A Narrative Review on Hospital-Acquired Anemia: Keeping Blood where It Belongs

Recommendations on Monitoring and Replacement of Antithrombin, Fibrinogen, and Von Willebrand Factor in Pediatric Patients on Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

OBJECTIVES

To derive systematic review informed, modified Delphi consensus regarding monitoring and replacement of specific coagulation factors during pediatric extracorporeal membrane oxygenation (ECMO) support for the Pediatric ECMO Anticoagulation CollaborativE.

DATA SOURCES

A structured literature search was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2020, with an update in May 2021.

STUDY SELECTION

Included studies assessed monitoring and replacement of antithrombin, fibrinogen, and von Willebrand factor in pediatric ECMO support.

DATA EXTRACTION

Two authors reviewed all citations independently, with conflicts resolved by a third reviewer if required. Twenty-nine references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form.

DATA SYNTHESIS

Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. A panel of 48 experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. We developed one weak recommendation and four expert consensus statements.

CONCLUSIONS

There is insufficient evidence to formulate recommendations on monitoring and replacement of antithrombin, fibrinogen, and von Willebrand factor in pediatric patients on ECMO. Optimal monitoring and parameters for replacement of key hemostasis parameters is largely unknown.

Blood over-testing: impact, ethical issues and mitigating actions

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).

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Assessment and management of postoperative anemia

Postoperative anemia is a complex clinical issue that requires attention due to its ramifications on the patient's recovery and prognosis. Originating from multiple determinants, such as intraoperative blood loss, hemolysis, nutritional deficiencies, systemic inflammation and impact on the bone marrow, postoperative anemia has varied and often challenging presentations. Patients undergoing major surgical procedures, in particular, are susceptible to developing anemia due to the considerable associated blood loss. Accurate diagnosis plays a crucial role in the approach, requiring meticulous hematological analysis, including hemoglobin, hematocrit and reticulocyte count, as well as an in-depth investigation of the underlying causes. An additional challenge arises in the form of the excessive practice of phlebotomy during hospitalization for clinical monitoring. Although it is essential to assess the progression of anemia, frequent removal of blood may contribute to iatrogenic anemia, further delaying recovery and possibly increasing susceptibility to infection.

Effect of using smaller blood volume tubes and closed blood collection devices on total blood loss in patients undergoing major cardiac and vascular surgery

BACKGROUND

Diagnostic laboratory tests are an integral part of managing hospitalized patients. In particular, patients in the intensive care units (ICUs) can experience a concerning amount of blood loss due to diagnostic testing, which can increase the risk developing iatrogenic anemia. Several interventions exist to curtail avoidable blood loss, for example computerized decision support, smaller phlebotomy tubes, and other blood conservation devices. Nevertheless, use of these interventions is not standardized. Therefore, the objective of our study was to quantify the daily phlebotomy volume taken from patients who had undergone major cardiac or vascular surgery.

METHODS

We estimated the number of blood analyses and volumes of drawn blood of 400 consecutive patients (≥ 18 yr) undergoing major cardiac or vascular surgery. The amount of blood saved using small-volume tubes and in combination with blood conservation device rather than standard-volume tubes was estimated for serum chemistry (serum), ethylenediaminetetraacetic acid (EDTA) tubes, sodium citrate coagulation (SCC) tubes, and arterial blood gas (ABG) analysis.

RESULTS

The mean total blood loss due to phlebotomy drawing using standard-volume tubes during hospitalization was 167.9 mL (95% confidence interval [CI], 158.0 to 177.8), 255.6 mL (95% CI, 226.5 to 284.6), and 695.3 mL (95% CI, 544.1 to 846.4) for patients undergoing cardiac surgery with a hospital length of stay (LOS) of 0-10, 11-20, and ≥ 21 days, respectively. The mean total blood loss due to phlebotomy during hospitalization was 80.5 mL (95% CI, 70.5 to 90.6), 225.0 mL (95% CI, 135.1 to 314.8 mL) and 470.3 mL (95% CI, 333.5 to 607.1) for vascular surgery patients with LOS 0-10, 11-20, and ≥ 21 days, respectively. Patients with at least a two-day stay at the ICU had a mean blood loss of 146.6 mL (95% CI, 134.6 to 158.6 mL) and those with ≥ 11 days incurred a loss of 1,428 mL (95% CI, 1,117.8 to 1,739.2). The use of closed blood collection device and small-volume tubes (serum, EDTA, SCC, and ABG) reduced blood loss by 82.8 mL for patients with an ICU stay of 2 days and up to 824.0 mL for patients with a ICU stay of ≥ 11 days.

CONCLUSION

Diagnostic laboratory tests are associated with significant patient blood loss, but are a modifiable risk factor. The use of small-volume tubes and closed blood collection devices decreases the volume of patient blood drawn for analysis and prevents blood waste.

Hospital-Acquired Anemia in Patients with Acute Coronary Syndrome: Epidemiology and Potential Impact on Long-Term Outcome

BACKGROUND

Anemia (either pre-existing or hospital-acquired) is considered an independent predictor of mortality in acute coronary syndromes. However, it is still not clear whether anemia should be considered as a marker of worse health status or a therapeutic target. We sought to investigate the relationship between hospital-acquired anemia and clinical and laboratory findings and to assess the association with mortality and major cardiovascular events at long-term follow-up.

METHODS

Patients consecutively admitted at Niguarda Hospital between February 2014 and November 2020 for an acute coronary syndrome were included in this cohort analysis and classified as anemic at admission (group A), with normal hemoglobin at admission but developing anemia during hospitalization (hospital-acquired anemia) (group B); and with normal hemoglobin levels throughout admission (group C).

RESULTS

Among 1294 patients included, group A included 353 (27%) patients, group B 468 (36%), and group C 473 patients (37%). In terms of cardiovascular burden and incidence of death, major cardiovascular events and bleeding at 4.9-year median follow-up, group B had an intermediate risk profile as compared with A and C. Baseline anemia was an independent predictor of death (hazard ratio 1.51; 95% confidence interval, 1.02-2.25; P = .04) along with frailty, Charlson comorbidity Index, estimated glomerular filtration rate, previous myocardial infarction, and left ventricular ejection fraction. Conversely, hospital-acquired anemia was not associated with increased mortality (hazard ratio 1.18; 95% confidence interval, 0.8-1.75; P = .4).

CONCLUSIONS

Hospital-acquired anemia affects one-third of patients hospitalized for acute coronary syndrome and is associated with age, frailty, and comorbidity burden, but was not found to be an independent predictor of long-term mortality.

Every Tube Counts: reducing extra tubes drawn in the emergency department

A common practice exists in hospitals where extra tubes of blood are collected for possible add-on testing, this practice contributes to wastage of consumables. Baseline estimates from a 5-month local lab information system audit revealed that ~65 extra tubes per day were being collected, with an additional 2-week manual audit of all extra tubes received in the laboratory confirming the practice. The audits showed that the majority of the tubes (~99%) were being drawn from the adult emergency department (ED). Furthermore, only 5% of the extra tubes were being used for add-on testing, whereas the remaining tubes had no testing performed on them and were discarded at the end of the day. This translates to over 23 000 extra tubes being wasted annually.After initial discussion with ED leadership, the practice was identified as primarily nurse driven. An educational intervention was created and entitled 'Every Tube Counts', with the aim to reduce extra tube collections in the adult ED by 50% within the first month of intervention. First, a memo with initial findings and a request to stop the practice of extra tube collection was sent out to all ED staff. After 2 weeks of additional data collection, it was noticed that extra tubes were still being collected. A second intervention, which consisted of another communication and utilisation of nurse educators to disseminate the information to nursing staff, saw a remarkable ~80% reduction in collection of extra tubes in the following few months after the second intervention. The practice was followed for an additional 15 months, which saw a slight increase of extra tube collections over time with a levelling off towards the latter period of the study. However, the target goal was maintained over the entire study period.

Risk Factors Analysis for Hemoglobin Decline Caused by Diagnostic Blood Collection in Respiratory Department in North China: A Case-Control Study

Purpose

This study aimed to investigate the correlation between hemoglobin decline and diagnostic blood collection in the respiratory department and analyze the decline's risk factors.

Patients and Methods

A case-control study in the respiratory department of a national tertiary hospital in north China, multivariable logistic regression analysis was used to find the risk factors. Patients excluding other factors affecting hemoglobin other than blood collection in the year 2021 were enrolled and divided into two groups according to the D-value of hemoglobin. The degree of hemoglobin decline caused by diagnostic blood collection between discharge and admission and its risk factors were analyzed.

Results

Among the 530 patients screened in the study, ΔHb (the D-value of hemoglobin between discharge and admission) showed a skewed distribution with an average value of -4.38±0.514 g/L. We defined the D-value less than mean-2SD (ΔHb<-5.408) as a significant hemoglobin decline, by which the patients were categorized into two groups. Some variables had apparent differences between the two groups. By multivariable logistic regression analysis on these variables, the independent risk factors for significant hemoglobin decline (ΔHb<-5.408g/L) were revealed: age (OR=1.020, 95% CI 1.008-1.032, p=0.001), Male gender (OR=1.544, 95% CI 1.011-2.358, p=0.044), hemoglobin value at admission (OR=1.052, 95% CI 1.039-1.065, p<0.001), total blood collection volume (OR=1.021, 95% CI 1.010-1.032, p<0.001).

Conclusion

In the respiratory department, older male and more diagnostic blood collection mean higher risks of significant hemoglobin decline. Surprisingly, the lower the hemoglobin value at admission, the lower the risk.

Vapor-Phase Synthesis of Molecularly Imprinted Polymers on Nanostructured Materials at Room-Temperature

Molecularly imprinted polymers (MIPs) have recently emerged as robust and versatile artificial receptors. MIP synthesis is carried out in liquid phase and optimized on planar surfaces. Application of MIPs to nanostructured materials is challenging due to diffusion-limited transport of monomers within the nanomaterial recesses, especially when the aspect ratio is >10. Here, the room temperature vapor-phase synthesis of MIPs in nanostructured materials is reported. The vapor phase synthesis leverages a >1000-fold increase in the diffusion coefficient of monomers in vapor phase, compared to liquid phase, to relax diffusion-limited transport and enable the controlled synthesis of MIPs also in nanostructures with high aspect ratio. As proof-of-concept application, pyrrole is used as the functional monomer thanks to its large exploitation in MIP preparation; nanostructured porous silicon oxide (PSiO2 ) is chosen to assess the vapor-phase deposition of PPy-based MIP in nanostructures with aspect ratio >100; human hemoglobin (HHb) is selected as the target molecule for the preparation of a MIP-based PSiO2 optical sensor. High sensitivity and selectivity, low detection limit, high stability and reusability are achieved in label-free optical detection of HHb, also in human plasma and artificial serum. The proposed vapor-phase synthesis of MIPs is immediately transferable to other nanomaterials, transducers, and proteins.

Confidence-based laboratory test reduction recommendation algorithm

BACKGROUND

We propose a new deep learning model to identify unnecessary hemoglobin (Hgb) tests for patients admitted to the hospital, which can help reduce health risks and healthcare costs.

METHODS

We collected internal patient data from a teaching hospital in Houston and external patient data from the MIMIC III database. The study used a conservative definition of unnecessary laboratory tests, which was defined as stable (i.e., stability) and below the lower normal bound (i.e., normality). Considering that machine learning models may yield less reliable results when trained on noisy inputs containing low-quality information, we estimated prediction confidence to assess the reliability of predicted outcomes. We adopted a "select and predict" design philosophy to maximize prediction performance by selectively considering samples with high prediction confidence for recommendations. Our model accommodated irregularly sampled observational data to make full use of variable correlations (i.e., with other laboratory test values) and temporal dependencies (i.e., previous laboratory tests performed within the same encounter) in selecting candidates for training and prediction.

RESULTS

The proposed model demonstrated remarkable Hgb prediction performance, achieving a normality AUC of 95.89% and a Hgb stability AUC of 95.94%, while recommending a reduction of 9.91% of Hgb tests that were deemed unnecessary. Additionally, the model could generalize well to external patients admitted to another hospital.

CONCLUSIONS

This study introduces a novel deep learning model with the potential to significantly reduce healthcare costs and improve patient outcomes by identifying unnecessary laboratory tests for hospitalized patients.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Patient Blood Management, Anemia, and Transfusion Optimization Across Surgical Specialties

Patient blood management (PBM) is a systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood and minimizing allogenic transfusion need and risk. According to the PBM approach, the goals of perioperative anemia management include early diagnosis, targeted treatment, blood conservation, restrictive transfusion except in cases of acute and massive hemorrhage, and ongoing quality assurance and research efforts to advance overall blood health.

Causes of Inappropriate Laboratory Test Ordering from the Perspective of Medical Laboratory Technical Professionals: Implications for Research and Education

OBJECTIVE

Inappropriate laboratory test ordering is a significant and persistent problem. Many causes have been identified and studied. Medical laboratory professionals (MLPs) are technical staff within clinical laboratories who are uniquely positioned to comment on why inappropriate ordering occurs. We aimed to characterize existing MLP perceptions in this domain to reveal new or underemphasized interventional targets.

METHODS

We developed and disseminated a self-administered survey to MLPs in Canada, including open-ended responses to questions about the causes of inappropriate laboratory test ordering.

RESULTS

Four primary themes were identified from qualitative analysis: ordering-provider factors, communication factors, existing test-ordering processes, and patient factors. Although these factors can largely be found in previous literature, some are under-studied.

CONCLUSION

MLP insights into nonphysician triage ordering and poor result communication provide targets for further investigation. A heavy focus on individual clinician factors suggests that current understandings and interprofessional skills in the MLP population can be improved.

Prevalence and risk factors for hospital-acquired anemia in internal medicine patients: learning from the "less is more" perspective

Hospital-acquired anemia is defined as a new-onset anemia in hospitalized patients who have a normal hemoglobin level at admission. Its prevalence is unknown and most studies published on this topic have been conducted in intensive care unit patients with limited applicability to less acute settings, such as internal medicine wards. We conducted a retrospective study and enrolled 129 patients who were admitted to an Internal Medicine Unit between October 2021 and February 2022. The median value of phlebotomy during hospitalization was 46 ml (IQR 30-72 ml), whereas the median length of hospital stay was 9 days (IQR 5-13 days). The median value of hemoglobin reduction was -0.63 g/dl (p < 0.001) and the maximum value of drop in hemoglobin value was -2.6 g/dl. All patients who experienced a phlebotomy > 85 ml had a hemoglobin reduction > 0.6 g/dl. 20.9% of patients developed anemia during the hospital stay (7% moderate and 13.9% mild). No cases of severe anemia were observed. The volume of blood drawn during the hospital stay and the Hb value on admission were the only two variables statistically associated with the development of anemia, whereas gender, age, and chronic diseases, such as diabetes, history of cancer, or heart failure, were not. Strategies, such as elimination of unnecessary laboratory tests and the use of smaller tubes for blood collection, are needed to reduce the volume of iatrogenic blood loss and avoid blood wastage occurring during hospitalization in internal medicine patients.

Association of hemoglobin trend and outcomes in aneurysmal subarachnoid hemorrhage: A single center cohort study

BACKGROUND

Anemia has been linked to delayed cerebral ischemia (DCI) and worse outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the association of hemoglobin (Hb) trend and outcomes is not well studied. We investigated predictors of Hb trend and its association with outcomes in patients with aSAH. Our hypothesis was that a negative Hb trend is associated with poorer outcomes independent of Hb values.

METHODS

We conducted a retrospective study of a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center (2016-2021). We tested the association of Hb trend and values with measures including DCI and poor functional outcome defined as modified Rankin scale 4-6 at 3 months after discharge. Multiple linear regression analysis was used to identify factors associated with Hb difference from admission to discharge.

RESULTS

We included 310 patients with confirmed aneurysmal etiology (mean age 57 years, SD13.6; 62 % female). Greater Hb decrement from admission to discharge was independently associated with higher likelihood of both DCI (OR 1.28 per 1 g/dl decrease in Hb, 95 % CI 1.08-1.47; p = 0.003) and poor functional outcome (OR 1.27 per 1 g/dl decrease in Hb, 1.03-1.53; p = 0.026) independent of any absolute Hb values. Predictors of Hb decrement from admission to discharge were hospital length of stay, Hunt and Hess grades, female sex and age.

CONCLUSION

Greater Hb decrement can be associated with higher likelihood of DCI and poor functional outcome in aSAH. More evidence is needed to use Hb trend to guide transfusion threshold in aSAH patients.

Is minimising waste volume for drawing blood samples in critically ill patients feasible?

INTRODUCTION

Drawing blood samples through a central venous catheter (CVC) is a customary practice in Intensive Care Units (ICUs). It is indicated to discard a volume of waste blood to avoid interference in the results.

AIM

To determine whether a lower discard volume for obtaining blood samples from temporary CVCs placed into the internal jugular, femoral or subclavian vein offers valid results.

METHOD

A quasi-experimental prospective cross-sectional study for which sixty-five patients of over 18 years of age in ICUs, who had been fitted with a triple lumen central venous catheter, were recruited over a period of eight months. Two consecutive blood samples were extracted with tubes for biochemistry, coagulation and hemogram from each patient from the distal lumen. The first sample was obtained with a discarded waste of 1.5 ml from a total extracted volume of 10.2 ml, similar to the usual waste in our ambit (10 ml). Subsequently the second sample was obtained. The paired t-test was used to analyse the data. The Bland-Altman plot and intraclass correlation coefficient (ICC) were used to measure the agreement between methods. The reference change value (RCV) was established as the admissible limit of variation between the pairs of samples.

RESULTS

A total of 65 sample pairs were drawn (intervention-control). The paired t-test found statistically significant differences with a significance level of α = .05 for chlorine (-.536; .012); prothrombin time (-.092; .019) and prothrombin activity (.284; 1.375).The ICC was greater than .9 in all the variables and the limit determined for the RCV was not surpassed by any value.

CONCLUSIONS

The results show the reliability of the blood samples drawn with a discard volume of 1.5 ml.

A Contemporary Analysis of Phlebotomy and Iatrogenic Anemia Development Throughout Hospitalization in Critically Ill Adults

BACKGROUND

Anemia is common in critically ill patients and may be exacerbated through phlebotomy-associated iatrogenic blood loss. Differences in phlebotomy practice across patient demographic characteristics, clinical features, and practice environments are unclear. This investigation provides a comprehensive description of contemporary phlebotomy practices for critically ill adults.

METHODS

This is an observational cohort study of adults ≥18 years of age requiring intensive care unit (ICU) admission between January 1, 2019, and December 31, 2019, at a large academic medical center. Descriptive statistics were utilized to summarize all phlebotomy episodes throughout hospitalization, with each phlebotomy episode defined by unique peripheral venous, central venous, or arterial accesses for laboratory draws, exclusive of finger sticks. Secondarily, financial costs of phlebotomy and the relationships between phlebotomy practices, hemoglobin concentrations, and red blood cell (RBC) transfusions were evaluated.

RESULTS

A total of 6194 patients were included: 59% were men with a median (interquartile range) age of 66 (54-76) years and median ICU and hospital durations of 2.1 (1.4-3.9) and 7.1 (4.3-11.8) days, respectively. The median number of unique laboratory draws was 41 (18-88) throughout hospitalization, with a median volume of 232 (121-442) mL, corresponding to 5.2 (2.6-8.8) draws and 29 (19-43) mL per day. Waste (ie, discard) volume was responsible for 10.8% of total phlebotomy volume. Surgical patients had a higher number of phlebotomy episodes and greater total phlebotomy volumes compared to nonsurgical patients. Phlebotomy practices differed across ICU types, with the greatest frequency of laboratory draws in the cardiac surgical ICU and the greatest daily phlebotomy volume in the medical ICU. Across hospitalization, ICU environments had the greatest frequency and volumes of laboratory draws, with the least intensive phlebotomy practice observed in the general hospital wards. Patients in the highest quartile of cumulative blood drawn experienced the longest hospitalizations, lowest nadir hemoglobin concentrations, and greatest RBC transfusion utilization. Differences in phlebotomy practice were limited across patient age, gender, and race. Hemoglobin concentrations declined during hospitalization, congruent with intensity of phlebotomy practice. Each 100 mL of phlebotomy volume during hospitalization was associated with a 1.15 (95% confidence interval [CI], 1.14-1.17; P < .001) multiplicative increase in RBC units transfused in adjusted analyses. Estimated annual phlebotomy costs exceeded $15 million (approximately $2500 per patient admission).

CONCLUSIONS

Phlebotomy continues to be a major source of blood loss in hospitalized patients with critical illness, and more intensive phlebotomy practices are associated with lower hemoglobin concentrations and greater transfusion utilization.

Hospital-acquired anemia among patients in a university hospital and the affiliated general practices in the capital region of Denmark, 2019

INTRODUCTION

Approximately 25% of the patients with hospital acquired anemia (HAA) develop moderate to severe HAA during hospitalization. This is related to an increased risk of prolonged stay, readmission and mortality. The primary aim was during one year to characterize a population with very frequent phlebotomies based on a university hospital in the Capital Region of Denmark and the related general practitioners.

MATERIAL AND METHODS

We conducted a retrospective cohort study using administrative data on phlebotomies from 1 January 2019 to 31 December 2019 analyzed at a university hospital.

RESULTS

A total of 203,811 patients had 10,083,207 requisitions and 1,373,013 tubes. One percent, 1985 patients, had an extreme of frequent phlebotomies >60 tubes and formed the basis for the study population. The study population was significantly older as compared to the excluded patients (<60 tubes) (mean 65.7 vs. 51.6 years, p < .001).The likelihood of hemoglobin decrease per 100 mL blood drawn were calculated at four levels of decreases: Hemoglobin decrease of 2 mmol/L (adjusted OR; 95%; 2.03, CI 1.79-2.31), hemoglobin decrease of 3 mmol/L (adjusted OR; 95%, 1.36, CI 1.28-1.45), hemoglobin decrease of 4 mmol/L, (adjusted OR; 95%, 1.27, CI 1.19-1.35) and hemoglobin decrease of 5 mmol/L, (adjusted OR; 95% 1.22, CI 1.13-1.31).

CONCLUSIONS

Moderate to severe HAA occurred in a limited group with excessive many phlebotomies. It was a worrisome trend that the frailest patients had the highest risk of developing HAA.

Nurses' experiences of blood sample collection from children: a qualitative study from Swedish paediatric hospital care

Background

Nurses play an active role in supporting the children with the blood sampling experience. Unfortunately, the blood sampling collection procedure is often affected by pre-analytical errors, leading to consequences such as delayed diagnosis as well as repeated sampling. Moreover, children state that needle procedures are the worst experience of their hospital stay. The nurses’ experiences of errors occurring during blood sample collection is unknown. Therefore, the aim of this study therefore was to describe paediatric nurses’ experiences of blood sampling collections from children.

Method

We used a qualitative study design with a (reflexive) thematic analysis (TA) method described by Braun and Clarke. Three focus group interviews were conducted, with 19 nurses collected by purposeful sampling from Sweden working at two different paediatric hospitals, focusing on their experiences of the blood sample collection procedure.

Results

From the three focus group interviews we analysed patterns and meanings of the following main theme Paediatric blood sampling is a challenge for the nurses and the four subthemes Nurses’ feelings of frustration with unsuccessful samplings, Nurses believe in team work, Venous blood sampling was experienced as the best option, and Nurses’ thoughts and needs regarding skills development in paediatric blood sampling.

Conclusion

The narrative results of this study illustrate that nurses working in paediatric hospital care face a big challenge in blood sampling collection from children. The nurses felt frustrated due to unsuccessful blood samplings and frequently could not understand why pre-analytical errors occurred. Nevertheless, they felt strengthened by colleagues in their team and shared feelings of responsibility to help each other with this complex procedure. The implications of this study are that paediatric hospital care needs to focus on improving guidelines for and increasing competence in blood sampling children and helping nurses to understand why samplings may be unsuccessful and how this can be avoided.

A New List for Choosing Wisely Canada From the "Hidden Profession" of Medical Laboratory Science

OBJECTIVES

Choosing Wisely Canada (CWC) publishes practices that may contribute to medical overuse and patient harm. Many practices concern laboratory testing, but the recommendations are often written for the test-ordering professionals. Our objective was to develop a list for CWC reflecting the scope of practice of nonpathologist medical laboratory professionals (MLPs).

METHODS

We used a national survey, a convention session, and a panel of MLPs from across Canada to generate content for the CWC list. We used a modified Delphi process to identify the most important items and scoping reviews to gather evidence supporting each item.

RESULTS

We identified 95 potential CWC list items. After 2 Delphi rounds, there was little movement in the top items. Scoping reviews revealed varying degrees of evidentiary support, which influenced the composition of the final list of 7 CWC items submitted. Three of the final recommendations address ways MLPs preserve the status quo with respect to overutilization of laboratory tests by other health care professionals. The remaining recommendations prompt MLPs to exert clinical judgment in specific scenarios, particularly where they can impact blood collection volumes.

CONCLUSIONS

This work brings a more nuanced and comprehensive understanding of the relationships among MLPs, patient safety, and resource waste.

Patient Blood Management in intensive care patients

PURPOSE OF REVIEW

Patients admitted to ICUs are a heterogeneous group, displaying multiple anaemia risk factors and comorbidities. Clinicians should therefore take all possible measures to identify modifiable risks. Patient Blood Management (PBM) is an approach promoting the timely application of evidence-based interventions designed to maintain patients own blood mass.

RECENT FINDINGS

Within ICU-patients, anaemia is highly prevalent. Generally, anaemia is associated with impaired outcome and need of blood transfusion. Currently, with ICUs working at full capacity and the global blood reserves exhausted, the SARS-CoV-2 pandemic reinforces the need for PBM implementation. For instance, implementation of a comprehensive coagulation management and measures to avoid iatrogenic blood loss may prevent bleeding-associated complications and adherence to blood transfusion guidelines may reduce adverse events associated with transfusion.

SUMMARY

Critically ill patients display various morbidities often requiring individualized treatment. PBM offers patient-centred measures to improve outcome any time during hospital stay.

Evaluation of the Use of Blood Products in ICU Hospitalized COVID-19 Patients

(1) Background: The COVID-19 pandemic tested the public health system’s readiness for crises and highlighted the importance of knowing the demand for blood products and the maintenance of the blood supply chain. The aim of this study was to evaluate blood product usage in a series of patients that were hospitalized due to COVID-19 and to analyze their demographics and clinical characteristics. (2) Methods: In this retrospective cohort study, we analyzed data from transfused COVID-19 patients that were treated in the University Hospital Medical Center Bezanijska Kosa in Belgrade, Serbia during the second wave of the epidemic. (3) Results: This study included 90 patients. The median age of the patients was 72 (range 23–95) years. The median time of hospitalization was 23 days (range 3–73 days). In intensive care units (ICUs) the median time of hospitalization was 9 days (range 0–73). One or more comorbidities were observed in 86 individuals (95.6%). The total number of transfused red blood cell concetrates (RBC) was 304 (139 in ICU, 165 in other wards), with a mean of 3 units/patient (range 1–14). Comorbidities, severity of illness and hospital duration in the ICU were statistically significant predictors of higher RBC use. (4) Conclusion: Knowledge of the transfusion profile of COVID-19 patients allowed better management of the hospital’s blood stocks during the COVID-19 pandemic.

The 10 most frequently requested blood tests in the Capital Region of Denmark, 2010-2019 and simulated effect of minimal retesting intervals

As healthcare costs continue to rise throughout the world, critical assessment of the appropriateness of expenses gain focus.

OBJECTIVES

We aimed to describe the developments in test numbers of the 10 most frequently requested tests, and to simulate the effect of introducing minimal retesting intervals.

DESIGN & METHODS

Data from the blood tests - albumin, alanine transaminase, cholesterol, creatinine, C-reactive protein, hemoglobin, hemoglobin A_1c, potassium, sodium, and thyrotropin - from 2,687,589 patients handled by the Capital Region of Denmark from 2010 to 2019 was used. Tallies of each test per year were graphed. A simulation of the effect of minimal retesting intervals on test count and blood sampling volume was performed by virtually removing requests made prior to a set of possible minimal retesting intervals.

RESULTS

Increases in requests were observed both from hospitals and general practitioners. The number of requests for hemoglobin A_1c increased more than the other tests. The increases could not be accounted for by an increase in population size and aging of the population, and therefore suggests possible inappropriate increase in monitoring of patients. The simulated effect of applying minimal retesting intervals showed large reductions in tests and blood sampled.

CONCLUSIONS

For hospitals, the simulation suggested that applying minimal retesting intervals could lead to significant reductions in both the number of blood tests performed and in the amount of blood drawn for testing. For general practitioners, the simulation showed only minimal reductions in number of tests and blood volume drawn.

The Importance of Iron Administration in Correcting Anaemia After Major Surgery

INTRODUCTION

Postoperative anaemia can affect more than 90% of patients undergoing major surgeries. Patients develop an absolute iron deficiency in the face of significant blood loss or preoperative anaemia and major surgery. Studies have shown the negative impact of these factors on transfusion requirements, infections, increased hospitalisation and long-term morbidities.

AIM OF THE STUDY

The research was performed to determine the correlation between intravenous iron administration in the postoperative period and improved haemoglobin correction trend.

MATERIAL AND METHODS

A prospective study was conducted to screen and treat iron deficiency in patients undergoing major surgery associated with significant bleeding. For iron deficiency anaemia screening, in the postoperative period, the following bioumoral parameters were assessed: haemoglobin, serum iron, transferrin saturation (TSAT), and ferritin, direct serum total iron-binding capacity (dTIBC), mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH). In addition, serum glucose, fibrinogen, urea, creatinine and lactate values were also collected.

RESULTS

Twenty-one patients undergoing major surgeries (52,38% were emergency and 47,61% elective interventions) were included in the study. Iron deficiency, as defined by ferritin 100-300 μg/L along with transferrin saturation (TSAT) < 20 %, mean corpuscular volume (MVC) < 92 fL, mean corpuscular haemoglobin (MCH) < 33 g/dL, serum iron < 10 μmol/L and direct serum total iron-binding capacity (dTIBC) > 36 μmol/L, was identified in all cases. To correct the deficit and optimise the haematological status, all patients received intravenous ferric carboxymaltose (500-1000 mg, single dose). Using Quadratic statistical analysis, the trend of haemoglobin correction was found to be a favourable one.

CONCLUSION

The administration of intravenous ferric carboxymaltose in the postoperative period showed the beneficial effect of this type of intervention on the haemoglobin correction trend in these groups of patients.

Performance evaluation of the Roche cobas 6800 system for quantifying cytomegalovirus DNA in plasma and urine samples

INTRODUCTION

Cytomegalovirus (CMV) nucleic acid amplification testing is important for CMV infection diagnosis and management. CMV DNA is found in plasma and various other fluids, including urine. If CMV can be reliably detected in urine, it may be considered a non-invasive alternative to blood tests. The cobas 6800 system (Roche Diagnostics, Mannheim, Germany) is a Food and Drug Administration-approved testing platform for measuring CMV DNA in plasma.

OBJECTIVE

To evaluate the analytical performance of the cobas 6800 system and compare the clinical feasibility of CMV detection in plasma and urine samples.

STUDY DESIGN

Imprecision, linearity, limit of quantitation (LOQ), and cross-reactivity of the cobas 6800 system were assessed, and reference interval verification was performed. Plasma CMV DNA quantification was compared to CMV DNA values in urine samples obtained from 129 pediatric patients (<18 years of age) from March 2020 to May 2020 at a tertiary hospital.

RESULTS

The assay precision was within the acceptable range. Linearity was observed within the tested concentration range (2.36-6.33 log IU/mL) with a coefficient of determination of 0.9972. The LOQ was 34.5 IU/mL. The assay did not show cross-reactivity with 15 other viruses. Plasma and urine detection results were stratified into three categories: negative, <LOQ, and positive to analyze the degree of agreement with the results. The quadratic weighted kappa value was 0.623 (P = 0.000), showing substantial concurrence.

CONCLUSION

The cobas 6800 system offers good sensitivity, precision, and linearity and is suitable for monitoring CMV viral loads in the plasma and urine samples.

Iatrogenic anaemia and transfusion thresholds in ICU patients with COVID-19 disease at a tertiary care hospital

BACKGROUND

Patients with severe COVID-19 disease frequently develop anaemia as the result of multiple mechanisms and often receive transfusions. The aims of this study were to assess the impact of repeated blood samplings on patients' anaemic state using standard-volume tubes, in comparison with the hypothetical use of low-volume tubes and to evaluate the transfusion policy adopted.

STUDY DESIGN AND METHODS

Transfusion data of mechanically ventilated non-bleeding patients with COVID-19 disease hospitalized in ICU for a minimum of 20 days were recorded. The total volume of blood drawn for samplings with standard-volume tubes and the corresponding red blood cell mass (RBCM) removed during hospitalization for each patient were calculated and compared with the hypothetical use of low-volume tubes.

RESULTS

Twenty-four patients fulfilled the inclusion criteria. Ten patients were anaemic at ICU admission (41.7 %). Overall, 6658 sampling tubes were employed, for a total of 16,786 mL of blood. The median RBCM subtracted by blood samplings per patient accounted for about one third of the total patients' RBCM decrease until discharge. The use of low-volume tubes would have led to a median saving of about one third of the drawn RBCM. Eleven patients were transfused (45.8 %) at a mean Hb value of 7.7 (± 0.5) g/dL.

CONCLUSION

The amount of blood drawn for sampling has a significant role in the development of anaemia and the use of low-volume tubes could minimize the problem. Large high-powered studies are warranted to assess the more appropriate transfusion thresholds in non-bleeding critically ill patients with COVID-19 disease.

Safety of intermediate dose of low molecular weight heparin in COVID-19 patients

Coagulopathy represents one of the most important determinants of morbidity and mortality in coronavirus disease-19 (COVID-19). Whether standard thromboprophylaxis is sufficient or higher doses are needed, especially in severe patients, is unknown. To evaluate the safety of intermediate dose regimens of low-weight molecular heparin (LWMH) in COVID-19 patients with pneumonia, particularly in older patients. We retrospectively evaluated 105 hospitalized patients (61 M, 44 F; mean age 73.7 years) treated with subcutaneous enoxaparin: 80 mg/day in normal weight and mild-to-moderate impair or normal renal function; 40 mg/day in severe chronic renal failure or low bodyweight (< 45 kg); 100 mg/day if bodyweight was higher than 100 kg. All the patients had radiologically confirmed pneumonia and 63.8% had severe COVID-19. None of the patients had fatal haemorrhage; two (1.9%) patients had a major bleeding event (one spontaneous hematoma and one gastrointestinal bleeding). Only 6.7% of patients needed transfusions of red blood cells. One thrombotic event (pulmonary embolism) was observed. When compared to younger patients, patients older than 85 years had a higher mortality (40% vs 13.3%), but not an increased risk of bleeding or need for blood transfusion. The use of an intermediate dose of LWMH appears to be feasible and data suggest safety in COVID-19 patients, although further studies are needed.