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Pennestrì F, Tomaiuolo R, Banfi G, Dolci A. Blood over-testing: impact, ethical issues and mitigating actions. Clin Chem Lab Med 2024; 62:1283-1287. [PMID: 38156643 DOI: 10.1515/cclm-2023-1227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
Plenty of studies demonstrate that hospital-acquired anemia (HAA) can increase transfusion rates, mortality, morbidity and cause unnecessary patient burden, including additional length of hospital stay, sleep disruption and venipuncture harms resulting from blood samples unlikely to change clinical management. Beyond patient costs, community costs should also be considered, such as laboratory time and resources waste, environmental impact, increasing pressure on labs and fewer tests available on time for patients who can benefit from them most. Blood over-testing does not support the principles of non-maleficence, justice and respect for patient autonomy, at the expense dubious beneficence. Reducing the number and frequency of orders is possible, to a certain extent, by adopting nudge strategies and raising awareness among prescribing doctors. However, reducing the orders may appear unsafe to doctors and patients. Therefore, reducing blood volume from each order is a better alternative, which is worth implementing through technological, purchasing and organizational arrangements, possibly combined according to need (smaller tubes, adequate analytic platforms, blind dilution, blood conservative devices, aggregating tests and laboratory units).
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Affiliation(s)
| | - Rossella Tomaiuolo
- IRCCS Istituto Ortopedico Galeazzi, Scientific Direction, Milan, Italy
- Vita-Salute San Raffaele University, School of Medicine, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Scientific Direction, Milan, Italy
- Vita-Salute San Raffaele University, School of Medicine, Milan, Italy
| | - Alberto Dolci
- SC Patologia Clinica, Dipartimento di Medicina di Laboratorio, Ospedale "Luigi Sacco", Milan, Italy
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Milan, Italy
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2
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Yin Y, Li Y, Liu Y, Fan C, Jiang Y. Baseline immune status and the effectiveness of response to enteral nutrition among ICU patients with COVID-19: An observational, retrospective study. Nutrition 2024; 122:112387. [PMID: 38430844 DOI: 10.1016/j.nut.2024.112387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES This study aimed to compare how immunocompromised and immunocompetent patients responded differently to enteral nutrition (EN) support in intensive care units (ICUs) during the COVID-19 pandemic, including serum nutritional biomarkers, inflammatory biomarkers, gastrointestinal (GI) intolerance symptoms, and clinical outcomes. METHODS An observational, retrospective study was conducted in the ICUs of a teaching hospital in southwest China. We recruited a convenience sample of 154 patients between December 2022 and February 2023. We defined immunocompromise as primary immunodeficiency diseases, active malignancy, receiving cancer chemotherapy, HIV infection, solid organ transplantation, hematopoietic stem cell transplantation, receiving corticosteroid therapy with a target dose, receiving biological immune modulators, or receiving disease-modifying antirheumatic drugs or other immunosuppressive drugs. We conducted a Mann-Whitney U test, χ2 test, or generalized estimation equation model to explore the differences between immunocompromised and immunocompetent patients. RESULTS Among the 154 study participants, 41 (27%) were defined as immunocompromised. The immunocompromised patients were younger than the immunocompetent patients. There were no statistically significant differences between the two groups with respect to serum nutritional biomarkers, inflammatory biomarkers, incidence of GI intolerance symptoms, and in-hospital mortality. However, the immunocompromised patients exhibited a longer hospitalization duration than the immunocompetent patients. CONCLUSION We found that the immunocompromised patients spent more time in the hospital. These findings may help us to standardize the participants before EN interventional studies better and better individualize EN supports based on patients' immunity status.
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Affiliation(s)
- Yao Yin
- Department of Neurosurgery, West China Hospital, Sichuan University/West China School of Nursing, Chengdu, People's Republic of China.
| | - Yijing Li
- Evidence-based Nursing Center, West China Hospital, Sichuan University/West China School of Nursing, Chengdu, People's Republic of China.
| | - Yan Liu
- Department of Neurosurgery, West China Hospital, Sichuan University/West China School of Nursing, Chengdu, People's Republic of China.
| | - Chaofeng Fan
- Department of Neurosurgery, West China Hospital, Sichuan University/West China School of Nursing, Chengdu, People's Republic of China.
| | - Yan Jiang
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Chengdu, People's Republic of China.
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3
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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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4
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Bolscher M, Koster SCE, Koopmans M, Haitsma Mulier JLG, Derde LPG, Juffermans NP. Anti-inflammatory therapies are associated with delayed onset of anemia and reduction in transfusion requirements in critically ill patients: results from two studies. Crit Care 2024; 28:114. [PMID: 38594746 PMCID: PMC11003051 DOI: 10.1186/s13054-024-04898-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Anemia is a hallmark of critical illness, which is largely inflammatory driven. We hypothesized that the use of anti-inflammatory agents limits the development of anemia and reduces the need for red blood cell (RBC) transfusions in patients with a hyper-inflammatory condition due to COVID-19. METHODS An observational cohort (n = 772) and a validation cohort (a subset of REMAP-CAP, n = 119) of critically ill patients with hypoxemic respiratory failure due to COVID-19 were analyzed, who either received no treatment, received steroids or received steroids plus IL-6 blocking agents. The trajectory of hemoglobin (Hb) decline and the need for RBC transfusions were compared using descriptive statistics as well as multivariate modeling. RESULTS In both cohorts, Hb level was higher in the treated groups compared to the untreated group at all time points. In the observational cohort, incidence and number of transfused patients were lower in the group receiving the combination treatment compared to the untreated groups. In a multivariate analysis controlling for baseline Hb imbalance and mechanical ventilation, receipt of steroids remained associated with a slower decline in Hb level and the combination treatment remained associated with a slower decline of Hb and with less transfusions. Results remained the same in the validation cohort. CONCLUSION Immunomodulatory treatment was associated with a slower decline in Hb level in critically ill patients with COVID-19 and with less transfusion. Findings point toward inflammation as an important cause for the occurrence of anemia in the critically ill.
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Affiliation(s)
- Madelief Bolscher
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, Amsterdam, The Netherlands
| | | | - Matty Koopmans
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, Amsterdam, The Netherlands
| | | | - Lennie P G Derde
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Molewaterplein 40, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Molewaterplein 40, Rotterdam, The Netherlands.
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Jeon J, Kang D, Park H, Lee K, Lee JE, Huh W, Cho J, Jang HR. Impact of anemia requiring transfusion or erythropoiesis-stimulating agents on new-onset cardiovascular events and mortality after continuous renal replacement therapy. Sci Rep 2024; 14:6556. [PMID: 38503801 PMCID: PMC10951301 DOI: 10.1038/s41598-024-56772-1] [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: 12/06/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
Anemia is common in critically ill patients undergoing continuous renal replacement therapy (CRRT). We investigated the impact of anemia requiring red blood cell (RBC) transfusion or erythropoiesis-stimulating agents (ESAs) on patient outcomes after hospital discharge in critically ill patients with acute kidney injury (AKI) requiring CRRT. In this retrospective cohort study using the Health Insurance Review and Assessment database of South Korea, 10,923 adult patients who received CRRT for 3 days or more between 2010 and 2019 and discharged alive were included. Anemia was defined as the need for RBC transfusion or ESAs. Outcomes included cardiovascular events (CVEs) and all-cause mortality after discharge. The anemia group showed a tendency to be older with more females and had more comorbidities compared to the control group. Anemia was not associated with an increased risk of CVEs (adjusted hazard ratio [aHR]: 1.05; 95% confidence interval [CI]: 0.85-1.29), but was associated with an increased risk of all-cause mortality (aHR: 1.41; 95% CI 1.30-1.53). For critically ill patients with AKI requiring CRRT, anemia, defined as requirement for RBC transfusion or ESAs, may increase the long-term risk of all-cause mortality.
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Affiliation(s)
- Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Kyungho Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea.
| | - Hye Ryoun Jang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea.
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Naderi-Boldaji V, Zand F, Asmarian N, Banifatemi M, Masjedi M, Sabetian G, Ouhadian M, Bayati N, Saeedizadeh H, Naderi N, Kasraian L. Does red blood cell transfusion affect clinical outcomes in critically ill patients? A report from a large teaching hospital in south Iran. Ann Saudi Med 2024; 44:84-92. [PMID: 38615186 PMCID: PMC11016154 DOI: 10.5144/0256-4947.2024.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/09/2023] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Despite the beneficial effects, RBC transfusion can be associated with infectious and non-infectious complications in critically ill patients. OBJECTIVES Investigate current RBC transfusion practices and their effect on the clinical outcomes of patients in intensive care units (ICUs). DESIGN Retrospective observational study. SETTING Three mixed medical-surgical adult ICUs of a large academic tertiary hospital. PATIENTS AND METHODS From March 2018 to February 2020, all adult patients admitted to medical or surgical ICU. Patients who received one or more RBC transfusions during the first month of ICU admission were included in the "transfusion" group, while the remaining patients were assigned to the "non-transfusion" group. MAIN OUTCOME MEASURES Mortality and length of ICU and hospital stay. SAMPLE SIZE 2159 patients. RESULTS Of 594 patients who recieved transfusions, 27% of patients received red blood cell (RBC) products. The mean pre-transfusion hemoglobin (Hb) level was 8.05 (1.46) g/dL. There was a significant relationship between higher APACHE II scores and ICU mortality in patients with Hb levels of 7-9 g/dL (OR adjusted=1.05). Also, ICU mortality was associated with age (OR adjusted=1.03), APACHE II score (OR adjusted=1.08), and RBC transfusion (OR adjusted=2.01) in those whose Hb levels were >9 (g/dl). CONCLUSION RBC transfusion was associated with an approximately doubled risk of ICU mortality in patients with Hb>9 g/dL. High APACHE II score and age increase the chance of death in the ICU by 8% and 3%, respectively. Hence, ICU physicians should consider a lower Hb threshold for RBC transfusion, and efforts must be made to optimize RBC transfusion practices. LIMITATIONS Single-center and retrospective study.
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Affiliation(s)
- Vida Naderi-Boldaji
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farid Zand
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naeimehossadat Asmarian
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Banifatemi
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mansoor Masjedi
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Golnar Sabetian
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Ouhadian
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Najmeh Bayati
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamideh Saeedizadeh
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nima Naderi
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Kasraian
- From the Iranian Blood Transfusion Research Center, High Institute for Education and Research in Transfusion Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Litton E, French C, Herschtal A, Stanworth S, Pellicano S, Palermo AM, Bates S, Van Der Laan S, Eroglu E, Griffith D, Shah A. Iron and erythropoietin to heal and recover after intensive care (ITHRIVE): A pilot randomised clinical trial. CRIT CARE RESUSC 2023; 25:201-206. [PMID: 38236513 PMCID: PMC10790015 DOI: 10.1016/j.ccrj.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
Objective To determine the feasibility of a pivotal randomised clinical trial of intravenous (IV) iron and erythropoietin in adult survivors of critical illness with anaemia requiring treatment in the intensive care unit. Design An investigator-initiated, parallel group, placebo-controlled, randomised feasibility trial. Setting A tertiary intensive care unit (ICU) in Perth, Western Australia. Participants Adults with anaemia (haemoglobin <100 g/L), requiring ICU-level care for more than 48 h, and likely to be ready for ICU discharge within 24 h. Interventions A single dose of IV ferric carboxymaltose and Epoetin alfa (active group) or an equal volume of 0.9% saline (placebo group). Main outcome measures Study feasibility was considered met if the pilot achieved a recruitment rate of ≥2 participants per site per month, ≥90% of participants received their allocated study treatment, and≥ 90% of participants were followed up for the proposed pivotal trial primary outcome - days alive and at home to day 90 (DAH90). Results The 40-participant planned sample size included twenty in each group and was enrolled between 1/9/2021 and 2/3/2022. Participants spent a median of 3.4 days (interquartile range 2.8-5.1) in the ICU prior to enrolment and had a mean baseline haemoglobin of 83.7 g/L (standard deviation 6.7). The recruitment rate was 6.7 participants per month [95% confidence interval (CI) 4.8-9.0], DAH90 follow-up was 100% (95% CI 91.2%-100%), and 39 (97.5%, 95% CI 86.8%-99.9%) participants received the allocated study intervention. No serious adverse events were reported. Conclusion The iron and erythropoietin to heal and recover after intensive care (ITHRIVE) pilot demonstrated feasibility based on predefined participant recruitment, study drug administration, and follow-up thresholds.
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Affiliation(s)
- Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth 6150, WA, Australia
- School of Medicine, University of Western Australia, 6009, WA, Australia
| | - Craig French
- Intensive Care Unit, Western Health, Melbourne, 3021, VIC, Australia
| | - Alan Herschtal
- School of Public Health and Preventative Medicine, Monash University, 4/553 St Kilda Road, Melbourne, VIC, Australia
| | - Simon Stanworth
- Haematology & Transfusion Medicine, John Radcliffe Hospital, Oxford UK
| | - Susan Pellicano
- Intensive Care Unit, Fiona Stanley Hospital, Perth 6150, WA, Australia
| | | | - Samantha Bates
- Intensive Care Unit, Western Health, Melbourne, 3021, VIC, Australia
| | | | - Ege Eroglu
- Intensive Care Unit, Fiona Stanley Hospital, Perth 6150, WA, Australia
| | - David Griffith
- Critical Care and Anaesthesia, Usher Institute, Edinburgh Medical School, Molecular, Genetic, and Population Health Sciences, The University of Edinburgh, UK
| | - Akshay Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Terrett LA, McIntyre L, Turgeon AF, English SW. Anemia and Red Blood Cell Transfusion in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:91-103. [PMID: 37634181 DOI: 10.1007/s12028-023-01815-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023]
Abstract
Anemia is very common in aneurysmal subarachnoid hemorrhage (aSAH), with approximately half of the aSAH patient population developing moderate anemia during their hospital stay. The available evidence (both physiologic and clinical) generally supports an association of anemia with unfavorable outcomes. Although aSAH shares a number of common mechanisms of secondary insult with other forms of acute brain injury, aSAH also has specific features that make it unique: an early phase (in which early brain injury predominates) and a delayed phase (in which delayed cerebral ischemia and vasospasm predominate). The effects of both anemia and transfusion are potentially variable between these phases, which may have unique considerations and possibly different risk-benefit profiles. Data on transfusion in this population are almost exclusively limited to observational studies, which suffer from significant heterogeneity and risk of bias. Overall, the results are conflicting, with the balance of the studies suggesting that transfusion is associated with unfavorable outcomes. The transfusion targets that are well established in other critically ill populations should not be automatically applied to patients with aSAH because of the unique disease characteristics of this population and the limited representation of aSAH in the clinical trials that established these targets. There are two upcoming clinical trials evaluating transfusion in aSAH that should help clarify specific transfusion targets. Until then, it is reasonable to base transfusion decisions on the current guidelines and use an individualized approach incorporating physiologic and clinical data when available.
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Affiliation(s)
- Luke A Terrett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Department of Adult Critical Care, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Unit, Centre hospitalier universitaire de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
- The Ottawa Hospital, Ottawa, ON, Canada.
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9
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Crooks CJ, West J, Morling JR, Simmonds M, Juurlink I, Briggs S, Cruickshank S, Hammond-Pears S, Shaw D, Card TR, Fogarty AW. Anaemia of acute inflammation: a higher acute systemic inflammatory response is associated with a larger decrease in blood haemoglobin levels in patients with COVID-19 infection. Clin Med (Lond) 2023; 23:201-205. [PMID: 37197805 PMCID: PMC11046552 DOI: 10.7861/clinmed.2022-0436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
AIMS The study tests the hypothesis that a higher acute systemic inflammatory response was associated with a larger decrease in blood hemoglobin levels in patients with Coronavirus 2019 (COVID-19) infection. METHODS All patients with either suspected or confirmed COVID-19 infection admitted to a busy UK hospital from February 2020 to December 2021 provided data for analysis. The exposure of interest was maximal serum C-reactive protein (CRP) level after COVID-19 during the same admission. RESULTS A maximal serum CRP >175mg/L was associated with a decrease in blood haemoglobin (-5.0 g/L, 95% confidence interval: -5.9 to -4.2) after adjustment for covariates, including the number of times blood was drawn for analysis.Clinically, for a 55-year-old male patient with a maximum haemoglobin of 150 g/L who was admitted for a 28-day admission, a peak CRP >175 mg/L would be associated with an 11 g/L decrease in blood haemoglobin, compared with only 6 g/L if the maximal CRP was <4 mg/L. CONCLUSIONS A higher acute systemic inflammatory response is associated with larger decreases in blood haemoglobin levels in patients with COVID-19. This represents an example of anaemia of acute inflammation, and a potential mechanism by which severe disease can increase morbidity and mortality.
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Affiliation(s)
| | - Joe West
- University of Nottingham, Nottingham, UK
| | | | - Mark Simmonds
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irene Juurlink
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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10
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Adkins BD, DeAnda A, Trieu JA, Polineni S, Okorodudu A, Yates SG. Central Line Access Is Predictive of Diagnostic Blood Loss and Transfusion in the Surgical Intensive Care Unit. Lab Med 2023; 54:173-181. [PMID: 36053232 DOI: 10.1093/labmed/lmac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Most patients in the surgical intensive care unit (SICU) have anemia and undergo extensive diagnostic laboratory testing (DLT). Consequently, patients undergo RBC transfusion, and many are discharged with anemia, both of which are associated with poorer outcomes. OBJECTIVE To characterize DLT blood loss in the SICU. MATERIALS AND METHODS We performed a 1-year retrospective study of 291 patients admitted to a SICU. The number of draws, average volume, and estimated discard volume were recorded, along with clinical and laboratory findings. RESULTS Patients who underwent greater amounts of DLT had lower hemoglobin levels at discharge (P ≤ .001). Admissions requiring central venous catheter (CVC) access (49.8%) demonstrated significantly higher DLT draws and rates of transfusion. CONCLUSION Findings from this study suggest that DLT blood loss contributes to anemia in the SICU, and that the presence and duration of CVC leads to increased testing, anemia, and RBC transfusion.
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Affiliation(s)
- Brian D Adkins
- The University of Texas Southwestern Medical Center-Pathology, Dallas, TX, USA
| | - Abe DeAnda
- University of Texas Medical Branch, Galveston, TX, USA
| | - Judy A Trieu
- Parkland Health and Hospital System, Dallas, TX, USA
| | | | - Anthony Okorodudu
- The University of Texas Southwestern Medical Center-Pathology, Dallas, TX, USA
| | - Sean G Yates
- The University of Texas Southwestern Medical Center-Pathology, Dallas, TX, USA
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11
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Kelly LS, Munley JA, Kannan KB, Pons EE, Coldwell PS, Bible LE, Parvataneni HK, Hagen JE, Efron PA, Mohr AM. Anemia Recovery after Trauma: A Longitudinal Study. Surg Infect (Larchmt) 2023; 24:39-45. [PMID: 36579920 PMCID: PMC9894600 DOI: 10.1089/sur.2022.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Post-injury inflammation and its correlation with anemia recovery after severe trauma is poorly described. Severe injury induces a systemic inflammatory response associated with critical illness and organ dysfunction, including disordered hematopoiesis, and anemia. This study sought to characterize the resolution of post-injury inflammation and anemia to identify risk factors associated with persistence of anemia. Patients and Methods: This single-institution study prospectively enrolled 73 trauma patients with an injury severity score >15, hemorrhagic shock, and a lower extremity long bone orthopedic injury. Blood was obtained at enrollment and after 14 days, one, three, and six months. Analytes were compared using Mann-Whitney U tests with correction for multiple comparisons. Results: Median age was 45 years and Injury Severity Score (ISS) was 27, with anemia rates of 97% at two weeks, 80% at one month, 52% at three months, and 30% at six months. Post-injury elevations in erythropoietin, interleukin-6, and C-reactive protein resolved by one month, three months, and six months, respectively. Median granulocyte colony-stimulating factor (G-CSF) and tumor necrosis factor (TNF)-α concentrations remained elevated throughout the six-month follow-up period. Patients with persistent anemia had longer intensive care unit and hospital lengths of stay, more infectious complications, and received more packed red blood cell transfusions compared to those with early anemia recovery. Conclusions: Severe trauma is associated with a prolonged inflammatory response, which is associated with increased transfusion requirements, lengths of stay, and persistent anemia. Further analysis is needed to identify correlations between prolonged inflammation and clinical outcomes after discharge.
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Affiliation(s)
- Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Preston S. Coldwell
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Hari K. Parvataneni
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer E. Hagen
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
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12
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Zuther M, Rübsam ML, Zimmermann M, Zarbock A, Hönemann C. Improved Diagnosis of Iron Deficiency Anemia in the Critically Ill via Fluorescence Flowcytometric Hemoglobin Biomarkers. Cells 2022; 12:cells12010140. [PMID: 36611936 PMCID: PMC9818818 DOI: 10.3390/cells12010140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/14/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Iron deficiency anemia (IDA) is common in critically ill patients treated in the intensive care unit (ICU), and it can lead to severe consequences. Precise and immediate diagnostics are not available, but they are inevitably needed to administer adequate therapy. Serological parameters such as serum ferritin and transferrin saturation (TSAT) are heavily influenced by simultaneous inflammation reactions, resulting in the need for more suitable parameters. Reticulocyte biomarkers such as reticulocyte hemoglobin content (RET-He) and Delta-hemoglobin equivalent (Delta-He) determined by fluorescence flowcytometry are more specific for the diagnosis of IDA-based anemia and should be investigated for this purpose. METHODS In a prospective cohort single-center study, serum ferritin and transferrin saturation (TSAT) were collected and compared to RET-He and Delta-He by performing a receiver operating curve (ROC) analysis. The sensitivity and specificity of a single variable or the combination of two variables, as well as cutoff values, for the diagnosis of IDA were calculated. A group comparison for IDA patients without IDA was performed for a control group. RESULTS A total of 314 patients were enrolled from an interdisciplinary ICU. RET-He (area under the curve (AUC) 0.847) and Delta-He (AUC 0.807) did indicate iron-deficient anemia that was more specific and sensitive in comparison to serum ferritin (AUC 0.678) and TSAT (AUC 0.754). The detection of functional iron deficiency (FID) occurred in 28.3% of cases with anemia. CONCLUSIONS Determination of RET-He and Delta-He allows for the increased precision and sensitivity of iron-deficient anemia in the ICU.
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Affiliation(s)
- Mascha Zuther
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, 48149 Münster, Germany
| | - Marie-Luise Rübsam
- Klinik für Anästhesiologie, Intensiv-, Notfall- und Schmerzmedizin, Universitätsmedizin Greifswald, 17475 Greifswald, Germany
| | - Mathias Zimmermann
- Institut für Labormedizin Köpenick, DRK Kliniken Berlin, 12559 Berlin, Germany
| | - Alexander Zarbock
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, 48149 Münster, Germany
| | - Christian Hönemann
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, 48149 Münster, Germany
- Abteilung für Anästhesiologie und Operative Intensivmedizin, St. Marienhospital Vechta, 49337 Vechta, Germany
- Correspondence: or ; Tel.: +49-(0)-15208961106
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13
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Czempik PF, Pluta MP, Krzych ŁJ. Hemoglobin Determination Using Pulse Co-Oximetry and Reduced-Volume Blood Gas Analysis in the Critically Ill: A Prospective Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12122908. [PMID: 36552914 PMCID: PMC9776962 DOI: 10.3390/diagnostics12122908] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/13/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Hospital-acquired anemia is common in patients hospitalized in the intensive care unit (ICU). A major source of iatrogenic blood loss in the ICU is the withdrawal of blood for laboratory testing. The aim of our study was to analyze the feasibility and accuracy of non-invasive spot-check pulse co-oximetry (SpHb), and a reduced-volume blood gas analysis (ABG Hb) for the determination of Hb concentration in critically ill patients. Comparisons between Hb determined with test devices and the gold standard—complete blood count (CBC)—were performed using Bland−Altman analysis and concordance correlation coefficient (CCC). The limits of agreement between SpHb and CBC Hb were −2.0 [95%CI −2.3−(−1.7)] to 3.6 (95%CI 3.3−3.9) g/dL. The limits of agreement between ABG Hb and CBC Hb were −0.6 [95%CI −0.7−(−0.4)] to 2.0 (95%CI 1.9−2.2) g/dL. Spearman’s coefficient and CCC between ABG Hb and CBC Hb were 0.96 (95%CI 0.95−0.97, p < 0.001) and 0.91 (95%CI 0.88−0.92), respectively. Non-invasive spot-check Hb co-oximetry is not sufficiently accurate for the monitoring of hemoglobin concentration in critically ill patients. Reduced volume arterial blood gas analysis has acceptable accuracy and could replace complete blood count for the monitoring of Hb concentration in critically ill patients, leading to a significant reduction in blood volume lost for anemia diagnostics.
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Affiliation(s)
- Piotr F. Czempik
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland
- Transfusion Committee, University Clinical Center of the Medical University of Silesia in Katowice, 40-055 Katowice, Poland
- Correspondence: ; Tel.: +48-327894201
| | - Michał P. Pluta
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland
| | - Łukasz J. Krzych
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland
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14
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Maira D, Duca L, Busti F, Consonni D, Salvatici M, Vianello A, Milani A, Guzzardella A, Di Pierro E, Aliberti S, Baldini IM, Bandera A, Blasi F, Cassinerio E, Cesari M, Fracanzani AL, Grasselli G, Graziadei G, Lombardi R, Marchi G, Montano N, Monzani V, Peyvandi F, Proietti M, Sandri M, Valenti L, Cappellini MD, Girelli D, Protti A, Motta I. The role of hypoxia and inflammation in the regulation of iron metabolism and erythropoiesis in COVID-19: The IRONCOVID study. Am J Hematol 2022; 97:1404-1412. [PMID: 36215667 PMCID: PMC9538950 DOI: 10.1002/ajh.26679] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/15/2022] [Accepted: 08/02/2022] [Indexed: 01/28/2023]
Abstract
Coronavirus Disease (COVID-19) can be considered as a human pathological model of inflammation combined with hypoxia. In this setting, both erythropoiesis and iron metabolism appear to be profoundly affected by inflammatory and hypoxic stimuli, which act in the opposite direction on hepcidin regulation. The impact of low blood oxygen levels on erythropoiesis and iron metabolism in the context of human hypoxic disease (e.g., pneumonia) has not been fully elucidated. This multicentric observational study was aimed at investigating the prevalence of anemia, the alterations of iron homeostasis, and the relationship between inflammation, hypoxia, and erythropoietic parameters in a cohort of 481 COVID-19 patients admitted both to medical wards and intensive care units (ICU). Data were collected on admission and after 7 days of hospitalization. On admission, nearly half of the patients were anemic, displaying mild-to-moderate anemia. We found that hepcidin levels were increased during the whole period of observation. The patients with a higher burden of disease (i.e., those who needed intensive care treatment or had a more severe degree of hypoxia) showed lower hepcidin levels, despite having a more marked inflammatory pattern. Erythropoietin (EPO) levels were also lower in the ICU group on admission. After 7 days, EPO levels rose in the ICU group while they remained stable in the non-ICU group, reflecting that the initial hypoxic stimulus was stronger in the first group. These findings strengthen the hypothesis that, at least in the early phases, hypoxia-driven stimuli prevail over inflammation in the regulation of hepcidin and, finally, of erythropoiesis.
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Affiliation(s)
- Diletta Maira
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoGeneral Medicine UnitMilanItaly
| | - Lorena Duca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoGeneral Medicine UnitMilanItaly
| | - Fabiana Busti
- Department of Medicine, Section of Internal Medicine, EuroBloodNet CenterUniversity of Verona and Azienda Ospedaliera Universitaria Integrata VeronaVeronaItaly
| | - Dario Consonni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoEpidemiology UnitMilanItaly
| | | | - Alice Vianello
- Department of Medicine, Section of Internal Medicine, EuroBloodNet CenterUniversity of Verona and Azienda Ospedaliera Universitaria Integrata VeronaVeronaItaly
| | - Angelo Milani
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele (Milan)Italy,Department of Anesthesia and Intensive Care UnitsIRCCS‐Humanitas Research HospitalRozzano (Milan)Italy
| | - Amedeo Guzzardella
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of AnesthesiaIntensive Care and EmergencyMilanItaly
| | - Elena Di Pierro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoGeneral Medicine UnitMilanItaly
| | - Stefano Aliberti
- Respiratory Unit, Humanitas Clinical and Research CenterIRCCSRozzano (Milan)Italy
| | - Itala Marina Baldini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoGeneral Medicine UnitMilanItaly
| | - Alessandra Bandera
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoInfectious Diseases UnitMilanItaly,Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Francesco Blasi
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Respiratory UnitFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Elena Cassinerio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoGeneral Medicine UnitMilanItaly
| | - Matteo Cesari
- Geriatric UnitIRCCS Istituti Clinici Scientifici MaugeriMilanItaly,Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
| | - Anna Ludovica Fracanzani
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoInternal Medicine and Metabolic Disease UnitMilanItaly
| | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of AnesthesiaIntensive Care and EmergencyMilanItaly,Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Giovanna Graziadei
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoGeneral Medicine UnitMilanItaly
| | - Rosa Lombardi
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoInternal Medicine and Metabolic Disease UnitMilanItaly
| | - Giacomo Marchi
- Department of Medicine, Section of Internal Medicine, EuroBloodNet CenterUniversity of Verona and Azienda Ospedaliera Universitaria Integrata VeronaVeronaItaly
| | - Nicola Montano
- Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly,Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoInternal Medicine, Immunology and Allergology UnitMilanItaly
| | - Valter Monzani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoHigh Care Internal Medicin UnitMilanItaly
| | - Flora Peyvandi
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoUOC Medicina Generale Emostasi e TrombosiMilanItaly
| | - Marco Proietti
- Geriatric UnitIRCCS Istituti Clinici Scientifici MaugeriMilanItaly,Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly,Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
| | | | - Luca Valenti
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoDepartment of Transfusion Medicine and Hematology, Biological Resource Center and Precision Medicine LabMilanItaly
| | | | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, EuroBloodNet CenterUniversity of Verona and Azienda Ospedaliera Universitaria Integrata VeronaVeronaItaly
| | - Alessandro Protti
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele (Milan)Italy,Department of Anesthesia and Intensive Care UnitsIRCCS‐Humanitas Research HospitalRozzano (Milan)Italy
| | - Irene Motta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoGeneral Medicine UnitMilanItaly,Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
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15
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Sertcakacilar G, Yildiz GO. Association between Anemia and New-Onset Atrial Fibrillation in Critically Ill Patients in the Intensive Care Unit: A Retrospective Cohort Analysis. Clin Pract 2022; 12:533-544. [PMID: 35892443 PMCID: PMC9326761 DOI: 10.3390/clinpract12040057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/05/2022] [Accepted: 07/09/2022] [Indexed: 01/28/2023] Open
Abstract
New-onset atrial fibrillation (NOAF) is one of the leading causes of morbidity and mortality, especially in older patients in the intensive care unit (ICU). Although many comorbidities are associated with NOAF, the effect of anemia on the onset of atrial fibrillation is still unknown. This study aimed to test the hypothesis that anemia is associated with an increased risk of developing NOAF in critically ill patients in intensive care. We performed a retrospective analysis of critically ill patients who underwent routine hemoglobin and electrocardiography monitoring in the ICU. Receiver operating characteristics analysis determined the hemoglobin (Hb) value that triggered NOAF formation. Bivariate correlation was used to determine the relationship between anemia and NOAF. The incidence of NOAF was 9.9% in the total population, and 12.8% in the patient group with anemia. Analysis of 1931 patients revealed a negative association between anemia and the development of NOAF in the ICU. The stimulatory Hb cut-off value for the formation of NOAF was determined as 9.64 g/dL. Anemia is associated with the development of NOAF in critically ill patients in intensive care.
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Affiliation(s)
- Gokhan Sertcakacilar
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anesthesiology and Reanimation, University of Health Science, Bakırköy Dr. Sadi Konuk Education and Research Hospital, 34147 Istanbul, Turkey;
- Correspondence:
| | - Gunes Ozlem Yildiz
- Department of Anesthesiology and Reanimation, University of Health Science, Bakırköy Dr. Sadi Konuk Education and Research Hospital, 34147 Istanbul, Turkey;
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16
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Hospital-Acquired Anemia in Patients Hospitalized in the Intensive Care Unit: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11143939. [PMID: 35887702 PMCID: PMC9322508 DOI: 10.3390/jcm11143939] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 11/20/2022] Open
Abstract
Hospital-acquired anemia (HAA) is prevalent in patients hospitalized in the intensive care unit (ICU). Iatrogenic blood loss (IBL) may aggravate existing anemia or lead to a need for red blood cell (RBC) transfusion. The aim of our study was to analyze hemoglobin (Hb) concentration changes in up to 14 days, as well as all potential sources of IBL, in consecutive patients admitted to the intensive care unit (ICU) in the years 2020−2021. Patients admitted due to bleeding were excluded. Anemia on admission was present in 218 (58.8%) patients—47 (48.9%) surgical and 171 (62.2%) non-surgical (p = 0.02). Gradual decrease in Hb was seen in all ICU patients. Eighty-one (21.8%) patients required RBC transfusion. The first unit of RBC was transfused on day 7 (IQR 2−13) and the second on day 11 (IQR 4−15) of ICU hospitalization. The median admission Hb in patients who required RBC transfusion was 10.2 (IQR 8.5−11.8) and, in those who did not require transfusion, it was 12.0 (IQR 10.2−13.6) g/dL (p < 0.01). Anemia on admission was associated with a need for RBC transfusion (p < 0.01). Average decrease in Hb during the first week of ICU hospitalization in patients with and without anemia on admission was 1.2 (IQR 0.2−2.3) and 2.8 (IQR 1.1−3.8) g/dL (p < 0.01), respectively. Percentage of patients who bled at the insertion site of invasive devices was as follows: percutaneous tracheostomy—46.7%, therapeutic plasma exchange (TPE) catheter—23.8%, dialysis catheter—13.3%, gastrostomy—9.5%, central venous catheter—7.8%. Moreover, circuit clotting occurred in 17.7 and 9.5% of patients undergoing dialysis and TPE, respectively. Median blood loss for repeated laboratory testing in our study population was 13.7 (IQR 9.9−19.3) mL per patient daily. Anemia is highly prevalent among medical and surgical patients on admission to ICU and is associated with RBC transfusion. Patients who required RBC transfusion had significantly lower daily Hb concentrations. Severity of disease did not seem to have impact on Hb concentration. IBL associated with invasive devices and extracorporeal therapies is frequent in ICU patients and may lead to a gradual decrease in Hb concentration. Further studies are required to analyze causes of HAA in the ICU.
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17
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Fritsch SJ, Dreher M, Simon TP, Marx G, Bickenbach J. Haemoglobin value and red blood cell transfusions in prolonged weaning from mechanical ventilation: a retrospective observational study. BMJ Open Respir Res 2022; 9:9/1/e001228. [PMID: 35701072 PMCID: PMC9198721 DOI: 10.1136/bmjresp-2022-001228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/30/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The role of haemoglobin (Hb) value and red blood cell (RBC) transfusions in prolonged weaning from mechanical ventilation (MV) is still controversial. Pathophysiological considerations recommend a not too restrictive transfusion strategy, whereas adverse effects of transfusions are reported. We aimed to investigate the association between Hb value, RBC transfusion and clinical outcome of patients undergoing prolonged weaning from MV. METHODS We performed a retrospective, single-centred, observational study including patients being transferred to a specialised weaning unit. Data on demographic characteristics, comorbidities, current and past medical history and the current course of treatment were collected. Weaning failure and mortality were chosen as primary and secondary endpoint, respectively. Differences between transfused and non-transfused patients were analysed. To evaluate the impact of different risk factors including Hb value and RBC transfusion on clinical outcome, a multivariate logistic regression analysis was used. RESULTS 184 patients from a specialised weaning unit were analysed, of whom 36 (19.6%) failed to be weaned successfully. In-hospital mortality was 18.5%. 90 patients (48.9%) required RBC transfusion during the weaning process, showing a significantly lower Hb value (g/L) (86.3±5.3) than the non-transfusion group (95.8±10.5). In the multivariate regression analysis (OR 3.24; p=0.045), RBC transfusion was associated with weaning failure. However, the transfusion group had characteristics indicating that these patients were still in a more critical state of disease. CONCLUSIONS In our analysis, the need for RBC transfusion was independently associated with weaning failure. However, it is unclear whether the transfusion itself should be considered an independent risk factor or an additional symptom of a persistent critical patient condition.
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Affiliation(s)
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
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18
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Mechanisms of improved erythroid progenitor growth with removal of chronic stress after trauma. Surgery 2022; 172:759-765. [PMID: 35672167 PMCID: PMC9283291 DOI: 10.1016/j.surg.2022.04.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/14/2022] [Accepted: 04/29/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Erythropoietic dysfunction after trauma and critical illness is associated with anemia, persistent inflammation, increased hematopoietic progenitor cell mobilization from the bone marrow, and reduced erythroid progenitor growth. Yet the duration and reversibility of these postinjury bone marrow changes remain unknown. This study sought to determine whether removal of chronic postinjury stress could induce improvements in erythroid progenitor growth. METHODS Sprague-Dawley rats (n = 8-11/group) were assigned to the following: naïve, lung contusion and hemorrhagic shock, lung contusion and hemorrhagic shock plus daily chronic stress for 7 days followed by 7 days of routine handling to allow recovery (lung contusion and hemorrhagic shock + chronic stress 7), or lung contusion and hemorrhagic shock plus chronic stress for 14 days (lung contusion and hemorrhagic shock + chronic stress 14). Circulating CD117+CD71+ erythroid progenitors were detected by flow cytometry. Rodents were killed on day 14, and bone marrow erythroid progenitor growth and erythroid transcription factors were assessed. Differences were assessed by analysis of variance (P < .05). RESULTS Compared to lung contusion and hemorrhagic shock + chronic stress 14, lung contusion and hemorrhagic shock + chronic stress 7 rodents had improved hemoglobin (8% ± 10% increase vs 6% ± 10% decrease) with fewer mobilized erythroid progenitors (898 × vs 1,524 cells), lower granulocyte-colony stimulating factor levels (3.1 ± 1.1 × pg/mL vs 5.9 ± 1.8 pg/mL), and improved erythroid progenitor growth. Cessation of stress had no impact on erythroid transcription factors GATA-1, GATA-2, LMO2, or KLF1. CONCLUSION Improvements in erythroid progenitor growth and reduced hematopoietic progenitor cell mobilization were seen 7 days after cessation of chronic stress and were associated with an improvement in hemoglobin. Early bone marrow erythropoietic functional recovery may result from resolution of hematopoietic progenitor mobilization rather than upregulation of pro-erythroid transcription factors. This study suggests that postinjury anemia is reversible and has the potential to improve with the cessation of stress.
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Red Blood Cell Transfusion at a Hemoglobin Threshold of Seven g/dL in Critically Ill Patients: A Regression Discontinuity Study. Ann Am Thorac Soc 2022; 19:1177-1184. [PMID: 35119978 DOI: 10.1513/annalsats.202109-1078oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE In critically ill patients, a hemoglobin transfusion threshold of <7.0 G/dl compared to <10.0 G/dl improves organ dysfunction. However, it is unclear if transfusion at a hemoglobin of <7.0 g/dL is superior to no transfusion. OBJECTIVES To compare levels of organ dysfunction between transfusion and no transfusion at a hemoglobin threshold of <7.0 G/dl among critically ill patients using quasi-experimental regression discontinuity methods. METHODS We performed regression discontinuity analysis using hemoglobin measurements from patients admitted to ICUs in three cohorts (MIMIC-IV, eICU, and Premier Inc.), estimating the change in organ dysfunction (modified sequential organ failure assessment score) in the 24-72-hour window following each hemoglobin measurement. We compared hemoglobin levels just above and below 7.0 g/dL using a 'fuzzy' discontinuity approach, based on the concept that measurement noise pseudorandomizes similar hemoglobin levels on either side of the transfusion threshold. RESULTS A total of 11,181, 13,664, and 167,142 patients were included in the MIMIC-IV, eICU, and Premier cohorts, respectively. Patient characteristics below the threshold did not differ from those above the threshold, except that crossing below the threshold resulted in a >20% absolute increase in transfusion rates in all three cohorts. Transfusion was associated with increases in hemoglobin level in the subsequent 24-72 hours (MIMIC-IV 2.4 [95% CI 1.1, 3.6] g/dL; eICU 0.7 [95% CI 0.3, 1.2] g/dL; Premier 1.9 [95% CI 1.5, 2.2] g/dL), but not with improvement in organ dysfunction (MIMIC-IV 4.6 [95% CI -1.2, 10] points; eICU 4.4 [95% CI 0.9, 7.8] points; Premier 1.1 [95% CI -0.2, 2.3] points), compared to no transfusion. CONCLUSIONS Transfusion was not associated with improved organ dysfunction compared to no transfusion at a hemoglobin threshold of 7.0 g/dL, suggesting that evaluation of transfusion targets other than a hemoglobin threshold of 7.0 G/dl may be warranted.
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Avoidable Blood Loss in Critical Care and Patient Blood Management: Scoping Review of Diagnostic Blood Loss. J Clin Med 2022; 11:jcm11020320. [PMID: 35054014 PMCID: PMC8777821 DOI: 10.3390/jcm11020320] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/27/2021] [Accepted: 01/04/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Anemia remains one of the most common comorbidities in intensive care patients worldwide. The cause of anemia is often multifactorial and triggered by underlying disease, comorbidities, and iatrogenic factors, such as diagnostic phlebotomies. As anemia is associated with a worse outcome, especially in intensive care patients, unnecessary iatrogenic blood loss must be avoided. Therefore, this scoping review addresses the amount of blood loss during routine phlebotomies in adult (>17 years) intensive care patients and whether there are factors that need to be improved in terms of patient blood management (PBM). Methods: A systematic search of the Medline Database via PubMed was conducted according to PRISMA guidelines. The reported daily blood volume for diagnostics and other relevant information from eligible studies were charted. Results: A total of 2167 studies were identified in our search, of which 38 studies met the inclusion criteria (9 interventional studies and 29 observational studies). The majority of the studies were conducted in the US (37%) and Canada (13%). An increasing interest to reduce iatrogenic blood loss has been observed since 2015. Phlebotomized blood volume per patient per day was up to 377 mL. All interventional trials showed that the use of pediatric-sized blood collection tubes can significantly reduce the daily amount of blood drawn. Conclusion: Iatrogenic blood loss for diagnostic purposes contributes significantly to the development and exacerbation of hospital-acquired anemia. Therefore, a comprehensive PBM in intensive care is urgently needed to reduce avoidable blood loss, including blood-sparing techniques, regular advanced training, and small-volume blood collection tubes.
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21
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Kelly LS, Apple CG, Darden DB, Kannan KB, Pons EE, Fenner BP, Parvataneni HK, Hagen JE, Brakenridge SC, Efron PA, Mohr AM. Transcriptomic Changes Within Human Bone Marrow After Severe Trauma. Shock 2022; 57:24-30. [PMID: 34172608 PMCID: PMC8678139 DOI: 10.1097/shk.0000000000001826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Severe trauma is associated with severe systemic inflammation and neuroendocrine activation that is associated with erythroid progenitor growth suppression and refractory anemia. Although distinct transcriptional profiles have been detected in numerous tissue types after trauma, no study has yet characterized this within the bone marrow. This study sought to identify a unique bone marrow transcriptomic response following trauma. METHODS In a prospective observational cohort study, bone marrow was obtained from severely injured trauma patients with a hip or femur fracture (n = 52), elective hip replacement patients (n = 33), and healthy controls (n = 11). RNA was isolated from bone marrow using a Purelink RNA mini kit. Direct quantification of mRNA copies was performed by NanoString Technologies on a custom gene panel. RESULTS Trauma patients displayed an upregulation of genes encoding receptors known to have inhibitory downstream effects on erythropoiesis, including ferroportin, interleukin-6 (IL-6) receptor, transforming growth factor-beta (TGF-β) receptor, and IL-10, as well as genes involved in innate immunity including toll-like receptor 4 (TLR4)-mediated signaling factors. In contrast, hip replacement patients had downregulated transcription of IL-1β, IL-6, TGF-β, tumor necrosis factor alpha, and the HAMP gene with no change in TLR4-mediated signaling factors. CONCLUSIONS A unique transcriptomic response within the bone marrow was identified following severe trauma compared to elective hip replacement. These transcriptomic differences were related to the innate immune response as well as known inhibitors of erythropoiesis. Although confined to just one time point, this differential transcriptional response may be linked to refractory anemia and inflammation after injury.
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Affiliation(s)
- Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Camille G. Apple
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Dijoia B. Darden
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Brittany P. Fenner
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Hari K. Parvataneni
- Department of Orthopaedic Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Jennifer E. Hagen
- Department of Orthopaedic Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Scott C. Brakenridge
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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22
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Hypoglycemic episodes predict length of stay in patients with acute burns. J Crit Care 2021; 64:68-73. [PMID: 33794469 DOI: 10.1016/j.jcrc.2021.03.005] [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: 08/10/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/23/2022]
Abstract
Hypoglycemic episodes are associated with worse hospital outcomes. All adult patients admitted to our burn center from 2015 to 2019 were retrospectively reviewed. Patient demographics and burn characteristics were recorded. The primary outcome was mortality, and secondary outcomes were total length-of-stay and intensive care unit length-of-stay. All patients experiencing at least one hypoglycemic episode were compared to patients who did not experience hypoglycemia. There were 914 patients with acute burns admitted during the study period, 33 of which (4%) experienced hypoglycemic episodes. Of these, 17 patients (52%) experienced a single hypoglycemic episode, while the remainder experienced multiple hypoglycemic episodes. Patients with one or more hypoglycemic events were matched to non-hypoglycemic controls using propensity matching. Patients that experienced hypoglycemia had significantly less TBSA involvement (5% vs. 13%,median, p < 0.0002), higher prevalence of diabetes (48% vs. 18%, p < 0.0001), higher mortality (18% vs. 7%, p = 0.01), longer total length-of-stay (22 vs. 8 days, median, p < 0.0001), and longer ICU length-of-stay (12 vs. 0 days, median, p < 0.0001). A single hypoglycemic episode was associated with prolonged total (IRR = 1.91, p < 0.0001) and ICU length-of-stay (IRR = 3.86, p < 0.0001). Hypoglycemia was not associated with higher mortality in the survival analysis (p = 0.46).
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23
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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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24
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Jonmarker S, Hollenberg J, Dahlberg M, Stackelberg O, Litorell J, Everhov ÅH, Järnbert-Pettersson H, Söderberg M, Grip J, Schandl A, Günther M, Cronhjort M. Dosing of thromboprophylaxis and mortality in critically ill COVID-19 patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:653. [PMID: 33225952 PMCID: PMC7680989 DOI: 10.1186/s13054-020-03375-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022]
Abstract
Background A substantial proportion of critically ill COVID-19 patients develop thromboembolic complications, but it is unclear whether higher doses of thromboprophylaxis are associated with lower mortality rates. The purpose of the study was to evaluate the association between initial dosing strategy of thromboprophylaxis in critically ill COVID-19 patients and the risk of death, thromboembolism, and bleeding. Method In this retrospective study, all critically ill COVID-19 patients admitted to two intensive care units in March and April 2020 were eligible. Patients were categorized into three groups according to initial daily dose of thromboprophylaxis: low (2500–4500 IU tinzaparin or 2500–5000 IU dalteparin), medium (> 4500 IU but < 175 IU/kilogram, kg, of body weight tinzaparin or > 5000 IU but < 200 IU/kg of body weight dalteparin), and high dose (≥ 175 IU/kg of body weight tinzaparin or ≥ 200 IU/kg of body weight dalteparin). Thromboprophylaxis dosage was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Cox proportional hazards regression was used to estimate hazard ratios with corresponding 95% confidence intervals of death within 28 days from ICU admission. Multivariable models were adjusted for sex, age, body mass index, Simplified Acute Physiology Score III, invasive respiratory support, and initial dosing strategy of thromboprophylaxis. Results A total of 152 patients were included: 67 received low-, 48 medium-, and 37 high-dose thromboprophylaxis. Baseline characteristics did not differ between groups. For patients who received high-dose prophylaxis, mortality was lower (13.5%) compared to those who received medium dose (25.0%) or low dose (38.8%), p = 0.02. The hazard ratio of death was 0.33 (95% confidence intervals 0.13–0.87) among those who received high dose, and 0.88 (95% confidence intervals 0.43–1.83) among those who received medium dose, as compared to those who received low-dose thromboprophylaxis. There were fewer thromboembolic events in the high (2.7%) vs medium (18.8%) and low-dose thromboprophylaxis (17.9%) groups, p = 0.04. Conclusions Among critically ill COVID-19 patients with respiratory failure, high-dose thromboprophylaxis was associated with a lower risk of death and a lower cumulative incidence of thromboembolic events compared with lower doses. Trial registration Clinicaltrials.gov NCT04412304 June 2, 2020, retrospectively registered. ![]()
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Affiliation(s)
- Sandra Jonmarker
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Otto Stackelberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Unit of Cardiovascular and Nutritional Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Jacob Litorell
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Hans Järnbert-Pettersson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Söderberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Jonathan Grip
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Anna Schandl
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden.
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25
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Warner MA, Hanson AC, Frank RD, Schulte PJ, Go RS, Storlie CB, Kor DJ. Prevalence of and Recovery From Anemia Following Hospitalization for Critical Illness Among Adults. JAMA Netw Open 2020; 3:e2017843. [PMID: 32970158 PMCID: PMC7516623 DOI: 10.1001/jamanetworkopen.2020.17843] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Anemia is common and has been associated with poor outcomes in the critically ill population, yet the timing and extent of hemoglobin recovery remains incompletely described, which may have important implications for clinical outcomes following discharge from intensive care. OBJECTIVES To describe longitudinal changes in anemia status during and after critical illness and assess the associations between hemoglobin concentrations and postdischarge mortality. DESIGN, SETTING, AND PARTICIPANTS A population-based cohort study was conducted from January 1, 2010, to December 31, 2016, in Olmsted County, Minnesota; data analysis was performed from June 1 to December 30, 2019. Participants included 6901 adults (age ≥18 years) admitted to intensive care. MAIN OUTCOMES AND MEASURES Hemoglobin concentrations in the 12 months before hospitalization, during hospitalization, and in the 12 months after discharge, categorized by anemia severity (mild, hemoglobin ≥10.0 to <12.0 g/dL in women or ≥10.0 to <13.5 g/dL in men; moderate, hemoglobin ≥8.0 to <10.0 g/dL; and severe, hemoglobin <8.0 g/dL). Complete recovery from anemia, defined as attainment of nonanemic status by 12 months post hospitalization, and 12-month mortality were also evaluated. RESULTS Of the 6901 patients included in the study, 3792 were men (55%); median (interquartile range [IQR]) age was 67 (IQR, 52-79) years. Prehospitalization hemoglobin concentrations were available in 83% of the population (n = 5694), with median hemoglobin concentrations of 13.1 (IQR, 11.6-14.4) g/dL. Forty-one percent of the patients (n = 2320) had anemia preceding hospitalization. Hemoglobin values at hospital discharge were 10.8 g/dL (IQR, 9.5-12.4 g/dL), with 80% (n = 5182 of 6460) having anemia: 58% mild, 39% moderate, and 3% severe. The prevalence of anemia post hospitalization was 56% (95% CI, 55%-58%) at 3 months, 52% (95% CI, 50%-54%) at 6 months, and 45% (95% CI, 43%-47%) at 12 months among those alive with available hemoglobin measurements. Rates of complete recovery from anemia at 12 months were 58% (95% CI, 56%-61%) for mild anemia, 39% (95% CI, 36%-42%) for moderate anemia, and 24% (95% CI, 15%-34%) for severe anemia. Of those without baseline anemia surviving hospitalization, 74% of the patients were anemic at hospital discharge, with rates of complete 12-month recovery of 73% (95% CI, 69%-76%) for mild anemia, 62% (95% CI, 57%-68%) for moderate anemia, and 59% (95% CI, 35%-82%) for severe anemia. Higher hospital discharge hemoglobin concentrations were associated with decreased mortality after multivariable adjustment (hazard ratio, 0.95 per 1-g/dL increase; 95% CI, 0.90-0.99, P = .02). CONCLUSIONS AND RELEVANCE The findings of this study suggest that anemia is common and often persistent in the first year after critical illness. Further studies are warranted to identify distinct anemia recovery profiles and assess associations with clinical outcomes.
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Affiliation(s)
- Matthew A. Warner
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew C. Hanson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Ryan D. Frank
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Phillip J. Schulte
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Ronald S. Go
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Curtis B. Storlie
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Daryl J. Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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26
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Abstract
OBJECTIVES To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES Source data were obtained from a PubMed literature review. STUDY SELECTION English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.
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27
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Warner MA, Kor DJ, Frank RD, Dinglas VD, Mendez-Tellez P, Himmelfarb CRD, Shanholtz CB, Storlie CB, Needham DM. Anemia in Critically Ill Patients With Acute Respiratory Distress Syndrome and Posthospitalization Physical Outcomes. J Intensive Care Med 2020; 36:557-565. [DOI: 10.1177/0885066620913262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: Anemia is common during critical illness and often persists after hospital discharge; however, its potential association with physical outcomes after critical illness is unclear. Our objective was to assess the associations between hemoglobin at intensive care unit (ICU) and hospital discharge with physical status at 3-month follow-up in acute respiratory distress syndrome (ARDS) survivors. Methods: This is a secondary analysis of a multisite prospective cohort study of 195 mechanically ventilated ARDS survivors from 13 ICUs at 4 teaching hospitals in Baltimore, Maryland. Multivariable regression was utilized to assess the relationships between ICU and hospital discharge hemoglobin concentrations with measures of physical status at 3 months, including muscle strength (Medical Research Council sumscore), exercise capacity (6-minute walk distance [6MWD]), and self-reported physical functioning (36-Item Short-Form Health Survey [SF-36v2] Physical Function score and Activities of Daily Living [ADL] dependencies). Results: Median (interquartile range) hemoglobin concentrations at ICU and hospital discharge were 9.5 (8.5-10.7) and 10.0 (9.0-11.2) g/dL, respectively. In multivariable regression analyses, higher ICU discharge hemoglobin concentrations (per 1 g/dL) were associated with greater 3-month 6MWD mean percent of predicted (3.7% [95% confidence interval 0.8%-6.5%]; P = .01) and fewer ADL dependencies (−0.2 [−0.4 to −0.1]; P = .02), but not with percentage of maximal muscle strength (0.7% [−0.9 to 2.3]; P = .37) or SF-36v2 normalized Physical Function scores (0.8 [−0.3 to 1.9]; P = .15). The associations of physical outcomes and hospital discharge hemoglobin concentrations were qualitatively similar, but none were statistically significant. Conclusions: In ARDS survivors, higher hemoglobin concentrations at ICU discharge, but not hospital discharge, were significantly associated with improved exercise capacity and fewer ADL dependencies. Future studies are warranted to further assess these relationships.
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Affiliation(s)
- Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daryl J. Kor
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan D. Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Victor D. Dinglas
- Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
| | - Pedro Mendez-Tellez
- Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Carl B. Shanholtz
- Pulmonary & Critical Care Medicine, University of Maryland, Baltimore, MD, USA
| | - Curtis B. Storlie
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
- Pulmonary & Critical Care Medicine, Physical Medicine & Rehabilitation, and Nursing, Johns Hopkins University, Baltimore, MD, USA
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28
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Jackson Chornenki NL, James TE, Barty R, Liu Y, Rochwerg B, Heddle NM, Siegal DM. Blood loss from laboratory testing, anemia, and red blood cell transfusion in the intensive care unit: a retrospective study. Transfusion 2019; 60:256-261. [DOI: 10.1111/trf.15649] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/08/2019] [Accepted: 11/22/2019] [Indexed: 02/04/2023]
Affiliation(s)
| | - Tyler E. James
- Department of Medicine McMaster University Hamilton Ontario Canada
| | - Rebecca Barty
- Department of Medicine McMaster University Hamilton Ontario Canada
- McMaster Centre for Transfusion Research McMaster University Hamilton Ontario Canada
| | - Yang Liu
- Department of Medicine McMaster University Hamilton Ontario Canada
- McMaster Centre for Transfusion Research McMaster University Hamilton Ontario Canada
| | - Bram Rochwerg
- Department of Medicine McMaster University Hamilton Ontario Canada
- Department of Health Research Methods Evidence and Impact at McMaster Hamilton Ontario Canada
| | - Nancy M. Heddle
- Department of Medicine McMaster University Hamilton Ontario Canada
- McMaster Centre for Transfusion Research McMaster University Hamilton Ontario Canada
| | - Deborah M. Siegal
- Department of Medicine McMaster University Hamilton Ontario Canada
- Population Health Research Institute McMaster University Hamilton Ontario Canada
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29
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Affiliation(s)
- Tomas Ganz
- From the Departments of Medicine and Pathology, David Geffen School of Medicine at UCLA, Los Angeles
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30
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Quinn JG, Levy AR, Cheng CK, Doucette S, Theriault C, Doiron D, Kiberd BA, Tennankore KK. A contemporary description of patients' estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center. Transfusion 2019; 59:2849-2856. [PMID: 31283032 DOI: 10.1111/trf.15434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/13/2019] [Accepted: 06/08/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospital-wide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations. STUDY DESIGN AND METHODS Data were obtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients. RESULTS Data were included on 59,715 subjects. Mean daily estimated blood loss varied from 8.5 ± 6.5 mL/day onward to 27.2 ± 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations). CONCLUSION Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy.
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Affiliation(s)
- Jason G Quinn
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada
| | - Adrian R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Calvino K Cheng
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada
| | - Steve Doucette
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Chris Theriault
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Don Doiron
- Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada
| | - Bryce A Kiberd
- Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada.,Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karthik K Tennankore
- Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada.,Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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31
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Pasqualetti S, Aloisio E, Birindelli S, Dolci A, Panteghini M. Impact of total automation consolidating first-line laboratory tests on diagnostic blood loss. ACTA ACUST UNITED AC 2019; 57:1721-1729. [DOI: 10.1515/cclm-2019-0133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Blood loss for laboratory testing may contribute to hospital-acquired anemia. When implementing the core laboratory (core-lab) section, we consolidated first-line tests decreasing the number of tubes previously dispatched to different sites. Here, hypothesized benefits of the amount of blood volume drawn were explored.
Methods
We retrieved, using a laboratory information system (LIS), the number of tubes received by laboratories interested in the change from all clinical wards in a year-based period, i.e. 2013 for pre-core-lab and 2015 for core-lab system, respectively. Data were expressed as the overall number of tubes sent to laboratories, the corresponding blood volume, and the number of laboratory tests performed, normalized for the number of inpatients.
Results
After consolidation, the average number of blood tubes per inpatient significantly decreased (12.6 vs. 10.7, p < 0.001). However, intensive care units (ICUs) did not reduce the number of tubes per patient, according to the needs of daily monitoring of their clinical status. The average blood volume sent to laboratories did not vary significantly because serum tubes for core-lab required higher volumes for testing up to 55 analytes in the same transaction. Finally, the number of requested tests per patient during the new osystem slightly decreased (−2.6%).
Conclusions
Total laboratory automation does not automatically mean reducing iatrogenic blood loss. The new system affected the procedure of blood drawing in clinical wards by significantly reducing the number of handled tubes, producing a benefit in terms of costs, labor and time consumption. Except in ICUs, this also slightly promoted some blood saving. ICUs which engage in phlebotomizing patients daily, did not take advantage from the test consolidation.
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Affiliation(s)
- Sara Pasqualetti
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco , Via GB Grassi 74 , 20157 Milan , Italy , Phone: +39 02 39042683, Fax: +39 02 39042364
| | - Elena Aloisio
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco , Milan , Italy
| | - Sarah Birindelli
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco , Milan , Italy
| | - Alberto Dolci
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco , Milan , Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco , Milan , Italy
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In a Mouse Model of Sepsis, Hepcidin Ablation Ameliorates Anemia More Effectively than Iron and Erythropoietin Treatment. Shock 2018; 48:490-497. [PMID: 28452907 DOI: 10.1097/shk.0000000000000886] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Intensive care unit (ICU) anemia is an extreme version of anemia of inflammation that occurs commonly in critically ill patients and is associated with increased morbidity and mortality. Currently available therapies for ICU anemia have shown inconsistent efficacies in clinical trials. We conducted a systematic study of the effects of early versus delayed iron (Fe) and/or erythropoietin (EPO) therapy in our previously characterized mouse model of ICU anemia based on an injection of heat-killed Brucella abortus. To study the effects of ongoing inflammation on the response to therapy, inflamed wild-type (WT) and hepcidin knockout (HKO) mice were treated at either early (days 1 and 2) or delayed (days 7 and 8) time points after the inflammatory stimulus. In the early treatment group, Fe and/or EPO therapy did not increase hemoglobin (Hgb) levels or reticulocyte production in either the inflamed WT or HKO groups. In the delayed treatment group, combination Fe + EPO therapy did increase Hgb and reticulocyte production in WT mice (mean ΔHgb in WT saline group -9.2 g/dL vs. Fe/EPO -5.5 g/dL; P < 0.001). The HKO mice in the delayed treatment group did not improve their Hgb, but HKO mice in all treatment groups developed a milder anemia than the WT mice. Our findings indicate that combination Fe + EPO therapy is effective in partially reversing ICU anemia when administered after the phase of acute inflammation. Hepcidin ablation alone was more effective in attenuating ICU anemia than Fe + EPO therapy, which indicates the potential of antihepcidin therapeutics in treating ICU anemia.
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Docherty AB, Turgeon AF, Walsh TS. Best practice in critical care: anaemia in acute and critical illness. Transfus Med 2018; 28:181-189. [DOI: 10.1111/tme.12505] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/09/2017] [Accepted: 12/11/2017] [Indexed: 01/28/2023]
Affiliation(s)
- A. B. Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine; University of Edinburgh; Edinburgh UK
| | | | - T. S. Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine; University of Edinburgh; Edinburgh UK
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Restrictive Transfusion Strategy Does Not Affect Clinical Prognosis in Patients with Ectopic Pregnancy. BIOMED RESEARCH INTERNATIONAL 2018; 2017:2679148. [PMID: 29349068 PMCID: PMC5733967 DOI: 10.1155/2017/2679148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 09/28/2017] [Accepted: 11/05/2017] [Indexed: 11/17/2022]
Abstract
To assess the effects of restrictive transfusion strategy on hemoglobin (Hb) levels and prognosis in patients with ectopic pregnancy and severe hemorrhage undergoing emergency surgery, patient data were collected from 2012 to 2016. Following transfusion guidelines, restrictive transfusion was performed; at Hb levels of 60-70 to 100 g/L, transfusion was continued or not based on disease status. The patients were divided into four groups: blood loss < 400 ml (N1), 400-799 ml (N2), 800-1199 ml (N3), and ≥1200 ml (N4). Several prognosis parameters were assessed. Group N4 was further divided based on blood loss amounts (1200-1999, 2000-2999, 3000-3999, and 4000-5000 ml) for subgroup analyses. Blood loss, hemoglobin levels at discharge, and American Society of Anesthesiologists (ASA) scores were not associated with patient prognostic parameters, including intensive care unit (ICU) occupancy, cure, and healing rates, and surgical complications and hospital stay. No statistically significant difference was obtained in hospital stay among N1, N2, and N3 groups. Compared with N1 patients, cases with blood loss ≥ 1200 ml had significantly longer hospital stay. Interestingly, hospital stay was correlated with surgical approach, location of pregnancy, and operation time. Restrictive transfusion strategy could be safely used for emergency surgery in ectopic pregnancy with acute blood loss.
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The Effect of Diagnostic Blood Loss on Anemia and Transfusion Among Postoperative Patients With Congenital Heart Disease in a Pediatric Intensive Care Unit. J Pediatr Nurs 2018; 38:62-67. [PMID: 29167083 DOI: 10.1016/j.pedn.2017.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/29/2017] [Accepted: 09/15/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate whether diagnostic blood loss can lead to anemia and consequent blood transfusion among postoperative patients with congenital heart disease (CHD) in the pediatric intensive care unit (PICU). DESIGN AND METHODS This prospective observational study was conducted in a university-affiliated tertiary hospital between January and August 2016. CHD patients aged <12years, undergoing cardiac surgery, with a PICU stay >48h were included (n=205). Multivariate logistic regression analyses were used to determine the effect of diagnostic blood loss on anemia and transfusion. RESULTS The mean daily phlebotomy volume was 5.40±1.94mL/d during the PICU stay (adjusted for body weight, 0.63±0.36mL/kg/d). Daily volume/kg was associated with cyanotic CHD, Pediatric Risk of Mortality III score, and Pediatric Logistic Organ Dysfunction (PELOD)-2 score. In total, 101 (49.3%) patients presented with new or more severe anemia after admission to PICU, which was not associated with phlebotomy volume. Forty-one (20.0%) children received one or more RBC transfusions during their PICU stay. Multivariate analysis indicated that PELOD-2 score>5, new or more severe anemia, and daily volume/kg of phlebotomy >0.63mL/kg/d were significantly associated with transfusion after 48h of admission to PICU. CONCLUSIONS Our findings indicate that diagnostic blood loss is not related to postoperative anemia in children with CHD; however, this factor does correlate with blood transfusion, since it somewhat reflects the severity of illness. PRACTICE IMPLICATIONS Strategies should be applied to reduce diagnostic blood loss, as appropriate.
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36
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Smith EM, Jones JL, Han JE, Alvarez JA, Sloan JH, Konrad RJ, Zughaier SM, Martin GS, Ziegler TR, Tangpricha V. High-Dose Vitamin D 3 Administration Is Associated With Increases in Hemoglobin Concentrations in Mechanically Ventilated Critically Ill Adults: A Pilot Double-Blind, Randomized, Placebo-Controlled Trial. JPEN J Parenter Enteral Nutr 2018; 42:87-94. [PMID: 29505145 PMCID: PMC5423855 DOI: 10.1177/0148607116678197] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/14/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Anemia and vitamin D deficiency are highly prevalent in critical illness, and vitamin D status has been associated with hemoglobin concentrations in epidemiologic studies. We examined the effect of high-dose vitamin D therapy on hemoglobin and hepcidin concentrations in critically ill adults. MATERIALS AND METHODS Mechanically ventilated critically ill adults (N = 30) enrolled in a pilot double-blind, randomized, placebo-controlled trial of high-dose vitamin D3 (D3 ) were included in this analysis. Participants were randomized to receive placebo, 50,000 IU D3 , or 100,000 IU D3 daily for 5 days (totaling 250,000 IU D3 and 500,000 IU D3 , respectively). Blood was drawn weekly throughout hospitalization for up to 4 weeks. Linear mixed-effects models were used to assess change in hemoglobin and hepcidin concentrations by treatment group over time. RESULTS At enrollment, >75% of participants in all groups had plasma 25-hydroxyvitamin D (25(OH)D) concentrations <30 ng/mL, and >85% of participants across groups were anemic. In the 500,000-IU D3 group, hemoglobin concentrations increased significantly over time (Pgroup × time = .01) compared with placebo but did not change in the 250,000-IU D3 group (Pgroup × time = 0.59). Hepcidin concentrations decreased acutely in the 500,000-IU D3 group relative to placebo after 1 week (P = .007). Hepcidin did not change significantly in the 250,000-IU D3 group. CONCLUSION In these critically ill adults, treatment with 500,000 IU D3 was associated with increased hemoglobin concentrations over time and acutely reduced serum hepcidin concentrations. These findings suggest that high-dose vitamin D may improve iron metabolism in critical illness and should be confirmed in larger studies.
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Affiliation(s)
- Ellen M. Smith
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Jennifer L. Jones
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Jenny E. Han
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica A. Alvarez
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - John H. Sloan
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Robert J. Konrad
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Susu M. Zughaier
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas R. Ziegler
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Vin Tangpricha
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
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Ramanan M, Fisher N. The Association between Arterial Oxygen Tension, Hemoglobin Concentration, and Mortality in Mechanically Ventilated Critically Ill Patients. Indian J Crit Care Med 2018; 22:477-484. [PMID: 30111921 PMCID: PMC6069304 DOI: 10.4103/ijccm.ijccm_66_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Hypoxemia and anemia are common findings in critically ill patients admitted to Intensive Care Units. Both are independently associated with significant morbidity and mortality. However, the interaction between oxygenation and anemia and their impact on mortality in critically ill patients has not been clearly defined. We undertook this study to determine whether hemoglobin (Hb) level would modify the association between hypoxemia and mortality in mechanically ventilated critically ill patients. Methods: We performed a retrospective cohort study of all mechanically ventilated adult patients (aged >16 years) in the Australian and New Zealand Intensive Care Society Adult Patient Database (APD) admitted over a 10-year period. Multivariate hierarchical logistic regression was used to assess the relationship between hypoxemia and hospital mortality stratified by Hb. Results: Of 1,196,089 patients in the APD, 219,723 satisfied our inclusion and exclusion criteria. There was a linear negative relationship between hypoxemia and hospital mortality which was significantly modified when stratified by Hb. Hb independently increased the risk of mortality in patients with arterial oxygen tension <102. Conclusions: Hb is an effect modifier on the association between oxygenation and mortality.
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Affiliation(s)
- Mahesh Ramanan
- Department of Intensive Care Medicine, Redcliffe, Caboolture and Prince Charles Hospitals, QLD, Australia.,School of Medicine, University of Queensland, Saint Lucia, QLD, Australia
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Maqueda-Palau M, Pérez-Juan E. Blood volume extracted from the critical patient in the first 24 hours after admission. ENFERMERIA INTENSIVA 2017; 29:14-20. [PMID: 29275137 DOI: 10.1016/j.enfi.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/10/2017] [Accepted: 09/25/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To calculate the number of analytical tests and blood volume drawn during the first 24hours of admission to the Intensive Care Unit (ICU). To analyse values of basal haemoglobin and at 24hours, relate them to blood loss, weight variation, and scoring system. METHOD An observational descriptive pilot study. Variables studied: age, sex, diagnosis on admission, analytical tests extracted, waste quantity before the extraction of samples, total volume blood extracted in 24hours, weight variation, APACHE, SAPS, basal haemoglobin and at 24hours. Statistical analysis with SPSS vs 20.0. Variables correlation sex, weight variation, the number of analytical tests and haemoglobin change. RESULTS The study included 100 patients. The average number of extractions per patient/day was 7.2 (±2.6). The average waste quantity was 32.61ml (±15.8). The blood volume used for determinations was 48.18ml / 24h (±16.74). The haemoglobin value decreased in the first 24hours of admission, being higher in men (P<.05). The scoring systems were statistically significant for levels of haemoglobin (Hb1 -0.3; P=.001; Hb2 -0.4; P=.001). CONCLUSIONS Of the total volume of blood extracted in ICU, 40% belongs to a volume of waste and 60% of blood is used for analytical tests. There is a decrease in haemoglobin exists 24hours after admission of the critical patient. Statistically, it has not been possible to demonstrate its relation with the number of analytical tests.
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Affiliation(s)
- M Maqueda-Palau
- Unidad de Cuidados Intensivos, Hospital Universitari Son Espases, Palma, Marllorca, España.
| | - E Pérez-Juan
- Unidad de Cuidados Intensivos, Hospital Universitari Son Espases, Palma, Marllorca, España
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39
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Zeroual N, Samarani G, Gallais J, Culas G, Saour M, Mourad M, Gaudard P, Colson PH. ScvO2
changes after red-blood-cell transfusion for anaemia in cardiothoracic and vascular ICU patients: an observational study. Vox Sang 2017; 113:136-142. [DOI: 10.1111/vox.12610] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 02/05/2023]
Affiliation(s)
- N. Zeroual
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
| | - G. Samarani
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
| | - J. Gallais
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
| | - G. Culas
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
| | - M. Saour
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
| | - M. Mourad
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
| | - P. Gaudard
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
- PhyMedExp; INSERM U1046; University of Montpellier; Montpellier France
| | - P. H. Colson
- Département d'anesthésie réanimation Arnaud de Villeneuve; Centre Hospitalier Régional et Universitaire; Montpellier France
- Institut de Génomique Fonctionnelle Endocrinology Department; CNRS UMR 5203; INSERM U1191; University of Montpellier; Montpellier France
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40
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Demaret P, Karam O, Tucci M, Lacroix J, Behal H, Duhamel A, Lebrun F, Mulder A, Leteurtre S. Anemia at pediatric intensive care unit discharge: prevalence and risk markers. Ann Intensive Care 2017; 7:107. [PMID: 29067568 PMCID: PMC5655401 DOI: 10.1186/s13613-017-0328-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 10/11/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Anemia is prevalent at pediatric intensive care unit (PICU) admission and incident during PICU stay, but little is known about anemia at PICU discharge . Anemia after critical illness is an important issue because it could impact post-PICU outcome. We aimed to estimate the prevalence of anemia at PICU discharge and to determine its risk markers. METHODS This is an ancillary study of a prospective observational study on transfusion practices conducted in the PICU of a tertiary care children's hospital. All children consecutively admitted to the PICU during a 1-year period were considered for inclusion. Data were prospectively collected from medical charts, except for hemoglobin (Hb) levels at PICU and hospital discharge that were collected retrospectively. Anemia was defined by an Hb concentration below the lower limit of the normal range for age. RESULTS Among the 679 children retained for analysis, 390 (57.4%) were anemic at PICU discharge. After multivariate adjustment, anemia at PICU admission was the strongest risk marker of anemia at PICU discharge. The strength of this association varied according to age (interaction): The odds ratio (OR) (95% CI) of anemia at PICU discharge was 4.85 (1.67-14.11) for 1-5-month-old infants anemic versus not anemic at PICU admission, and it was 73.13 (13.43, 398.19) for adolescents anemic versus not anemic at PICU admission. Children admitted after a non-cardiac surgery had an increased risk of anemia at PICU discharge [OR 2.30 (1.37, 3.88), p = 0.002]. The proportion of anemic children differed between age categories, while the median Hb level did not exhibit significant variations according to age. CONCLUSIONS Anemia is highly prevalent at PICU discharge and is strongly predicted by anemia at PICU admission. The usual age-based definitions of anemia may not be relevant for critically ill children. The consequences of anemia at PICU discharge are unknown and deserve further scrutiny.
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Affiliation(s)
- Pierre Demaret
- Pediatric Intensive Care Unit, Department of Pediatrics, CHC, Liège, Belgium. .,Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.
| | - Oliver Karam
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland.,Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Canada
| | - Hélène Behal
- Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, Unité de Biostatistique, 59000, Lille, France
| | - Alain Duhamel
- Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, Unité de Biostatistique, 59000, Lille, France
| | - Frédéric Lebrun
- Pediatric Intensive Care Unit, Department of Pediatrics, CHC, Liège, Belgium
| | - André Mulder
- Pediatric Intensive Care Unit, Department of Pediatrics, CHC, Liège, Belgium
| | - Stéphane Leteurtre
- Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.,Pediatric Intensive Care Unit, CHU Lille, 59000, Lille, France
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41
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Patient Blood Management in the Intensive Care Unit. Transfus Med Rev 2017; 31:264-271. [DOI: 10.1016/j.tmrv.2017.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/14/2017] [Accepted: 07/25/2017] [Indexed: 01/28/2023]
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Harutyunyan G, Hauer L, Dünser MW, Moser T, Pikija S, Leitinger M, Novak HF, Aichhorn W, Trinka E, Sellner J. Risk Factors for Intensive Care Unit Admission in Patients with Autoimmune Encephalitis. Front Immunol 2017; 8:835. [PMID: 28804482 PMCID: PMC5532517 DOI: 10.3389/fimmu.2017.00835] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/03/2017] [Indexed: 01/15/2023] Open
Abstract
Background Prevention and early recognition of critical illness in patients with autoimmune encephalitis (AE) is essential to achieve better outcome. Aim of the study To evaluate risk factors for intensive care unit (ICU) admission and its prognostic impact in patients with AE. Patients and methods A reclassification of patients hospitalized between 2011 and 2016 revealed 17 “definite” and 15 “probable” AE cases. Thirteen patients (41%) developed critical illness and required ICU admission. The underlying conditions were intractable seizures or status epilepticus (54%), altered mental state (39%), and respiratory failure (8%). Results ICU admission was associated with longer time from first symptoms to hospitalization (p = 0.046). Regression analysis revealed that anemia on hospital admission and definite diagnosis of AE was associated with a higher risk of acquiring critical illness. At last follow-up after a median of 31 months (range 2.5–52.4), seven patients had died (23%) and 63% had a good outcome [modified Rankin Scale (mRS) 0–3]. Anemia was associated with poor prognosis (p = 0.021), whereas development of critical illness did not impact mortality and functional outcome. Conclusion We confirmed the need for ICU care in a subgroup of patients and the prevailing objective is improved seizure control, and definite diagnosis of AE and anemia were identified as risk factors for development of critical illness. However, prognosis was not affected by ICU admission.
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Affiliation(s)
- Gayane Harutyunyan
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Larissa Hauer
- Department of Psychiatry and Psychotherapy, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Martin W Dünser
- Department of Critical Care, University College of London Hospital, London, United Kingdom
| | - Tobias Moser
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Helmut F Novak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Wolfgang Aichhorn
- Department of Psychiatry and Psychotherapy, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Suffredini DA, Xu W, Sun J, Barea-Mendoza J, Solomon SB, Brashears SL, Perlegas A, Kim-Shapiro DB, Klein HG, Natanson C, Cortés-Puch I. Parenteral irons versus transfused red blood cells for treatment of anemia during canine experimental bacterial pneumonia. Transfusion 2017; 57:2338-2347. [PMID: 28656646 DOI: 10.1111/trf.14214] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND No studies have been performed comparing intravenous (IV) iron with transfused red blood cells (RBCs) for treating anemia during infection. In a previous report, transfused older RBCs increased free iron release and mortality in infected animals when compared to fresher cells. We hypothesized that treating anemia during infection with transfused fresh RBCs, with minimal free iron release, would prove superior to IV iron therapy. STUDY DESIGN AND METHODS Purpose-bred beagles (n = 42) with experimental Staphylococcus aureus pneumonia rendered anemic were randomized to be transfused RBCs stored for 7 days or one of two IV iron preparations (7 mg/kg), iron sucrose, a widely used preparation, or ferumoxytol, a newer formulation that blunts circulating iron levels. RESULTS Both irons increased the alveolar-arterial oxygen gradient at 24 to 48 hours (p = 0.02-0.001), worsened shock at 16 hours (p = 0.02-0.003, respectively), and reduced survival (transfusion 56%; iron sucrose 8%, p = 0.01; ferumoxytol 9%, p = 0.04). Compared to fresh RBC transfusion, plasma iron measured by non-transferrin-bound iron levels increased with iron sucrose at 7, 10, 13, 16, 24, and 48 hours (p = 0.04 to p < 0.0001) and ferumoxytol at 7, 24, and 48 hours (p = 0.04 to p = 0.004). No significant differences in cardiac filling pressures or performance, hemoglobin (Hb), or cell-free Hb were observed. CONCLUSIONS During canine experimental bacterial pneumonia, treatment of mild anemia with IV iron significantly increased free iron levels, shock, lung injury, and mortality compared to transfusion of fresh RBCs. This was true for iron preparations that do or do not blunt circulating free iron level elevations. These findings suggest that treatment of anemia with IV iron during infection should be undertaken with caution.
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Affiliation(s)
- Dante A Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Wanying Xu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jesús Barea-Mendoza
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Steven B Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Samuel L Brashears
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, North Carolina
| | - Andreas Perlegas
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, North Carolina
| | - Daniel B Kim-Shapiro
- Department of Physics and the Translational Science Center, Wake Forest University, Winston-Salem, North Carolina
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Irene Cortés-Puch
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
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Epidemiology of RBC Transfusions in Patients With Severe Acute Kidney Injury: Analysis From the Randomized Evaluation of Normal Versus Augmented Level Study. Crit Care Med 2016; 44:892-900. [PMID: 26619086 DOI: 10.1097/ccm.0000000000001518] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To assess the epidemiology and outcomes associated with RBC transfusion in patients with severe acute kidney injury requiring continuous renal replacement therapy. DESIGN Post hoc analysis of data from a multicenter, randomized, controlled trial. SETTING Thirty-five ICUs in Australia and New Zealand. PATIENTS Cohort of 1,465 patients enrolled in the Randomized Evaluation of Normal versus Augmented Level replacement therapy study. INTERVENTIONS Daily information on morning hemoglobin level and amount of RBC transfused were prospectively collected in the Randomized Evaluation of Normal versus Augmented Level study. We analyzed the epidemiology of such transfusions and their association with clinical outcomes. MEASUREMENTS AND MAIN RESULTS Overall, 977 patients(66.7%) received a total of 1,192 RBC units. By day 5, 785 of 977 transfused patients (80.4%) had received at least one RBC transfusion. Hemoglobin at randomization was lower in transfused than in nontransfused patients (94 vs 111 g/L; p < 0.001). Mean daily hemoglobin was 88 ± 7 and 99 ± 12 g/L in transfused and nontransfused patients. Among transfused patients, 228 (46.7%) had died by day 90 when compared with 426 (43.6%) of nontransfused patients (p = 0.27). Survivors received on average 316 ± 261 mL of RBC, whereas nonsurvivors received 302 ± 362 mL (p = 0.42). On multivariate Cox regression analysis, RBC transfusion was independently associated with lower 90-day mortality (hazard ratio, 0.55; 95% CI, 0.38-0.79). However, we found no independent association between RBC transfusions and mortality when the analyses were restricted to patients surviving at least 5 days (hazard ratio, 1.29; 95% CI, 0.90-1.85). We found no independent association between RBC transfusion and renal replacement therapy-free days, mechanical ventilator-free days, or length of stay in ICU or hospital. CONCLUSIONS In patients with severe acute kidney injury treated with continuous renal replacement therapy, we found no association of RBC transfusion with 90-day mortality or other patient-centered outcomes. The optimal hemoglobin threshold for RBC transfusion in such patients needs to be determined in future randomized controlled trials.
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Rawal G, Kumar R, Yadav S, Singh A. Anemia in Intensive Care: A Review of Current Concepts. ACTA ACUST UNITED AC 2016; 2:109-114. [PMID: 29967848 DOI: 10.1515/jccm-2016-0017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 06/29/2016] [Indexed: 12/13/2022]
Abstract
Anemia in patients admitted to an intensive care unit is common and affects almost all critically ill patients. The intensivist is faced with the challenge of treating multifactorial etiologies, mainly bleeding and blood loss due to phlebotomy and decreased erythropoiesis. Red cell transfusion, the most common treatment for anemia, comes with associated risks, which may further reduce the chance of survival of these patients. The best evidence suggests the practice of restrictive RBC transfusion (transfusion at Hb<7 g/dl). In this article, the etiopathogenesis of the anemia in critically ill is reviewed, and current opinion on the pros and cons of various management strategies are discussed with emphasize on restrictive transfusion policy.
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Affiliation(s)
- Gautam Rawal
- Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Raj Kumar
- Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Sankalp Yadav
- Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India
| | - Amrita Singh
- Gen-X Diagnostics, Madhu Vihar, New Delhi, India
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Wang CH, Huang CH, Chang WT, Tsai MS, Yu PH, Wang AY, Chen NC, Chen WJ. Association between hemoglobin levels and clinical outcomes in adult patients after in-hospital cardiac arrest: a retrospective cohort study. Intern Emerg Med 2016; 11:727-36. [PMID: 26758060 DOI: 10.1007/s11739-015-1386-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 12/24/2015] [Indexed: 01/06/2023]
Abstract
In addition to cardiac output, oxygen delivery is determined by the amount of oxygen carried by hemoglobin, which is estimated by the product of hemoglobin level and peripheral hemoglobin oxygen saturation (SpO2). Optimal hemoglobin concentration for post-cardiac arrest syndrome (PCAS) has not yet been investigated thoroughly. We conducted a retrospective observational study in a single medical center. We included adult patients between 2006 and 2012 who experienced in-hospital cardiac arrest, and achieved sustained return of spontaneous circulation (ROSC). We used multivariable logistic regression analysis to identify factors associated with favorable neurological status at hospital discharge, defined as a score of 1 or 2 on the Cerebral Performance Category scale. Minimum hemoglobin concentration and SpO2 during the initial 24 h after ROSC were used for analysis. Anemia was defined by the World Health Organization criteria as a hemoglobin concentration <12 g/dL in women and <13 g/dL in men. Of the 426 patients included in our analysis, 387 patients (90.8 %) met the criteria for anemia. The mean minimum hemoglobin concentration among all the patients was 9.2 g/dL. The product of hemoglobin × SpO2 was correlated with a favorable neurological outcome (odds ratio 1.003, 95 % confidence interval 1.002-1.004). According to recommended SpO2 by resuscitation guidelines (94-98 %), we calculated the corresponding range of minimum required hemoglobin concentration to be 8.6-9.0 g/dL for a favorable neurological outcome. Anemia common among PCAS patients. Neurological outcome in PCAS might be correlated with hemoglobin concentration following resuscitation.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, No. 579, Sec. 2, Yunlin Rd., Douliu City, 640, Yunlin County, Taiwan, ROC
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Ping-Hsun Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, No. 127, Siyuan Rd., Xinzhuang Dist., New Taipei City, 242, Taiwan, ROC
| | - An-Yi Wang
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Nai-Chuan Chen
- Department of Emergency Medicine, Tao Yuan General Hospital, Ministry of Health and Welfare, No. 1492, Zhongshan Rd., Taoyuan Dist., Taoyuan City, 330, Taiwan, ROC
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC.
- Department of Emergency Medicine, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan, ROC.
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Lynch AM, Respess M, Boll AE, Bozych M, McMichael M, Fletcher DJ, De Laforcade AM, Rozanski EA. Hospital-acquired Anemia in Critically Ill Dogs and Cats: A Multi-Institutional Study. J Vet Intern Med 2016; 30:141-6. [PMID: 26578290 PMCID: PMC4913629 DOI: 10.1111/jvim.13650] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 08/17/2015] [Accepted: 09/21/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hospital-acquired anemia is commonly described in people but limited information currently is available regarding its prevalence in animals. HYPOTHESIS/OBJECTIVES Assess the prevalence of hospital-acquired anemia in hospitalized critically ill dogs and cats, and examine its relationship with phlebotomy practices, transfusion administration, and survival to discharge. ANIMALS Eight hundred and fifty-one client-owned animals (688 dogs and 163 cats). METHODS A multicenter, observational study was conducted in which packed cell volume (PCV) was recorded at the time of admission and on subsequent hospitalization days. Signalment, number of blood samples obtained, underlying disease, whether or not blood products were administered, duration of hospitalization, and survival to discharge were recorded. RESULTS Admission anemia prevalence was 32%, with overall prevalence during the hospitalization period of 56%. The last recorded PCV was significantly lower than the admission PCV for both dogs (admission PCV, 42% [range, 6-67%]; last recorded PCV, 34% [range, 4-64%], P < .0001) and cats (admission PCV, 31% [range, 6-55%]; last recorded PCV, 26% [range, 10-46%], P < .0001). Patients that developed anemia had significantly more blood samples obtained (nonanemic, 5 blood samples [range, 2-54]; anemic, 7 blood samples [range, 2-49], P < .0001). Hospitalized cats were significantly more likely to develop anemia compared to dogs (P < .0001), but anemic dogs were significantly less likely to survive to discharge (P = .0001). Surgical patients were at higher risk of developing hospital-acquired anemia compared to medical patients (OR, 0.63; 95% CI, 0.4-0.9; P = .01). CONCLUSIONS AND CLINICAL RELEVANCE Hospital-acquired anemia occurred frequently, especially in surgical patients. Additional studies focused on the direct effect of phlebotomy practices on the likelihood of anemia development in hospitalized animals are warranted.
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Affiliation(s)
- A M Lynch
- Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA
- College of Veterinary Medicine, University of Florida, Gainesville, FL
| | | | - A E Boll
- Cornell University College of Veterinary Medicine, Ithaca, NY
| | - M Bozych
- College of Veterinary Medicine at the University of Illinois, Urbana, IL
| | - M McMichael
- College of Veterinary Medicine at the University of Illinois, Urbana, IL
| | - D J Fletcher
- Cornell University College of Veterinary Medicine, Ithaca, NY
| | - A M De Laforcade
- Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA
| | - E A Rozanski
- Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA
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Hsu CY, Liu SH, Chao CH, Chan YL, Tsai TC, Chen LM, Wu CC, Chen KF. STROBE-compliant article: Blood Transfusions within the First 24 Hours of Hospitalization Did Not Impact Mortality Among Patients with Severe Sepsis. Medicine (Baltimore) 2016; 95:e2601. [PMID: 26825911 PMCID: PMC5291581 DOI: 10.1097/md.0000000000002601] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Transfusion of packed red blood cells is common during resuscitation of critically ill patients. However, the association between in-hospital mortality and blood transfusion among patients with severe sepsis during the first 24 hours of hospitalization has not yet been determined. A cohort study was conducted of adult nontrauma patients who visited the emergency department of a tertiary hospital and were diagnosed with severe sepsis. Propensity score (PS) matching was conducted, based on patient demographics, underlying illnesses, laboratory results, and vital signs presented at the emergency department, and multivariate logistic regression was performed to adjust for potential residual confounding between the 2 transfused and nontransfused groups to assess the risk of in-hospital mortality. Of 3448 patients included in this study, 265 underwent blood transfusion during the first 24 hours of hospitalization. Despite comparable severity of sepsis, patients who received transfusions tended to have lower mean arterial pressures (86 vs 98 mmHg) and hemoglobin levels (7.6 vs 11.2 g/dL), and were more likely to have chronic kidney disease (12% vs 6%) and hematologic organ dysfunction (57% vs 35%, all P < 0.001). Transfused patients tended to have higher mortality rates (26% vs 9%, respectively, P < 0.001). After PS matching, 177 pairs of transfused and nontransfused patients were analyzed. After adjusting for residual confounding factors by multivariate logistic regression in the matched patient pairs, no significant differences in in-hospital mortality were observed (odds ratio [OR] = 1.52, 95% confidence interval: 0.92-2.51). In this PS-matched cohort study of adult nontrauma patients with severe sepsis, the in-hospital mortality rate was not significantly different in patients who received blood transfusions during the first 24 hours of hospitalization.
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Affiliation(s)
- Chih-Yi Hsu
- From the Department of Emergency Medicine, Chang Gung Memorial Hospital, Kaohsiung (C-YH, T-CT); Department of Family Medicine, Chang Gung Memorial Hospital, Linkou (S-HL); Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou (C-HC, Y-LC); School of Medicine, Chang Gung University, Taoyuan (S-HL); Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung (L-MC, C-CW, K-FC); Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung (K-FC); and Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan (K-FC)
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Abstract
It is well recognized that anaemia, a frequent complication of critical illness, is associated with poor outcomes, perhaps particularly in patients with ischaemic heart disease. But studies have also reported increased morbidity and mortality in patients who receive blood transfusions. So which carries the biggest risk, when should we transfuse and when should we hold off? Should we have fixed transfusion triggers and if so in all patients, or different triggers for different groups of patients? Indeed, these are more complex decisions than initially apparent. ICU patients are very heterogeneous and will react differently to the same intervention. As such, decisions to transfuse or not must be individualized, taking into account specific patient factors, such as age and comorbidities, physiologic variables, as well as the haemoglobin value. This approach will ensure that anaemia is treated when necessary while avoiding unnecessary exposure to red blood cells.
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Transfusion de concentrés globulaires en réanimation : moins, c’est mieux ! MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-014-1015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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