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Guglielmi A, Graziano F, Bogossian EG, Turgeon AF, Taccone FS, Citerio G. Haemoglobin values, transfusion practices, and long-term outcomes in critically ill patients with traumatic brain injury: a secondary analysis of CENTER-TBI. Crit Care 2024; 28:199. [PMID: 38877571 PMCID: PMC11177426 DOI: 10.1186/s13054-024-04980-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024] Open
Abstract
Haemoglobin (Hb) thresholds and red blood cells (RBC) transfusion strategies in traumatic brain injury (TBI) are controversial. Our objective was to assess the association of Hb values with long-term outcomes in critically ill TBI patients. We conducted a secondary analysis of CENTER-TBI, a large multicentre, prospective, observational study of European TBI patients. All patients admitted to the Intensive Care Unit (ICU) with available haemoglobin data on admission and during the first week were included. During the first seven days, daily lowest haemoglobin values were considered either a continous variable or categorised as < 7.5 g/dL, between 7.5-9.5 and > 9.5 g/dL. Anaemia was defined as haemoglobin value < 9.5 g/dL. Transfusion practices were described as "restrictive" or "liberal" based on haemoglobin values before transfusion (e.g. < 7.5 g/dL or 7.5-9.5 g/dL). Our primary outcome was the Glasgow outcome scale extended (GOSE) at six months, defined as being unfavourable when < 5. Of 1590 included, 1231 had haemoglobin values available on admission. A mean Injury Severity Score (ISS) of 33 (SD 16), isolated TBI in 502 (40.7%) and a mean Hb value at ICU admission of 12.6 (SD 2.2) g/dL was observed. 121 (9.8%) patients had Hb < 9.5 g/dL, of whom 15 (1.2%) had Hb < 7.5 g/dL. 292 (18.4%) received at least one RBC transfusion with a median haemoglobin value before transfusion of 8.4 (IQR 7.7-8.5) g/dL. Considerable heterogeneity regarding threshold transfusion was observed among centres. In the multivariable logistic regression analysis, the increase of haemoglobin value was independently associated with the decrease in the occurrence of unfavourable neurological outcomes (OR 0.78; 95% CI 0.70-0.87). Congruous results were observed in patients with the lowest haemoglobin values within the first 7 days < 7.5 g/dL (OR 2.09; 95% CI 1.15-3.81) and those between 7.5 and 9.5 g/dL (OR 1.61; 95% CI 1.07-2.42) compared to haemoglobin values > 9.5 g/dL. Results were consistent when considering mortality at 6 months as an outcome. The increase of hemoglobin value was associated with the decrease of mortality (OR 0.88; 95% CI 0.76-1.00); haemoglobin values less than 7.5 g/dL was associated with an increase of mortality (OR 3.21; 95% CI 1.59-6.49). Anaemia was independently associated with long-term unfavourable neurological outcomes and mortality in critically ill TBI patients.Trial registration: CENTER-TBI is registered at ClinicalTrials.gov, NCT02210221, last update 2022-11-07.
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Affiliation(s)
- Angelo Guglielmi
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
- University of Pavia, PhD in Experimental Medicine, Pavia, Italy
- Intensive Care Department 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Graziano
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Québec City, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.
- Neurological Intensive Care Unit, Department Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
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Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
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Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Yu Y, Fu Y, Li W, Sun T, Cheng C, Chong Y, Han R, Cui W. Red blood cell transfusion in neurocritical patients: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:106. [PMID: 38504153 PMCID: PMC10949741 DOI: 10.1186/s12871-024-02487-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Anemia can lead to secondary brain damage by reducing arterial oxygen content and brain oxygen supply. Patients with acute brain injury have impaired self-regulation. Brain hypoxia may also occur even in mild anemia. Red blood cell (RBC) transfusion is associated with increased postoperative complications, poor neurological recovery, and mortality in critically ill neurologic patients. Balancing the risks of anemia and red blood cell transfusion-associated adverse effects is challenging in neurocritical settings. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE (PubMed) from inception to January 31, 2024. We included all randomized controlled trials (RCTs) assessing liberal versus restrictive RBC transfusion strategies in neurocritical patients. We included all relevant studies published in English. The primary outcome was mortality at intensive care unit (ICU), discharge, and six months. RESULTS Of 5195 records retrieved, 84 full-text articles were reviewed, and five eligible studies were included. There was no significant difference between the restrictive and liberal transfusion groups in ICU mortality (RR: 2.53, 95% CI: 0.53 to 12.13), in-hospital mortality (RR: 2.34, 95% CI: 0.50 to 11.00), mortality at six months (RR: 1.42, 95% CI: 0.42 to 4.78) and long-term mortality (RR: 1.22, 95% CI: 0.64 to 2.33). The occurrence of neurological adverse events and most major non-neurological complications was similar in the two groups. The incidence of deep venous thrombosis was lower in the restrictive strategy group (RR: 0.41, 95% CI: 0.18 to 0.91). CONCLUSIONS Due to the small sample size of current studies, the evidence is insufficiently robust to confirm definitive conclusions for neurocritical patients. Therefore, further investigation is encouraged to define appropriate RBC transfusion thresholds in the neurocritical setting.
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Affiliation(s)
- Yun Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Yuxuan Fu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Wenying Li
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, 5 Shijingshan Rd, Shijingshan District, Beijing, PR China
| | - Tiantian Sun
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, PR China
| | - Chan Cheng
- Department of Anesthesiology, Beijing Stomatological Hospital Affiliated to Capital Medical University, No.4 Tiantan Xili, Dongcheng District, Beijing, 100050, PR China
| | - Yingzi Chong
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Weihua Cui
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China.
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Filipovic MG, Luedi MM. Transfusion strategies in traumatic brain injury - A clinical debate. J Clin Anesth 2023; 90:111233. [PMID: 37633045 DOI: 10.1016/j.jclinane.2023.111233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/13/2023] [Accepted: 08/16/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Mark G Filipovic
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Eman G, Marsh A, Gong MN, Hope AA. Utility of Screening for Cognitive Impairment at Hospital Discharge in Adult Survivors of Critical Illness. Am J Crit Care 2022; 31:306-314. [PMID: 35773197 DOI: 10.4037/ajcc2022447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Few studies have explored the utility of screening for cognitive impairment near hospital discharge in intensive care unit survivors. OBJECTIVES To explore baseline and hospitalization characteristics associated with cognitive impairment at hospital discharge and the relationship between cognitive impairment and 6-month disability and mortality outcomes. METHODS Hospital disability status and treatment variables were collected from 2 observational cohort studies. Patients were screened for cognitive impairment at hospital discharge using the Montreal Cognitive Assessment (MoCA)-Blind, and telephone follow-up was conducted 6 months after discharge to assess vital and physical disability status. RESULTS Of 423 patients enrolled, 320 were alive at hospital discharge. A total of 213 patients (66.6%) were able to complete the MoCA near discharge; 47 patients (14.7%) could not complete it owing to cognitive impairment. In MoCA completers, the median (IQR) score was 17 (14-19). Older age (β per year increase, -0.09 [95% CI, -0.13 to -0.05]) and blood transfusions during hospitalization (β, -1.20 [95% CI, -2.26 to -0.14]) were associated with lower MoCA scores. At 6-month follow-up, 176 of 213 patients (82.6%) were alive, of whom 41 (23.3%) had new severe physical disabilities. Discharge MoCA score was not significantly associated with 6-month mortality (adjusted odds ratio, 1.03 [95% CI, 0.93-1.14]) but was significantly associated with risk of new severe disability at 6 months (adjusted odds ratio, 0.85 [95% CI, 0.76-0.94]). CONCLUSION Assessing for cognitive impairment at hospital discharge may help identify intensive care unit survivors at higher risk of severe physical disabilities after critical illness.
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Affiliation(s)
- Gerardo Eman
- Gerardo Eman is an internal medicine resident, Albert Einstein College of Medicine, Bronx, New York
| | - Amber Marsh
- Amber Marsh is a medical student, Albert Einstein College of Medicine, Bronx, New York
| | - Michelle Ng Gong
- Michelle Ng Gong is division chief, Pulmonary and Critical Care Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Aluko A Hope
- Aluko A. Hope is an associate professor of medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon
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Factors Associated With Brain Tissue Oxygenation Changes After RBC Transfusion in Acute Brain Injury Patients. Crit Care Med 2022; 50:e539-e547. [PMID: 35132018 DOI: 10.1097/ccm.0000000000005460] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Anemia is common after acute brain injury and can be associated with brain tissue hypoxia. RBC transfusion (RBCT) can improve brain oxygenation; however, predictors of such improvement remain unknown. We aimed to identify the factors associated with PbtO2 increase (greater than 20% from baseline value) after RBCT, using a generalized mixed model. DESIGN This is a multicentric retrospective cohort study (2012-2020). SETTING This study was conducted in three European ICUs of University Hospitals located in Belgium, Switzerland, and Austria. PATIENTS All patients with acute brain injury who were monitored with brain tissue oxygenation (PbtO2) catheters and received at least one RBCT. INTERVENTION Patients received at least one RBCT. PbtO2 was recorded before, 1 hour, and 2 hours after RBCT. MEASUREMENTS AND MAIN RESULTS We included 69 patients receiving a total of 109 RBCTs after a median of 9 days (5-13 d) after injury. Baseline hemoglobin (Hb) and PbtO2 were 7.9 g/dL [7.3-8.7 g/dL] and 21 mm Hg (16-26 mm Hg), respectively; 2 hours after RBCT, the median absolute Hb and PbtO2 increases from baseline were 1.2 g/dL [0.8-1.8 g/dL] (p = 0.001) and 3 mm Hg (0-6 mm Hg) (p = 0.001). A 20% increase in PbtO2 after RBCT was observed in 45 transfusions (41%). High heart rate (HR) and low PbtO2 at baseline were independently associated with a 20% increase in PbtO2 after RBCT. Baseline PbtO2 had an area under receiver operator characteristic of 0.73 (95% CI, 0.64-0.83) to predict PbtO2 increase; a PbtO2 of 20 mm Hg had a sensitivity of 58% and a specificity of 73% to predict PbtO2 increase after RBCT. CONCLUSIONS Lower PbtO2 values and high HR at baseline could predict a significant increase in brain oxygenation after RBCT.
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Montgomery EY, Barrie U, Kenfack YJ, Edukugho D, Caruso JP, Rail B, Hicks WH, Oduguwa E, Pernik MN, Tao J, Mofor P, Adeyemo E, Ahmadieh TYE, Tamimi MA, Bagley CA, Bedros N, Aoun SG. Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence. Neurotrauma Rep 2022; 3:554-568. [PMID: 36636743 PMCID: PMC9811955 DOI: 10.1089/neur.2022.0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.
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Affiliation(s)
- Eric Y. Montgomery
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Address correspondence to: Eric Y. Montgomery, BA, Department of Neurosurgery, The University of Texas Southwestern, 5151 Harry Hines Boulevard, Dallas, TX 75235, USA.
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yves J. Kenfack
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Derrek Edukugho
- Department of Neurological Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA
| | - James P. Caruso
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin Rail
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William H. Hicks
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuella Oduguwa
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan Tao
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paula Mofor
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuel Adeyemo
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tarek Y. El Ahmadieh
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mazin Al Tamimi
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bedros
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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9
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Egea-Guerrero JJ, García-Sáez I, Quintana-Díaz M. Trigger transfusion in severe traumatic brain injury. Med Intensiva 2021; 46:157-160. [PMID: 34952791 DOI: 10.1016/j.medine.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/08/2021] [Accepted: 03/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- J J Egea-Guerrero
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, IBIS/CSIC/Universidad de Sevilla, Sevilla, Spain.
| | - I García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, Spain
| | - M Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario de La Paz, Idipaz, Madrid, Spain
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Egea-Guerrero JJ, García-Sáez I, Quintana-Díaz M. Trigger transfusion in severe traumatic brain injury. Med Intensiva 2021; 46:S0210-5691(21)00071-1. [PMID: 33962806 DOI: 10.1016/j.medin.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/08/2021] [Accepted: 03/21/2021] [Indexed: 11/17/2022]
Affiliation(s)
- J J Egea-Guerrero
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla. IBIS/CSIC/Universidad de Sevilla, Sevilla, España.
| | - I García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, España
| | - M Quintana-Díaz
- Servicio deMedicina Intensiva, Hospital Universitario de La Paz. Idipaz, Madrid, España
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KIYOHIRA M, SUEHIRO E, SHINOYAMA M, FUJIYAMA Y, HAJI K, SUZUKI M. Combined Strategy of Burr Hole Surgery and Elective Craniotomy under Intracranial Pressure Monitoring for Severe Acute Subdural Hematoma. Neurol Med Chir (Tokyo) 2021; 61:253-259. [PMID: 33597319 PMCID: PMC8048118 DOI: 10.2176/nmc.oa.2020-0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/25/2020] [Indexed: 11/24/2022] Open
Abstract
Burr hole surgery in the emergency room can be lifesaving for patients with acute subdural hematoma (ASDH). In the first part of this study, a strategy of combined burr hole surgery, a period of intracranial pressure (ICP) monitoring, and then craniotomy was examined for safe and effective treatment of ASDH. Since 2012, 16 patients with severe ASDH with indications for burr hole surgery were admitted to Kenwakai Otemachi Hospital. From 2012 to 2016, craniotomy was performed immediately after burr hole surgery (emergency [EM] group, n = 10). From 2017, an ICP sensor was placed before burr hole surgery. After a period for correction of traumatic coagulopathy, craniotomy was performed when ICP increased (elective [EL] group, n = 6). Patient background, bleeding tendency, intraoperative blood transfusion, and outcomes were compared between the groups. In the second part of the study, ICP was measured before and after burr hole surgery in seven patients (including two of the six in the EL group) to assess the effect of this surgery. Activated partial thromboplastin time (APTT) and prothrombin time-international normalized ratio (PT-INR) were significantly prolonged after craniotomy in the EM group, but not in the EL group, and the EM group tended to require a higher intraoperative transfusion volume. The rate of good outcomes was significantly higher in the EL group, and ICP was significantly decreased after burr hole surgery. These results suggest the value of burr hole surgery followed by ICP monitoring in patients with severe ASDH. Craniotomy can be performed safely using this method, and this may contribute to improved outcomes.
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Affiliation(s)
- Miwa KIYOHIRA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Eiichi SUEHIRO
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Chiba, Japan
| | - Mizuya SHINOYAMA
- Department of Neurosurgery, Kenwakai Otemachi Hospital, Kitakyushu, Fukuoka, Japan
| | - Yuichi FUJIYAMA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
- Department of Neurosurgery, Shinyurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kohei HAJI
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Michiyasu SUZUKI
- Department of Neurosurgery, Shinyurigaoka General Hospital, Kawasaki, Kanagawa, Japan
- Department of Advanced ThermoNeuroBiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
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Culliton K, Louati H, Laneuville O, Ramsay T, Trudel G. Six degrees head-down tilt bed rest caused low-grade hemolysis: a prospective randomized clinical trial. NPJ Microgravity 2021; 7:4. [PMID: 33589644 PMCID: PMC7884785 DOI: 10.1038/s41526-021-00132-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/13/2021] [Indexed: 01/31/2023] Open
Abstract
This study aimed to measure hemolysis before, during and after 60 days of the ground-based spaceflight analog bed rest and the effect of a nutritional intervention through a prospective randomized clinical trial. Twenty male participants were hospitalized for 88 days comprised of 14 days of ambulatory baseline, 60 days of 6° head-down tilt bed rest and 14 days of reambulation. Ten participants each received a control diet or daily polyphenol associated with omega-3, vitamin E, and selenium supplements. The primary outcome was endogenous carbon monoxide (CO) elimination measured by gas chromatography. Hemolysis was also measured with serial bilirubin, iron, transferrin saturation blood levels and serial 3-day stool collections were used to measure urobilinoid excretion using photometry. Total hemoglobin mass (tHb) was measured using CO-rebreathing. CO elimination increased after 5, 11, 30, and 57 days of bed rest: +289 ppb (95% CI 101-477 ppb; p = 0.004), +253 ppb (78-427 ppb; p = 0.007), +193 ppb (89-298 ppb; p = 0.001) and +858 ppb (670-1046 ppb; p < 0.000), respectively, compared to baseline. Bilirubin increased after 20 and 49 days of bed rest +0.8 mg/l (p = 0.013) and +1.1 mg/l (p = 0.012), respectively; and iron increased after 20 days of bed rest +10.5 µg/dl (p = 0.032). The nutritional intervention did not change CO elimination. THb was lower after 60 days of bed rest -0.9 g/kg (p = 0.001). Bed rest enhanced hemolysis as measured through all three by-products of heme oxygenase. Ongoing enhanced hemolysis over 60 days contributed to a 10% decrease in tHb mass. Modulation of red blood cell control towards increased hemolysis may be an important mechanism causing anemia in astronauts.
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Affiliation(s)
- Kathryn Culliton
- grid.412687.e0000 0000 9606 5108Department of Medicine, Division of Physical Medicine and Rehabilitation, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Hakim Louati
- grid.412687.e0000 0000 9606 5108Department of Medicine, Division of Physical Medicine and Rehabilitation, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Odette Laneuville
- grid.28046.380000 0001 2182 2255Department of Biology, Faculty of Science, University of Ottawa, Ottawa, ON Canada
| | - Tim Ramsay
- grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
| | - Guy Trudel
- grid.412687.e0000 0000 9606 5108Department of Medicine, Division of Physical Medicine and Rehabilitation, Ottawa Hospital Research Institute, Ottawa, ON Canada ,grid.28046.380000 0001 2182 2255Department of Biochemistry, Microbiology, and Immunology, University of Ottawa, Ottawa, ON Canada
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Leal-Noval SR, Rincón-Ferrari MD, Múñoz-Gómez M. Red blood cell transfusion may be more detrimental than anemia for the clinical outcome of patients with severe traumatic brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:189. [PMID: 31133054 PMCID: PMC6535857 DOI: 10.1186/s13054-019-2470-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/10/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Santiago R Leal-Noval
- Critical Care Division, University Hospital 'Virgen del Rocío', Unidad de Cuidados Intensivos, 1ª planta, Avda Manuel Siurot s/n, 41013, Seville, Spain.
| | - María D Rincón-Ferrari
- Critical Care Division, University Hospital 'Virgen del Rocío', Unidad de Cuidados Intensivos, 1ª planta, Avda Manuel Siurot s/n, 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, University of Málaga, campus de Teatinos s/n, 29010, Málaga, Spain
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Lessard Bonaventure P, Lauzier F, Zarychanski R, Boutin A, Shemilt M, Saxena M, Zolfagari P, Griesdale D, Menon DK, Stanworth S, English S, Chassé M, Fergusson DA, Moore L, Kramer A, Robitaille A, Myburgh J, Cooper J, Hutchinson P, Turgeon AF. Red blood cell transfusion in critically ill patients with traumatic brain injury: an international survey of physicians' attitudes. Can J Anaesth 2019; 66:1038-1048. [PMID: 31012052 DOI: 10.1007/s12630-019-01369-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Restrictive transfusion strategies have been advocated in critically ill patients. Nevertheless, considerable uncertainty exists regarding optimal transfusion thresholds in traumatic brain injury (TBI) patients because the injured brain is susceptible to hypoxemic damage. We aimed to identify the determinants of red blood cell (RBC) transfusion and the perceived optimal transfusion thresholds in adult patients with moderate-to-severe TBI. METHODS We conducted an electronic, self-administered survey targeting critical care specialists and neurosurgeons from Canada, Australia, and the United Kingdom caring for TBI patients. The questionnaire was initially developed by a panel of experts using a structured process (domains/items generation and reduction). The questionnaire was validated for clinical sensibility, reliability, and content. RESULTS The response rate was 28.7% (218/760). When presented with the hypothetical scenario of a young adult TBI patient, a wide range of transfusion practices was observed, with 47 (95% confidence interval [CI], 41 to 54)% favouring RBC transfusion at a hemoglobin level of ≤ 70 g·L-1 in the acute phase of care, while 73 (95% CI, 67 to 79)% would use this trigger in the plateau phase of care. Multiple trauma, neuro-monitoring data, hemorrhagic shock, and planned surgery were the main factors that influenced the need for transfusion. The lack of clinical evidence and guidelines was responsible for uncertainty regarding RBC transfusion strategies in this patient population. CONCLUSION In our survey about critically ill TBI patients, transfusion practice was found to be mainly influenced by the acuity of care, patient characteristics, and neuro-monitoring. Clinical equipoise regarding optimal transfusion strategy is believed to be mainly attributed to the lack of clear clinical evidence and guidelines. Appropriate randomized-controlled trials are required to determine the optimal transfusion strategies in TBI patients.
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Affiliation(s)
- Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, QC, Canada
| | - Francois Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Department of Medicine, Université Laval, Québec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, of Haematology and of Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Amélie Boutin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - Michèle Shemilt
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - Manoj Saxena
- The George Institute for Global Health, Sydney, Australia
| | - Parjam Zolfagari
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Donald Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David K Menon
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Simon Stanworth
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford University Hospitals and the University of Oxford, Oxford, UK
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Michaël Chassé
- CHUM Research Center, Université de Montréal, Montréal, QC, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Department of Preventive and Social Medicine, Université Laval, Québec City, QC, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Foothills Medical Center, Calgary, AB, Canada
| | - Amélie Robitaille
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - John Myburgh
- The George Institute for Global Health, Sydney, Australia
| | - Jamie Cooper
- The George Institute for Global Health, Sydney, Australia.,The Alfred Hospital, Melbourne, Australia
| | - Peter Hutchinson
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada. .,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.
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Liberal red blood cell transfusions impair quality of life after cardiac surgery. Med Intensiva 2019; 43:156-164. [DOI: 10.1016/j.medin.2018.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 01/28/2023]
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Abstract
Purpose of review The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. Recent findings Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. Summary Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion.
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Leal-Noval SR, Casado-Méndez M, Múñoz-Gómez M. Red blood cell transfusion based on tissue oxygenation rather than on haemoglobin concentration. Br J Anaesth 2018; 121:504-505. [PMID: 30032896 DOI: 10.1016/j.bja.2018.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/10/2018] [Indexed: 11/12/2022] Open
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Kumar MA, Levine J, Faerber J, Elliott JP, Winn HR, Doerfler S, Le Roux P. The Effects of Red Blood Cell Transfusion on Functional Outcome after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 108:807-816. [PMID: 29038077 DOI: 10.1016/j.wneu.2017.09.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. OBJECTIVE To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. METHODS A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. RESULTS Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65). CONCLUSIONS Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Levine
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Faerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Paul Elliott
- Colorado Neurological Institute, Englewood, Colorado, USA
| | - H Richard Winn
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Le Roux
- Brain and Spine Center and Lankenau Institute of Medical Research Lankenau Medical Center, Wynnewood, Pennsylvania, USA.
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Leal-Noval SR, Arellano-Orden V, Muñoz-Gómez M, Cayuela A, Marín-Caballos A, Rincón-Ferrari MD, García-Alfaro C, Amaya-Villar R, Casado-Méndez M, Dusseck R, Murillo-Cabezas F. Red Blood Cell Transfusion Guided by Near Infrared Spectroscopy in Neurocritically Ill Patients with Moderate or Severe Anemia: A Randomized, Controlled Trial. J Neurotrauma 2017; 34:2553-2559. [DOI: 10.1089/neu.2016.4794] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
| | | | - Manuel Muñoz-Gómez
- Perioperative Transfusion Medicine, School of Medicine, University of Málaga, Málaga, Spain
| | - Aurelio Cayuela
- Public Health Department, Statistics and Design Division, University Hospital “Virgen del Valme,” Seville, Spain
| | | | | | | | | | | | - Reginal Dusseck
- Neurocritical Care Unit, University Hospital “Virgen del Rocío,” Seville, Spain
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