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Solhpour A, Kumar S, Koch MJ, Doré S. Impact of blood component transfusions, tranexamic acid and fluids on subarachnoid hemorrhage outcomes. BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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2
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[G-CSF for prophylaxis of neutropenia and febrile neutropenia, anemia in cancer : Guidelines on supportive treatment part 1]. Urologe A 2022; 61:537-551. [PMID: 35476110 PMCID: PMC9044390 DOI: 10.1007/s00120-022-01831-6] [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] [Accepted: 04/06/2022] [Indexed: 02/01/2023]
Abstract
Infections in patients with neutropenia following chemotherapy are mostly manifested as fever (febrile neutropenia, FN). Some of the most important determinants of the risk of FN are the type of chemotherapy, the dose intensity and patient-specific factors. When the risk of FN is 20% or more granulopoiesis is prophylactically stimulated with granulocyte colony stimulating factor (G-CSF) after the treatment. Anemia should always be clarified and if necessary be treated according to the cause when symptomatic. If an absolute or functional iron deficiency is present, intravenous iron substitution is mostly necessary. Erythropoiesis-stimulating agents can be used after chemotherapy with hemoglobin (Hb) levels less than 10 g/dl (6.2 mmol/l). In cases of chronic anemia and Hb levels less than 7-8 g/dl (<4.3-5.0 mmol/l) the indications for transfusion of erythrocyte concentrates should be assessed primarily based on the individual clinical symptoms.
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Jutras C, Charlier J, François T, Du Pont-Thibodeau G. <p>Anemia in Pediatric Critical Care</p>. INTERNATIONAL JOURNAL OF CLINICAL TRANSFUSION MEDICINE 2020. [DOI: 10.2147/ijctm.s229764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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4
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Mesgarpour B, Heidinger BH, Roth D, Schmitz S, Walsh CD, Herkner H. Harms of off-label erythropoiesis-stimulating agents for critically ill people. Cochrane Database Syst Rev 2017; 8:CD010969. [PMID: 28841235 PMCID: PMC6373621 DOI: 10.1002/14651858.cd010969.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Anaemia is a common problem experienced by critically-ill people. Treatment with erythropoiesis-stimulating agents (ESAs) has been used as a pharmacologic strategy when the blunted response of endogenous erythropoietin has been reported in critically-ill people. The use of ESAs becomes more important where adverse clinical outcomes of transfusing blood products is a limitation. However, this indication for ESAs is not licensed by regulatory authorities and is called off-label use. Recent studies concern the harm of ESAs in a critical care setting. OBJECTIVES To focus on harms in assessing the effects of erythropoiesis-stimulating agents (ESAs), alone or in combination, compared with placebo, no treatment or a different active treatment regimen when administered off-label to critically-ill people. SEARCH METHODS We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO via OvidSP, CINAHL, all evidence-based medicine (EBM) reviews including IPA and SCI-Expanded, Conference Proceedings Citation Index- Science, BIOSIS Previews and TOXLINE up to February 2017. We also searched trials registries, checked reference lists of relevant studies and tracked their citations by using SciVerse Scopus. SELECTION CRITERIA We considered randomized controlled trials (RCTs) and controlled observational studies, which compared scheduled systemic administration of ESAs versus other effective interventions, placebo or no treatment in critically-ill people. DATA COLLECTION AND ANALYSIS Two review authors independently screened and evaluated the eligibility of retrieved records, extracted data and assessed the risks of bias and quality of the included studies. We resolved differences in opinion by consensus or by involving a third review author. We assessed the evidence using GRADE and created a 'Summary of findings' table. We used fixed-effect or random-effects models, depending on the heterogeneity between studies. We fitted three-level hierarchical Bayesian models to calculate overall treatment effect estimates. MAIN RESULTS Of the 27,865 records identified, 39 clinical trials and 14 observational studies, including a total of 945,240 participants, were eligible for inclusion. Five studies are awaiting classification. Overall, we found 114 adverse events in 33 studies (30 RCTs and three observational studies), and mortality was reported in 41 studies (32 RCTs and nine observational studies). Most studies were at low to moderate risk of bias for harms outcomes. However, overall harm assessment and reporting were of moderate to low quality in the RCTs, and of low quality in the observational studies. We downgraded the GRADE quality of evidence for venous thromboembolism and mortality to very low and low, respectively, because of risk of bias, high inconsistency, imprecision and limitations of study design.It is unclear whether there is an increase in the risk of any adverse events (Bayesian risk ratio (RR) 1.05, 95% confidence interval (CI) 0.93 to 1.21; 3099 participants; 9 studies; low-quality evidence) or venous thromboembolism (Bayesian RR 1.04, 95% CI 0.70 to 1.41; 18,917 participants; 18 studies; very low-quality evidence).There was a decreased risk of mortality with off-label use of ESAs in critically-ill people (Bayesian RR 0.76, 95% CI 0.61 to 0.92; 930,470 participants; 34 studies; low-quality evidence). AUTHORS' CONCLUSIONS Low quality of evidence suggests that off-label use of ESAs may reduce mortality in a critical care setting. There was a lack of high-quality evidence about the harm of ESAs in critically-ill people. The information for biosimilar ESAs is less conclusive. Most studies neither evaluated ESAs' harm as a primary outcome nor predefined adverse events. Any further studies of ESA should address the quality of evaluating, recording and reporting of adverse events.
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Affiliation(s)
| | | | - Dominik Roth
- Medical University of ViennaDepartment of Emergency MedicineAllgemeines Krankenhaus, Währinger Gürtel
18‐20,ViennaAustria1090
| | - Susanne Schmitz
- Luxembourg Institute of HealthDepartment of Population Health1A‐B, rue Thomas EdisonStrassenLuxembourg1445
| | - Cathal D Walsh
- Department of Mathematics and StatisticsHealth Research Institute (HRI) and MACSIUniversity of LimerickIreland
| | - Harald Herkner
- Medical University of ViennaDepartment of Emergency MedicineAllgemeines Krankenhaus, Währinger Gürtel
18‐20,ViennaAustria1090
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Da Silva IRF, Gomes JA, Wachsman A, de Freitas GR, Provencio JJ. Hematologic counts as predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2016; 37:126-129. [PMID: 27718411 DOI: 10.1016/j.jcrc.2016.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 09/14/2016] [Accepted: 09/14/2016] [Indexed: 01/13/2023]
Abstract
PURPOSE Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality, but currently no single clinical method or ancillary test can reliably predict which subset of patients will develop delayed cerebral ischemia (DCI). The aim of this study was to find hematologic derangements and clinical factors present during the first 7 days after bleeding that could help identify patients at risk for development of DCI. MATERIALS AND METHODS Databank analysis of patients with SAH admitted between 2010 and 2012 in a single center. Data from demographics, imaging, laboratory, and clinical factors were collected. Statistical testing was conducted to test for association to the outcome, and multivariate logistic regression was used to design a predictive model. RESULTS Of 55 patients, 14 developed DCI (25%). Anemia and leukocytosis on the third day after bleeding were significantly correlated with the outcome (for anemia: P<.032; confidence interval, 1.12-15.16; odds ratio, 4.12; for leukocytosis: P<.046; confidence interval, 1.03-26.13; odds ratio, 5.18). Anemia and leukocytosis were still statistically significant after adjustment for age, sex, modified Fisher scale, and Hunt-Hess scale. CONCLUSION The presence of leukocytosis and anemia during the third day after SAH was statistically correlated with the occurrence of DCI.
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Affiliation(s)
| | - Joao Antonio Gomes
- Summa Health, Akron City Hospital and Northeast Ohio Medical University, Akron, OH.
| | - Ari Wachsman
- Cleveland Clinic-Akron General Medical Center, Akron, OH.
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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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Quantification of recombinant human erythropoietin by amino acid analysis using isotope dilution liquid chromatography–tandem mass spectrometry. Anal Bioanal Chem 2014; 406:4401-9. [DOI: 10.1007/s00216-014-7838-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/09/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
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8
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Mesgarpour B, Heidinger BH, Roth D, Schmitz S, Walsh CD, Herkner H. Safety of off-label erythropoiesis-stimulating agents for critically ill patients. Cochrane Database Syst Rev 2014. [DOI: 10.1002/14651858.cd010969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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9
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Can we target the α2-macroglobulin-hepcidin interaction to treat pathologic hypoferremia? Future Med Chem 2013; 6:13-6. [PMID: 24358944 DOI: 10.4155/fmc.13.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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10
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Jelkmann I, Jelkmann W. Impact of erythropoietin on intensive care unit patients. ACTA ACUST UNITED AC 2013; 40:310-8. [PMID: 24273484 DOI: 10.1159/000354128] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/06/2013] [Indexed: 12/13/2022]
Abstract
Anemia is common in intensive care unit (ICU) patients. Red blood cell (RBC) transfusions are mainstays of their treatment and can be life-saving. Allogeneic blood components inherently bear risks of infection and immune reactions. Although these risks are rare in developed countries, recombinant human erythropoietin (rhEpo) and other erythropoiesis-stimulating agents (ESAs) have been considered alternative anti-anemia treatment options. As summarized herein, however, most of the clinical studies suggest that ESAs are not usually advisable in ICU patients unless approved indications exist (e.g., renal disease). First, ESAs act in a delayed way, inducing an increase in reticulocytes only after a lag of 3-4 days. Second, many critically ill patients present with ESA resistance as inflammatory mediators impair erythropoietic cell proliferation and iron availability. Third, the ESA doses used for treatment of ICU patients are very high. Fourth, ESAs are not legally approved for general use in ICU patients. Solely in distinct cases, such as Jehovah's Witnesses who refuse allogeneic blood transfusions due to religious beliefs, ESAs may be considered an exceptional therapy.
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Affiliation(s)
- Ines Jelkmann
- Department of Surgery, University of Lübeck, Germany
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11
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Safety of off-label erythropoiesis stimulating agents in critically ill patients: a meta-analysis. Intensive Care Med 2013; 39:1896-908. [PMID: 23928897 DOI: 10.1007/s00134-013-3030-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 07/12/2013] [Indexed: 12/27/2022]
Abstract
PURPOSE Erythropoiesis stimulating agents (ESAs) are used to treat anemia in critically ill patients. This indication is off-label, because it is not licensed by regulatory authorities. Recently ESAs were suspected to harm critically ill patients. Our objective was to assess the safety of ESAs in off-label indications in critically ill patients. METHODS Eleven databases were searched up to April 2012. We considered randomized controlled trials (RCTs) and controlled observational studies in any language that compared off-label ESAs treatment with other effective interventions, placebo or no treatment in critically ill patients. Two authors independently screened and evaluated retrieved records, extracted data and assessed risk of bias and quality of reporting. RESULTS We used frequentist and Bayesian models to combine studies, and performed sensitivity and subgroup analyses. From 12,888 citations, we included 48 studies (34 RCTs; 14 observational), involving 944,856 participants. Harm reporting was of medium to low quality. There was no statistically significant increased risk of adverse events in general, serious adverse events, the most frequently reported adverse events, and death in critically ill patients treated with ESAs. These results were robust against risk of bias and analysis methods. There is evidence that ESAs increase the risk of clinically relevant thrombotic vascular events, and there is some less certain evidence that ESAs might increase the risk for venous thromboembolism. CONCLUSIONS In critically ill patients, administration of ESAs is associated with a significant increase in clinically relevant thrombotic vascular events but not with other frequently reported adverse events and death.
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12
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Lawen A, Lane DJR. Mammalian iron homeostasis in health and disease: uptake, storage, transport, and molecular mechanisms of action. Antioxid Redox Signal 2013. [PMID: 23199217 DOI: 10.1089/ars.2011.4271] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Iron is a crucial factor for life. However, it also has the potential to cause the formation of noxious free radicals. These double-edged sword characteristics demand a tight regulation of cellular iron metabolism. In this review, we discuss the various pathways of cellular iron uptake, cellular iron storage, and transport. Recent advances in understanding the reduction and uptake of non-transferrin-bound iron are discussed. We also discuss the recent progress in the understanding of transcriptional and translational regulation by iron. Furthermore, we discuss recent advances in the understanding of the regulation of cellular and systemic iron homeostasis and several key diseases resulting from iron deficiency and overload. We also discuss the knockout mice available for studying iron metabolism and the related human conditions.
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Affiliation(s)
- Alfons Lawen
- Department of Biochemistry and Molecular Biology, School of Biomedical Sciences, Monash University, Melbourne, Australia.
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13
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Patel NS, Collino M, Yaqoob MM, Thiemermann C. Erythropoietin in the intensive care unit: beyond treatment of anemia. Ann Intensive Care 2011; 1:40. [PMID: 21943500 PMCID: PMC3224459 DOI: 10.1186/2110-5820-1-40] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 09/23/2011] [Indexed: 12/13/2022] Open
Abstract
Erythropoietin (EPO) is the major hormone stimulating the production and differentiation of red blood cells. EPO is used widely for treating anemia of critical illness or anemia induced by chemotherapy. EPO at pharmacological doses is used in this setting to raise hemoglobin levels (by preventing the apoptosis of erythroid progenitor cells) and is designed to reduce patient exposure to allogenic blood through transfusions. Stroke, heart failure, and acute kidney injury are a frequently encountered clinical problem. Unfortunately, in the intensive care unit advances in supportive interventions have done little to reduce the high mortality associated with these conditions. Tissue protection with EPO at high, nonpharmacological doses after injury has been found in the brain, heart, and kidney of several animal models. It is now well known that EPO has anti-apoptotic effects in cells other than erythroid progenitor cells, which is considered to be independent of EPOs erythropoietic activities. This review article summarizes what is known in preclinical models of critical illness and discusses why this does not correlate with randomized, controlled clinical trials.
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Affiliation(s)
- Nimesh Sa Patel
- Centre for Translational Medicine & Therapeutics, Queen Mary University of London, William Harvey Research Institute, Barts and The London, London, UK.
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14
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:320-35. [PMID: 21627922 PMCID: PMC3136601 DOI: 10.2450/2011.0076-10] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- Units of Immunohaematology, Transfusion Medicine and Clinical Pathology, San Giovanni Calibita Fatebenefratelli Hospital, Rome.
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15
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Anderson ER, Xue X, Shah YM. Intestinal hypoxia-inducible factor-2alpha (HIF-2alpha) is critical for efficient erythropoiesis. J Biol Chem 2011; 286:19533-40. [PMID: 21498508 DOI: 10.1074/jbc.m111.238667] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Erythropoiesis is a coordinated process by which RBCs are produced. Erythropoietin, a kidney-derived hormone, and iron are critical for the production of oxygen-carrying mature RBCs. To meet the high demands of iron during erythropoiesis, small intestinal iron absorption is increased through an undefined mechanism. In this study, erythropoietic induction of iron absorption was further investigated. Hypoxia-inducible factor-2α (HIF-2α) signaling was activated in the small intestine during erythropoiesis. Genetic disruption of HIF-2α in the intestine abolished the increase in iron absorption genes as assessed by quantitative real-time reverse transcription-PCR and Western blot analyses. Moreover, the increase in serum iron following induction of erythropoiesis was entirely dependent on intestinal HIF-2α expression. Complete blood count analysis demonstrated that disruption of intestinal HIF-2α inhibited efficient erythropoiesis; mice disrupted for HIF-2α demonstrated lower hematocrit, RBCs, and Hb compared with wild-type mice. These data further cement the essential role of HIF-2α in regulating iron absorption and also demonstrate that hypoxia sensing in the intestine, as well as in the kidney, is essential for regulation of erythropoiesis by HIF-2α.
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Affiliation(s)
- Erik R Anderson
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48108, USA
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16
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Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*. Crit Care Med 2009; 37:3124-57. [DOI: 10.1097/ccm.0b013e3181b39f1b] [Citation(s) in RCA: 364] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Kanakaris NK, Petsatodis G, Chalidis B, Manidakis N, Kontakis G, Giannoudis PV. The role of erythropoietin in the acute phase of trauma management: evidence today. Injury 2009; 40:21-7. [PMID: 19117559 DOI: 10.1016/j.injury.2008.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 09/05/2008] [Accepted: 09/05/2008] [Indexed: 02/02/2023]
Abstract
Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its administration as an alternative. The existing evidence on the early use of EPO-A in the acute phase of trauma patients management consists of only 14 publications. The level of evidence of these studies and the number of treated patients was not found to be adequate to support its generalised use, despite their favourable results. Its safety profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly encourage further controlled studies assessing its use in the acute setting of initial trauma management.
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Affiliation(s)
- N K Kanakaris
- Academic Department of Trauma & Orthopaedics, Leeds Teaching Hospitals, Leeds, UK
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Lapchak PA, Araujo DM. Advances in hemorrhagic stroke therapy: conventional and novel approaches. Expert Opin Emerg Drugs 2007; 12:389-406. [PMID: 17874968 DOI: 10.1517/14728214.12.3.389] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Treatments for spontaneous intracerebral, thrombolytic-induced and intraventricular hemorrhages (IVH) are still at the preclinical or early clinical investigational stages. There has been some renewed interest in the use of surgical evacuation surgery or thrombolytics to remove hematomas, but these techniques can be used only for specific types of brain bleeding. The STICH (Surgical Trial in Intracerebral Haemorrhage) clinical trials should provide some insight into the potential for such techniques to counteract hematoma-induced damage and subsequently, morbidity and mortality. More recently, clinical trials (ATACH [Antihypertensive Treatment in Acute Cerebral Hemorrhage] and INTERACT [Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial]) have begun testing whether or not regulating blood pressure affects the well-being of hemorrhage patients, but the findings thus far have not conclusively demonstrated a positive result. More promising trials, such as the early stage CHANT (Cerebral Hemorrhagic And NXY-059 Treatment) and the late stage FAST (Factor VIIa for Acute Hemorrhagic Stroke Treatment), have addressed whether or not manipulating oxidative stress and components of the blood coagulation cascade can achieve an improved prognosis following spontaneous hemorrhages. However, CHANT was halted prematurely because although it showed that the spin trap agent NXY-059 was safe, it also demonstrated that the drug was ineffective in treating acute ischemic stroke. In addition, the recombinant activated factor VII FAST trial recently concluded with only modestly positive results. Despite a beneficial effect on the primary end point of reducing hemorrhage volume, controlling the coagulation cascade with recombinant factor VIIa did not decrease the mortality rate. Consequently, Novo Nordisk has abandoned further development of the drug for the treatment of intracerebral hemorrhaging. Even though progress in hemorrhage therapy that successfully reduces the escalating morbidity and mortality rate associated with brain bleeding is slow, perseverance and applied translational drug development will eventually be productive. The urgent need for such therapy becomes more evident in light of concerns related to uncontrolled high blood pressure in the general population, increased use of blood thinners by the elderly (e.g., warfarin) and thrombolytics by acute ischemic stroke patients, respectively. The future of drug development for hemorrhage may require a multifaceted approach, such as combining drugs with diverse mechanisms of action. Because of the substantial benefit of factor VIIa in reducing hemorrhage volume, it should be considered as a prime drug candidate included in combination therapy as an off-label use if the FAST trial proves that the risk of thromboembolic events is not increased with drug administration. Other promising drugs that may be considered in combination include uncompetitive NMDA receptor antagonists (such as memantine), antioxidants, metalloprotease inhibitors, statins and erythropoietin analogs, all of which have been shown to reduce hemorrhage and behavioral deficits in one or more animal models.
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Affiliation(s)
- Paul A Lapchak
- University of California San Diego, Department of Neuroscience, MTF 316, 9500 Gilman Drive, La Jolla, CA 92093-0624, USA.
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Robinson Y, Hostmann A, Matenov A, Ertel W, Oberholzer A. Erythropoiesis in multiply injured patients. ACTA ACUST UNITED AC 2006; 61:1285-91. [PMID: 17099548 DOI: 10.1097/01.ta.0000240969.13891.9b] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Posttraumatic anemia in multiply injured patients is caused by hemorrhage, reduced red blood cell survival, and impaired erythropoiesis. Trauma-induced hyperinflammation causes impaired bone-marrow function by means of blunted erythropoietin (EPO) response, reduced iron availability, suppression and egress of erythroid progenitor cells. To treat posttraumatic anemia in severely injured patients, symptomatic therapy by blood transfusion is not sufficient. Furthermore, EPO, iron, and the use of red cell substitutes should be considered. The posttraumatic systemic inflammatory response syndrome (SIRS) induces posttraumatic anemia. Thus, a worsening of SIRS by a "second-hit" through blood transfusion ought to be avoided.
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Affiliation(s)
- Yohan Robinson
- Department of Trauma and Reconstructive Surgery, Charité - Campus Benjamin Franklin, Berlin, Germany.
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20
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Remmers PA, Speer AJ. Clinical strategies in the medical care of Jehovah's Witnesses. Am J Med 2006; 119:1013-8. [PMID: 17145240 DOI: 10.1016/j.amjmed.2006.04.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Accepted: 04/03/2006] [Indexed: 11/17/2022]
Abstract
Jehovah's Witnesses are primarily known to physicians for their refusal of blood transfusions. Conflict arises at times with the medical staff concerning how best to manage their care. This article will begin with a brief description of the beliefs of Jehovah's Witnesses and will then recommend specific clinical strategies highlighting newer potential therapies according to the principles of bloodless medicine. The scenarios of bleeding and acute and chronic anemia will be discussed in detail for the care of these patients refusing red blood cell transfusions. An update in the use of blood substitutes will be mentioned as well as the surgical advances used today that can minimize blood loss for all patients. The experience of organ transplantation in Jehovah's Witnesses will be detailed. Further resources for physicians with questions in the care of these patients will be listed. Stressed throughout the article will be the need for a team approach and good communication between physicians to successfully care for their patients who are Jehovah's Witnesses.
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Affiliation(s)
- Paul A Remmers
- Department of Internal Medicine, Division of General Medicine, University of Texas Medical Branch, Galveston, TX 77555-1167, USA.
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Abstract
PURPOSE OF REVIEW Transfusion of red blood cells in the trauma patient can be lifesaving. The question is how much and when? It is important to weigh the risks and benefits of red blood cell transfusions, as well alternatives to transfusion as these products are not benign. RECENT FINDINGS We explore the evidence, and provide the rationale for current and future red blood cell transfusion strategies within a framework of prehospital and hospital care of the trauma patient. We also describe how red blood cell transfusion trends are changing in trauma, discuss alternatives to red blood cell transfusion and present evidence from randomized controlled trials that support a lower transfusion trigger. SUMMARY Optimal transfusion practice and use of alternatives in trauma is a rapidly expanding and important area of research. Strong clinical evidence derived by future randomized controlled trials in the area of transfusion triggers as well as transfusion alternatives is required to determine their roles in clinical practice.
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Affiliation(s)
- Lauralyn A McIntyre
- Department of Medicine, Division of Critical Care, Centre for Transfusion and Critical Care Research, Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.
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Dasta J, Mody S, McLaughlin T, LeBlanc J, Shen Y, Genetti M, Raut MK, Piech CT. PROGNOSTIC FACTORS ASSOCIATED WITH PACKED RED BLOOD CELL TRANSFUSIONS IN CRITICALLY ILL PATIENTS. Chest 2006. [DOI: 10.1378/chest.130.4_meetingabstracts.219s-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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