, Pimenta LP, Millar JE, Fanning JP, Van Haren F, Anstey CM, Cullen L, Suen J, Shekar K, Maitland K, Fraser JF. Pre-clinical study protocol: Blood transfusion in endotoxaemic shock. MethodsX 2019; 6:1124-1132. [PMID: 31193460 PMCID: PMC6529713 DOI: 10.1016/j.mex.2019.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 05/04/2019] [Indexed: 12/29/2022] Open
Abstract
The Surviving Sepsis Campaign (SCC) and the American College of Critical Care Medicine (ACCM) guidelines recommend blood transfusion in sepsis when the haemoglobin concentration drops below 7.0 g/dL and 10.0 g/dL respectively, while the World Health Organisation (WHO) guideline recommends transfusion in septic shock 'if intravenous (IV) fluids do not maintain adequate circulation', as a supportive measure of last resort. Volume expansion using crystalloid and colloid fluid boluses for haemodynamic resuscitation in severe illness/sepsis, has been associated with adverse outcomes in recent literature. However, the volume expansion effect(s) following blood transfusion for haemodynamic circulatory support, in severe illness remain unclear with most previous studies having focused on evaluating effects of either different RBC storage durations (short versus long duration) or haemoglobin thresholds (low versus high threshold) pre-transfusion. •We describe the protocol for a pre-clinical randomised controlled trial designed to examine haemodynamic effect(s) of early volume expansion using packed RBCs (PRBCs) transfusion (before any crystalloids or colloids) in a validated ovine-model of hyperdynamic endotoxaemic shock.•Additional exploration of mechanisms underlying any physiological, haemodynamic, haematological, immunologic and tissue specific-effects of blood transfusion will be undertaken including comparison of effects of short (≤5 days) versus long (≥30 days) storage duration of PRBCs prior to transfusion.
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Affiliation(s)
- Nchafatso G. Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- IDeAL/KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Liam Byrne
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- The Canberra Hospital Intensive Care, Garran, ACT, Australia
- Australia National University, Canberra, ACT, Australia
| | - John-Paul Tung
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Australian Red Cross Blood Service, Kelvin Grove, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane City, QLD Australia
| | - Gabriela Simonova
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Australian Red Cross Blood Service, Kelvin Grove, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Sara D. Diab
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Kimble R. Dunster
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane City, QLD Australia
| | - Margaret R. Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Ai-Ching Boon
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Louise See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Sanne Engkilde-Pedersen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Australian Red Cross Blood Service, Kelvin Grove, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane City, QLD Australia
| | - Arlanna Esguerra-Lallen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Australian Red Cross Blood Service, Kelvin Grove, Brisbane, Queensland, Australia
| | - Mohd H. Fauzi
- School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kelantan, Malaysia
| | - Leticia P. Pimenta
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Jonathan E. Millar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Jonathon P. Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Frank Van Haren
- The Canberra Hospital Intensive Care, Garran, ACT, Australia
- Australia National University, Canberra, ACT, Australia
- The University of Canberra, Bruce, ACT, Australia
| | - Chris M. Anstey
- Sunshine Coast University Hospital Intensive Care, Birtinya, Qld, Australia
| | - Louise Cullen
- University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Kiran Shekar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
| | - Kathryn Maitland
- IDeAL/KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, Faculty of Medicine, Imperial College London, United Kingdom
| | - John F. Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane City, QLD Australia
- Adult Intensive Care, The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia
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233
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Visagie M, Pearson KR, Purvis TE, Gehrie EA, Resar LMS, Frank SM. Greater anemia tolerance among hospitalized females compared to males. Transfusion 2019; 59:2551-2558. [PMID: 31063596 DOI: 10.1111/trf.15338] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/22/2019] [Accepted: 04/23/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although females have a lower baseline hemoglobin (Hb) compared to males, it is unknown whether females have a greater tolerance for anemia when hospitalized. We tested the hypothesis that females tolerate severe anemia better than males, with decreased inpatient mortality in this setting. STUDY DESIGN AND METHODS We conducted a retrospective cohort study in 230,644 adult patients admitted to Johns Hopkins Hospital from January 2009 to June 2016. The relationships between nadir Hb and percentage change in Hb with inpatient mortality were assessed for nontransfused males and females. A multivariable logistic regression was used to determine risk-adjusted differences between males and females for the likelihood of inpatient mortality at nadir Hb levels of 5, 6, and 7 g/dL. RESULTS Males had increased mortality when nadir Hb was 6.0 g/dL or less (p < 0.05), whereas females did not. The risk-adjusted likelihood for inpatient mortality was greater for males compared to females at a nadir Hb of 6 g/dL or less (odds ratio, 1.84; 95% confidence interval, 1.09-3.16) (p = 0.02), but this sex-related difference was not significant at a nadir Hb of 5 or 7 g/dL or less. Inpatient mortality increased significantly in both males and females when the percentage decrease in Hb was greater than 50% from baseline (p < 0.05). CONCLUSIONS Compared to males, females tolerate a lower nadir Hb, but a similar percentage change in Hb, before an increase in inpatient mortality is recognized. The findings suggest that females may be "preconditioned" to tolerate anemia better than males.
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Affiliation(s)
- Mereze Visagie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Eric A Gehrie
- Department of Pathology (Transfusion Medicine), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Linda M S Resar
- Department of Medicine (Hematology), Department of Oncology, Department of Pathology, Institute for Cellular Engineering, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- Johns Hopkins Health System Blood Management Program, Department of Anesthesiology/Critical Care Medicine, Faculty, Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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234
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Lamarche MC, Hammond DE, Hopman WM, Sirosky‐Yanyk A, Shepherd L, Bhella SD. Can we transfuse wisely in patients undergoing chemotherapy for acute leukemia or autologous stem cell transplantation? Transfusion 2019; 59:2308-2315. [DOI: 10.1111/trf.15335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Michelle C. Lamarche
- Department of Medicine, Division of General Internal MedicineQueen's University Kingston Ontario Canada
| | - Danielle E. Hammond
- Department of Medicine, Division of HematologyQueen's University Kingston Ontario Canada
| | - Wilma M. Hopman
- Kingston General Hospital Research Institute, and Department of Public Health SciencesQueen's University Kingston Ontario Canada
| | - Angela Sirosky‐Yanyk
- Department of Pathology and Molecular MedicineQueen's University Kingston Ontario Canada
| | - Lois Shepherd
- Department of Pathology and Molecular MedicineQueen's University Kingston Ontario Canada
| | - Sita D. Bhella
- Department of Medicine, Division of HematologyQueen's University Kingston Ontario Canada
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235
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Wood MD, Jacobson JA, Maslove DM, Muscedere JG, Boyd JG. The physiological determinants of near-infrared spectroscopy-derived regional cerebral oxygenation in critically ill adults. Intensive Care Med Exp 2019; 7:23. [PMID: 31049754 PMCID: PMC6497723 DOI: 10.1186/s40635-019-0247-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/07/2019] [Indexed: 02/08/2023] Open
Abstract
Background To maintain adequate oxygen delivery to tissue, resuscitation of critically ill patients is guided by assessing surrogate markers of perfusion. As there is no direct indicator of cerebral perfusion used in routine critical care, identifying an accurate strategy to monitor brain perfusion is paramount. Near-infrared spectroscopy (NIRS) is a non-invasive technique to quantify regional cerebral oxygenation (rSO2) that has been used for decades during cardiac surgery which has led to targeted algorithms to optimize rSO2 being developed. However, these targeted algorithms do not exist during critical care, as the physiological determinants of rSO2 during critical illness remain poorly understood. Materials and methods This prospective observational study was an exploratory analysis of a nested cohort of patients within the CONFOCAL study (NCT02344043) who received high-fidelity vital sign monitoring. Adult patients (≥ 18 years) admitted < 24 h to a medical/surgical intensive care unit were eligible if they had shock and/or required mechanical ventilation. Patients underwent rSO2 monitoring with the FORESIGHT oximeter for 24 h, vital signs were concurrently recorded, and clinically ordered arterial blood gas samples and hemoglobin concentration were also documented. Simultaneous multiple linear regression was performed using all available predictors, followed by model selection using the corrected Akaike information criterion (AICc). Results Our simultaneous multivariate model included age, heart rate, arterial oxygen saturation, mean arterial pressure, pH, partial pressure of oxygen, partial pressure of carbon dioxide (PaCO2), and hemoglobin concentration. This model accounted for a significant proportion of variance in rSO2 (R2 = 0.58, p < 0.01) and was significantly associated with PaCO2 (p < 0.05) and hemoglobin concentration (p < 0.01). Our selected regression model using AICc accounted for a significant proportion of variance in rSO2 (R2 = 0.54, p < 0.01) and was significantly related to age (p < 0.05), PaCO2 (p < 0.01), hemoglobin (p < 0.01), and heart rate (p < 0.05). Conclusions Known and established physiological determinants of oxygen delivery accounted for a significant proportion of the rSO2 signal, which provides evidence that NIRS is a viable modality to assess cerebral oxygenation in critically ill adults. Further elucidation of the determinants of rSO2 has the potential to develop a NIRS-guided resuscitation algorithm during critical illness. Trial registration This trial is registered on clinicaltrials.gov (Identifier: NCT02344043), retrospectively registered January 8, 2015. Electronic supplementary material The online version of this article (10.1186/s40635-019-0247-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael D Wood
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada
| | - Jill A Jacobson
- Department of Psychology, Queen's University, 62 Arch Street, 318 Craine Hall, Kingston, ON, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada.,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada. .,Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada. .,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada.
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Schmoch T, Al-Saeedi M, Hecker A, Richter DC, Brenner T, Hackert T, Weigand MA. Evidenzbasierte, interdisziplinäre Behandlung der abdominellen Sepsis. Chirurg 2019; 90:363-378. [DOI: 10.1007/s00104-019-0795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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238
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Fluid Management in Septic Shock: a Review of Physiology, Goal-Directed Therapy, Fluid Dose, and Selection. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00330-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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239
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Prediction of bleeding by thromboelastography in ICU patients with haematological malignancy and severe sepsis. Blood Coagul Fibrinolysis 2019; 29:683-688. [PMID: 30439767 DOI: 10.1097/mbc.0000000000000777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
: ICU patients with haematological malignancy have an increased risk of bleeding. Recently, global haemostatic methods such as thromboelastography (TEG) have gained impact in evaluating coagulation. The aim of this study was to observe whether TEG could predict bleeding in haematological ICU patients with severe sepsis. Post-hoc single-centre analysis of patients with haematological malignancy included in the Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial. Clinical characteristics, TEG measurements and details regarding bleeding complications were retrieved from the 6S database. The association between TEG and bleeding were analysed by Cox regression and receiver operating characteristic curves. A total of 202 patients with severe sepsis were admitted to the ICU of Rigshospitalet, Copenhagen and included in the 6S trial. Forty-one had haematological malignancy and were analysed in the current study. During ICU stay, 20 patients (49%) had bleeding complications and 13 (32%) patients bled within the first 5 ICU days. We observed no associations between TEG and subsequent bleeding in Cox regression models. TEG variables at baseline had low predictive value for bleeding. Baseline TEG variables did not add value in identifying patients with high risk of bleeding in ICU patients with haematological malignancy and severe sepsis.
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240
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Delayed recovery following thoracic surgery: persistent issues and potential interventions. Curr Opin Anaesthesiol 2019; 32:3-9. [PMID: 30507683 DOI: 10.1097/aco.0000000000000669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges. RECENT FINDINGS Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes. SUMMARY Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.
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241
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Scholkmann F, Wolf U. The Pulse-Respiration Quotient: A Powerful but Untapped Parameter for Modern Studies About Human Physiology and Pathophysiology. Front Physiol 2019; 10:371. [PMID: 31024336 PMCID: PMC6465339 DOI: 10.3389/fphys.2019.00371] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/18/2019] [Indexed: 01/06/2023] Open
Abstract
A specific and unique aspect of cardiorespiratory activity can be captured by dividing the heart rate (HR) by the respiration rate (RR), giving the pulse-respiration quotient (PRQ = HR/RR). In this review article, we summarize the main findings of studies using and investigating the PRQ. We describe why the PRQ is a powerful parameter that captures complex regulatory states of the cardiorespiratory system, and we highlight the need to re-introduce the use of this parameter into modern studies about human physiology and pathophysiology. In particular, we show that the PRQ (i) changes during human development, (ii) is time-dependent (ultradian, circadian, and infradian rhythms), (iii) shows specific patterns during sleep, (iv) changes with physical activity and body posture, (v) is linked with psychophysical and cognitive activity, (vi) is sex-dependent, and (vii) is determined by the individual physiological constitution. Furthermore, we discuss the medical aspects of the PRQ in terms of applications for disease classification and monitoring. Finally, we explain why there should be a revival in the use of the PRQ for basic research about human physiology and for applications in medicine, and we give recommendations for the use of the PRQ in studies and medical applications.
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Affiliation(s)
- Felix Scholkmann
- Institute of Complementary and Integrative Medicine, University of Bern, Bern, Switzerland
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Soril LJJ, Noseworthy TW, Stelfox HT, Zygun DA, Clement FM. A retrospective observational analysis of red blood cell transfusion practices in stable, non-bleeding adult patients admitted to nine medical-surgical intensive care units. J Intensive Care 2019; 7:19. [PMID: 30988954 PMCID: PMC6449900 DOI: 10.1186/s40560-019-0375-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/22/2019] [Indexed: 01/28/2023] Open
Abstract
Background Red blood cell (RBC) transfusions are common procedures performed in the intensive care unit (ICU). However, conservative transfusion approaches have been recommended to avoid RBC transfusions that are not clinically necessary and to achieve optimal patient outcomes. The objective of this study was to examine the utilization and costs of RBC transfusions in medical-surgical ICUs and to compare this information against clinical guideline recommendations for best practice. Methods Retrospective observational analysis of RBC transfusions in stable, non-bleeding adult patients was examined in a geographically-defined, population-based cohort of nine integrated ICUs between April 1, 2014 and December 31, 2016. RBC transfusions associated with a pre-transfusion hemoglobin value of 70 g/L or more were examined through linear and logistic regression. The total costs of RBC transfusions, based on the RBC unit cost, were estimated. Results A total of 4632 RBC transfusions (2287 ICU admissions) were included. Pre-transfusion hemoglobin values were identified for 4487 transfusions. On average, 61% occurred at or above a hemoglobin value of 70 g/L (mean 73.4 ± 9.2 g/L). Factors associated with such transfusions included being male, age over 75, Sequential Organ Failure Assessment (SOFA) score greater or equal to 10, transfer from operating room, gastrointestinal bleeding, and trauma. A pre-transfusion hemoglobin value at or above 70 g/L was associated with increased odds of ICU mortality; there was no impact on overall hospital mortality. The total estimated cost of RBC transfusions was $2.99M Canadian dollars (CAD), with $1.82M CAD attributed to those with a hemoglobin value at or above 70 g/L. Conclusions Over half of the examined RBC transfusions may not have aligned with recommended best practice; this suggests significant opportunity for improvement. The present findings are an essential step towards optimizing RBC transfusions in the ICU. Electronic supplementary material The online version of this article (10.1186/s40560-019-0375-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lesley J J Soril
- 1Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D18, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada.,2O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
| | - Tom W Noseworthy
- 1Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D18, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada.,2O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
| | - Henry T Stelfox
- 1Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D18, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada.,2O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada.,3Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, 1403 29 Street NW, Calgary, Alberta T2N 2T9 Canada
| | - David A Zygun
- 4Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Room 2-124 Clinical Sciences Building, 8440 - 112 Street, Edmonton, Alberta T6G 2B7 Canada
| | - Fiona M Clement
- 1Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D18, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada.,2O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
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Zenor L, Anderson CJ. Bridge over Troubled Water. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 696] [Impact Index Per Article: 139.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Bolliger D, Buser A, Tanaka KA. Transfusion Requirements in Anesthesia and Intensive Care. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00320-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Gyawali B, Ramakrishna K, Dhamoon AS. Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Med 2019; 7:2050312119835043. [PMID: 30915218 PMCID: PMC6429642 DOI: 10.1177/2050312119835043] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 02/11/2019] [Indexed: 12/11/2022] Open
Abstract
There has been a significant evolution in the definition and management of sepsis over the last three decades. This is driven in part due to the advances made in our understanding of its pathophysiology. There is evidence to show that the manifestations of sepsis can no longer be attributed only to the infectious agent and the immune response it engenders, but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. This has contributed significantly to the overall improved outcomes with sepsis. Investigation into clinically relevant biomarkers of sepsis are ongoing and have yet to yield effective results. Scoring systems such as the sequential organ failure assessment and Acute Physiology and Chronic Health Evaluation help risk-stratify patients with sepsis. Advances in precision medicine techniques and the development of targeted therapy directed at limiting the excesses of the inflammatory and coagulatory cascades offer potentially viable avenues for future research. This review summarizes the progress made in the diagnosis and management of sepsis over the past two decades and examines promising avenues for future research.
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Affiliation(s)
- Bishal Gyawali
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Karan Ramakrishna
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Amit S Dhamoon
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
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247
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Perioperative Fluid Strategies to Prevent Lung Injury. Int Anesthesiol Clin 2019; 56:107-117. [PMID: 29189438 DOI: 10.1097/aia.0000000000000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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248
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Chuma M, Makishima M, Imai T, Tochikura N, Suzuki S, Kuwana T, Sawada N, Iwabuchi S, Sekimoto M, Nakayama T, Sakaue T, Kikuchi N, Yoshida Y, Kinoshita K. Relationship between hemoglobin levels and vancomycin clearance in patients with sepsis. Eur J Clin Pharmacol 2019; 75:929-937. [PMID: 30868193 DOI: 10.1007/s00228-019-02661-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/03/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE It is important to accurately estimate accurate vancomycin (VCM) clearance (CLvcm) for appropriate VCM dosing in the treatment of patients with sepsis. However, the pathophysiology of sepsis can make CLvcm prediction less accurate. Clearance of hydrophilic antibiotics is disturbed by organ dysfunction, and hemoglobin levels are negatively correlated with sequential organ function assessment scores. We investigated whether hemoglobin levels are associated with CLvcm in sepsis patients. METHODS We performed a retrospective cohort study of patients treated with VCM in the Emergency and Critical Care Center of Nihon University Itabashi Hospital between 2005 and 2015. We enrolled 72 patients after exclusion of patients who received renal replacement therapy or surgery, had a change in hemoglobin levels more than 2 g/dL or received an erythrocyte infusion during the interval between initial VCM administration and measurement of initial trough levels, had a serum baseline creatinine level of ≥ 2 mg/dL, or were under 18 years old. RESULTS Enrolled patients consisted of 13 non-sepsis patients and 59 sepsis patients. In sepsis patients, although CLvcm was correlated with CrCl in HGB ≥ 9 group as well as in non-sepsis patients, its correlation was not observed in HGB < 9 group. Hemoglobin levels were correlated with CLvcm in sepsis patients but not in non-sepsis patient. Multiple linear regression analysis also indicated that lower CLvcm was associated with lower hemoglobin and CrCl. CONCLUSION Lower hemoglobin levels influence a relationship between CLvcm and CrCl in sepsis patients. We propose that VCM dosing should be adjusted for hemoglobin levels in sepsis patients.
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Affiliation(s)
- Masayuki Chuma
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan.,Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Makoto Makishima
- Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Toru Imai
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Naohiro Tochikura
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Shinichiro Suzuki
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Tsukasa Kuwana
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Nami Sawada
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - So Iwabuchi
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Masao Sekimoto
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takahiro Nakayama
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takako Sakaue
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | | | - Yoshikazu Yoshida
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
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Mueller MM, Van Remoortel H, Meybohm P, Aranko K, Aubron C, Burger R, Carson JL, Cichutek K, De Buck E, Devine D, Fergusson D, Folléa G, French C, Frey KP, Gammon R, Levy JH, Murphy MF, Ozier Y, Pavenski K, So-Osman C, Tiberghien P, Volmink J, Waters JH, Wood EM, Seifried E. Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference. JAMA 2019; 321:983-997. [PMID: 30860564 DOI: 10.1001/jama.2019.0554] [Citation(s) in RCA: 363] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEW The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018. FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCE The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.
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Affiliation(s)
- Markus M Mueller
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Kari Aranko
- European Blood Alliance (EBA), Amsterdam, the Netherlands
| | - Cécile Aubron
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Jeffrey L Carson
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | | | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Departments of Medicine, Surgery, Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gilles Folléa
- Société Française de Transfusion Sanguine (SFTS), Paris, France
| | - Craig French
- Intensive Care, Western Health, Melbourne, Australia
| | | | | | - Jerrold H Levy
- Department of Cardiothoracic Intensive Care Medicine, Duke University Medical Centre, Durham, North Carolina
| | - Michael F Murphy
- National Health Service Blood and Transplant and University of Oxford, Oxford, United Kingdom
| | - Yves Ozier
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Cynthia So-Osman
- Sanquin Blood Bank, Leiden and Department of Haematology, Groene Hart Hospital, Gouda, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
| | | | - Jimmy Volmink
- Department of Clinical Epidemiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jonathan H Waters
- Departments of Anesthesiology and Bioengineering, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania
| | - Erica M Wood
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erhard Seifried
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
- European Blood Alliance (EBA), Amsterdam, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
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Pantoprazole prophylaxis in ICU patients with high severity of disease: a post hoc analysis of the placebo-controlled SUP-ICU trial. Intensive Care Med 2019; 45:609-618. [DOI: 10.1007/s00134-019-05589-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
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