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Zhao BC, Xie YS, Luo WC, Lei SH, Liu JM, Yang X, Dong YH, Liu WF, Liu KX. Postoperative haemoglobin and anaemia-associated ischaemic events after major noncardiac surgery: A sex-stratified cohort study. J Clin Anesth 2024; 95:111439. [PMID: 38471194 DOI: 10.1016/j.jclinane.2024.111439] [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: 04/29/2023] [Revised: 01/01/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
STUDY OBJECTIVE To determine the sex-specific associations between postoperative haemoglobin and mortality or complications reflecting ischaemia or inadequate oxygen supply after major noncardiac surgery. DESIGN A retrospective cohort study with prospective validation. SETTING A large university hospital health system in China. PATIENTS Men and women undergoing elective major noncardiac surgery. INTERVENTIONS AND MEASUREMENTS The primary exposure was nadir haemoglobin within 48 h after surgery. The outcome of interest was a composite of postoperative mortality or ischaemic events including myocardial injury, acute kidney injury and stroke within hospitalisation. MAIN RESULTS The study included 26,049 patients (15,757 men and 10,292 women). Low postoperative haemoglobin was a strong predictor of the composite outcome in both sexes, with the risk progressively increasing as the nadir haemoglobin concentration dropped below 130 g l-1 in men and 120 g l-1 in women (adjusted odds ratio [OR] 1.43, 95% CI 1.37-1.50 in men, and OR 1.45, 95% CI 1.35-1.55 in women, per 10 g l-1 decrease in postoperative nadir haemoglobin). Above these sex-specific thresholds, the change of nadir haemoglobin was no longer associated with odds of the composite outcome in either men or women. There was no significant interaction between patient sex and the association between postoperative haemoglobin and the composite outcome (Pinteraction = 0.673). Validation in an external prospective cohort (n = 2120) with systematic postoperative troponin and creatinine measurement confirmed our findings. CONCLUSIONS Postoperative haemoglobin levels following major noncardiac surgery were nonlinearly associated with ischaemic complications or mortality, without any clinically important interaction with patient sex.
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Affiliation(s)
- Bing-Cheng Zhao
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yi-Shan Xie
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wen-Chi Luo
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shao-Hui Lei
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jia-Ming Liu
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao Yang
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ye-Hong Dong
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-Feng Liu
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Ke-Xuan Liu
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Bjurström MF, Linder YC, Kjeldsen-Kragh J, Bengtsson J, Kander T. Adherence to a restrictive red blood cell transfusion strategy in critically ill patients: An observational study. Acta Anaesthesiol Scand 2024; 68:812-820. [PMID: 38453453 DOI: 10.1111/aas.14402] [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: 10/02/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Randomized controlled trials relatively consistently show that restrictive red blood cell (RBC) transfusion strategies are safe and associated with similar outcomes compared to liberal transfusion strategies in critically ill patients. Based on these data, the general threshold for RBC transfusion was changed to 70 g/L at a 9-bed tertiary level intensive care unit in September 2020. Implementation measures included lectures, webinars and feedback during clinical practice. The aim of this study was to investigate how implementation of a restrictive transfusion strategy influenced RBC usage, haemoglobin trigger levels and adherence to prescribed trigger levels. METHODS In this registry-based, observational study, critically ill adult patients without massive bleeding were included and divided into a pre-cohort, with admissions prior to the change of transfusion strategy, and a post-cohort, with admissions following the change of transfusion strategy. These cohorts were compared regarding key RBC transfusion-related variables. RESULTS In total 5626 admissions were included in the analyses (pre-cohort n = 4373, post-cohort n = 1253). The median volume (interquartile range, IQR) of RBC transfusions per 100 admission days, in the pre-cohort was 6120 (4110-8110) mL versus 3010 (2890-4970) mL in the post-cohort (p < .001). This corresponds to an estimated median saving of 1128 € per 100 admission days after a restrictive RBC transfusion strategy was implemented. In total, 26% of the admissions in the pre-cohort and 19% in the post-cohort (p < .001) received RBC transfusion(s) during days 0-10. Both median (IQR) prescribed trigger levels (determined by intensivist) and actual haemoglobin trigger levels (i.e., levels prior to actual administration of transfusion) were higher in the pre- versus post-cohort (90 [80-100] vs. 80 [72-90] g/L, p < .001 and 89 [82-96] g/L vs. 83 [79-94], p < .001, respectively). Percentage of days without compliance with the prescribed transfusion trigger was higher in the pre-cohort than in the post-cohort (23% vs. 14%, p < .001). Sensitivity analyses, excluding patients with traumatic brain injury, ischemic heart disease and COVID-19 demonstrated similar results. CONCLUSIONS Implementation of a restrictive transfusion trigger in a critical care setting resulted in lasting decreased RBC transfusion use and costs, decreased prescribed and actual haemoglobin trigger levels and improved adherence to prescribed haemoglobin trigger levels.
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Affiliation(s)
- Martin F Bjurström
- Department of Intensive and Perioperative Care, Skåne University Hospital and Lund University, Lund, Sweden
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Ylva C Linder
- Department of Clinical Immunology and Transfusion Medicine, Office for Medical Services, Laboratory Medicine and Lund University, Lund, Sweden
| | - Jens Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine, Office for Medical Services, Laboratory Medicine and Lund University, Lund, Sweden
| | - Jesper Bengtsson
- Department of Clinical Immunology and Transfusion Medicine, Office for Medical Services, Laboratory Medicine and Lund University, Lund, Sweden
| | - Thomas Kander
- Department of Intensive and Perioperative Care, Skåne University Hospital and Lund University, Lund, Sweden
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Laghi F, Shaikh H, Caccani N. Basing intubation of acutely hypoxemic patients on physiologic principles. Ann Intensive Care 2024; 14:86. [PMID: 38864960 PMCID: PMC11169311 DOI: 10.1186/s13613-024-01327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 05/31/2024] [Indexed: 06/13/2024] Open
Abstract
The decision to intubate a patient with acute hypoxemic respiratory failure who is not in apparent respiratory distress is one of the most difficult clinical decisions faced by intensivists. A conservative approach exposes patients to the dangers of hypoxemia, while a liberal approach exposes them to the dangers of inserting an endotracheal tube and invasive mechanical ventilation. To assist intensivists in this decision, investigators have used various thresholds of peripheral or arterial oxygen saturation, partial pressure of oxygen, partial pressure of oxygen-to-fraction of inspired oxygen ratio, and arterial oxygen content. In this review we will discuss how each of these oxygenation indices provides inaccurate information about the volume of oxygen transported in the arterial blood (convective oxygen delivery) or the pressure gradient driving oxygen from the capillaries to the cells (diffusive oxygen delivery). The decision to intubate hypoxemic patients is further complicated by our nescience of the critical point below which global and cerebral oxygen supply become delivery-dependent in the individual patient. Accordingly, intubation requires a nuanced understanding of oxygenation indexes. In this review, we will also discuss our approach to intubation based on clinical observations and physiologic principles. Specifically, we consider intubation when hypoxemic patients, who are neither in apparent respiratory distress nor in shock, become cognitively impaired suggesting emergent cerebral hypoxia. When deciding to intubate, we also consider additional factors including estimates of cardiac function, peripheral perfusion, arterial oxygen content and its determinants. It is not possible, however, to pick an oxygenation breakpoint below which the benefits of mechanical ventilation decidedly outweigh its hazards. It is futile to imagine that decision making about instituting mechanical ventilation in an individual patient can be condensed into an algorithm with absolute numbers at each nodal point. In sum, an algorithm cannot replace the presence of a physician well skilled in the art of clinical evaluation who has a deep understanding of pathophysiologic principles.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital (111N) and Loyola University of Chicago Stritch School of Medicine, 60141, Hines, IL, USA.
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital (111N) and Loyola University of Chicago Stritch School of Medicine, 60141, Hines, IL, USA
| | - Nicola Caccani
- Department of Physiology and Pharmacology, Center for Molecular Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Ma H, Li S, Dou R, Lui KY, Song X, Qian X, Liang Y, Guan X, Cai C. Impact of red blood cell transfusion and hemoglobin threshold on 1-year mortality among surgical sepsis survivors: A propensity score matching study. Am J Surg 2024:115790. [PMID: 38849279 DOI: 10.1016/j.amjsurg.2024.115790] [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: 03/12/2024] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Despite the fact that red blood cell (RBC) transfusion is commonly applied in surgical intensive care unit (ICU), the effect of RBC transfusion on long-term outcomes remains undetermined. We aimed to explore the association between RBC transfusion and the long-term prognosis of surgical sepsis survivors. METHODS This retrospective study was conducted on adult sepsis patients admitted to a tertiary surgical ICU center in China. Patients were divided into transfusion and non-transfusion groups based on the presence of RBC transfusion. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW)were performed to balance the potential confounders. RESULTS A total of 1421 surgical sepsis survivors were enrolled, including 403 transfused patients and 1018 non-transfused patients. There was a significant difference in 1-year mortality between the two groups (23.1 % vs 12.7 %, HR: 1.539, 95 % confidence interval [CI]: 1.030-2.299, P < 0.001). After PSM and IPTW, transfused patients still showed significantly increased 1-year mortality risks compared to non-transfused individuals (PSM: 23.6 % vs 15.9 %, HR 1.606, 95 % CI 1.036-2.488 P = 0.034; IPTW: 20.1 % vs 12.9 %, HR 1.600, 95 % CI 1.040-2.462 P = 0.032). Among patients with nadir hemoglobin below 70 g/L, 1-year mortality risks in both groups were similar (HR 1.461, 95 % CI 0.909-2.348, P = 0.118). However, among patients with nadir hemoglobin above 70 g/L, RBC transfusion was correlated with increased 1-year mortality risk (HR 1.556, 95 % CI 1.020-2.374, P = 0.040). CONCLUSION For surgical sepsis survivors, RBC transfusion during ICU stay was associated with increased 1-year mortality, especially when patients show hemoglobin levels above 70 g/L.
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Affiliation(s)
- Huan Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
| | - Shuhe Li
- University of Exeter Medical School, University of Exeter, Heavitree Road, Exeter, EX12LU, Devon, UK.
| | - Ruoxu Dou
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
| | - Ka Yin Lui
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
| | - Xiaodong Song
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
| | - Xiayan Qian
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
| | - Yujun Liang
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
| | - Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
| | - Changjie Cai
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, No.58, Zhongshan 2nd Road, Yuexiu District, 510080, Guangzhou, Guangdong Province, China.
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Hess AS. Oxygen Extraction Ratios to Guide Red Blood Cell Transfusion. Transfus Med Rev 2024:150834. [PMID: 38839487 DOI: 10.1016/j.tmrv.2024.150834] [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: 01/17/2024] [Revised: 04/09/2024] [Accepted: 04/24/2024] [Indexed: 06/07/2024]
Abstract
Hemoglobin-based red blood cell transfusion (RBC) triggers do not clearly identify which patients with moderate anemia (hemoglobin 7-10 g/dL) will benefit from RBC transfusion. The National Heart, Lung, and Blood Institute has recognized the need for bedside oxygenation measures to enhance transfusion decision-making. This narrative review uses four studies to explore the potential of the oxygen extraction ratio (O2ER)-the ratio of consumed oxygen to delivered oxygen in a critical tissue bed as a more physiologically relevant indicator for guiding RBC transfusions in patients with moderate anemia. The aim of this review is to present existing data on the relationship between O2ER and responsiveness to RBC transfusion, as well as the feasibility of O2ER as bedside measure of tissue oxygenation. This review presents a narrative appraisal of three critical papers that investigate the relationship between O2ER and transfusion outcomes, and one paper that demonstrates proof-of-concept for a noninvasive device to measure O2ER at the bedside. Despite limitations in the existing studies, including small sample sizes and observational designs, the evidence collectively suggests that O2ER has the potential to enhance transfusion decision accuracy. The development of noninvasive measurement devices could facilitate widespread implementation in many kinds of care settings.
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Affiliation(s)
- Aaron S Hess
- Departments of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin, Madison, WI, USA.
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Cody N, Bradbury I, McMullan RR, Quinn G, O'Neill A, Ward K, McCann J, McAuley DF, Silversides JA. Physiologic Determinants of Near-Infrared Spectroscopy-Derived Cerebral and Tissue Oxygen Saturation Measurements in Critically Ill Patients. Crit Care Explor 2024; 6:e1094. [PMID: 38727717 PMCID: PMC11090623 DOI: 10.1097/cce.0000000000001094] [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] [Indexed: 05/15/2024] Open
Abstract
OBJECTIVES Near-infrared spectroscopy (NIRS) is a potentially valuable modality to monitor the adequacy of oxygen delivery to the brain and other tissues in critically ill patients, but little is known about the physiologic determinants of NIRS-derived tissue oxygen saturations. The purpose of this study was to assess the contribution of routinely measured physiologic parameters to tissue oxygen saturation measured by NIRS. DESIGN An observational sub-study of patients enrolled in the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomized feasibility trial. SETTING Two ICUs in the United Kingdom. PATIENTS Patients were recruited for the RADAR-2 study, which compared a conservative approach to fluid therapy and deresuscitation with usual care. Those included in this sub-study underwent continuous NIRS monitoring of cerebral oxygen saturations (SctO2) and quadriceps muscle tissue saturations (SmtO2). INTERVENTION Synchronized and continuous mean arterial pressure (MAP), heart rate (HR), and pulse oximetry (oxygen saturation, Spo2) measurements were recorded alongside NIRS data. Arterial Paco2, Pao2, and hemoglobin concentration were recorded 12 hourly. Linear mixed effect models were used to investigate the association between these physiologic variables and cerebral and muscle tissue oxygen saturations. MEASUREMENTS AND MAIN RESULTS Sixty-six patients were included in the analysis. Linear mixed models demonstrated that Paco2, Spo2, MAP, and HR were weakly associated with SctO2 but only explained 7.1% of the total variation. Spo2 and MAP were associated with SmtO2, but together only explained 0.8% of its total variation. The remaining variability was predominantly accounted for by between-subject differences. CONCLUSIONS Our findings demonstrated that only a small proportion of variability in NIRS-derived cerebral and tissue oximetry measurements could be explained by routinely measured physiologic variables. We conclude that for NIRS to be a useful monitoring modality in critical care, considerable further research is required to understand physiologic determinants and prognostic significance.
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Affiliation(s)
- Neil Cody
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Ian Bradbury
- Independent Consulting Statistician, Aviemore, Scotland
| | - Ross R McMullan
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Gerard Quinn
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Aisling O'Neill
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Kathryn Ward
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Justine McCann
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Daniel F McAuley
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Jonathan A Silversides
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
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Eriksson M, Lipcsey M, Ilboudo Y, Yoshiji S, Richards B, Hultström M. Uromodulin in sepsis and severe pneumonia: a two-sample Mendelian randomization study. Physiol Genomics 2024; 56:409-416. [PMID: 38369967 DOI: 10.1152/physiolgenomics.00145.2023] [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: 11/27/2023] [Revised: 01/30/2024] [Accepted: 02/12/2024] [Indexed: 02/20/2024] Open
Abstract
The outcome for patients with sepsis-associated acute kidney injury in the intensive care unit (ICU) remains poor. Low serum uromodulin (sUMOD) protein levels have been proposed as a causal mediator of this effect. We investigated the effect of different levels of sUMOD on the risk of sepsis and severe pneumonia and outcomes in these conditions. A two-sample Mendelian randomization (MR) study was performed. Single-nucleotide polymorphisms (SNPs) associated with increased levels of sUMOD were identified and used as instrumental variables for association with outcomes. Data from different cohorts were combined based on disease severity and meta-analyzed. Five SNPs associated with increased sUMOD levels were identified and tested in six datasets from two biobanks. There was no protective effect of increased levels of sUMOD on the risk of sepsis [two cohorts, odds ratio (OR) 0.99 (95% confidence interval 0.95-1.03), P = 0.698, and OR 0.95 (0.91-1.00), P = 0.060, respectively], risk of sepsis requiring ICU admission [OR 1.04 (0.93-1.16), P = 0.467], ICU mortality in sepsis [OR 1.00 (0.74-1.37), P = 0.987], risk of pneumonia requiring ICU admission [OR 1.05 (0.98-1.14), P = 0.181], or ICU mortality in pneumonia [OR 1.17 (0.98-1.39), P = 0.079]. Meta-analysis of hospital-admitted and ICU-admitted patients separately yielded similar results [OR 0.98 (0.95-1.01), P = 0.23, and OR 1.05 (0.99-1.12), P = 0.86, respectively]. Among patients with sepsis and severe pneumonia, there was no protective effect of different levels of sUMOD. Results were consistent regardless of geographic origins and not modified by disease severity. NEW & NOTEWORTHY The presence of acute kidney injury in severe infections increases the likelihood of poor outcome severalfold. A decrease in serum uromodulin (sUMOD), synthetized in the kidney, has been proposed as a mediator of this effect. Using the Mendelian randomization technique, we tested the hypothesis that increased sUMOD is protective in severe infections. Analyses, however, showed no evidence of a protective effect of higher levels of sUMOD in sepsis or severe pneumonia.
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Affiliation(s)
- Mikael Eriksson
- Department of Surgical Sciences, Section of Anesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Miklós Lipcsey
- Department of Surgical Sciences, Section of Anesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Yann Ilboudo
- Lady Davis Institute of Medical Research, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Satoshi Yoshiji
- Lady Davis Institute of Medical Research, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Department of Human Genetics, McGill University, Montréal, Québec, Canada
- Kyoto-McGill International Collaborative Program in Genomic Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Brent Richards
- Lady Davis Institute of Medical Research, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
- Department of Twin Research, King's College London, London, United Kingdom
- 5 Prime Sciences, Montréal, Québec, Canada
| | - Michael Hultström
- Department of Surgical Sciences, Section of Anesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
- Lady Davis Institute of Medical Research, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
- Department of Medical Cell Biology, Integrative Physiology, Uppsala University, Uppsala, Sweden
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8
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Yao RJR, Fordyce CB. Optimal Transfusion Threshold for Anemic Patients Presenting With Myocardial Infarction and Heart Failure: Dream or REALITY? Can J Cardiol 2024:S0828-282X(24)00299-X. [PMID: 38604338 DOI: 10.1016/j.cjca.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/13/2024] Open
Affiliation(s)
- Ren Jie Robert Yao
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.
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De Santis GC, Costa L, Brunetta DM, Magnus MM, Benites BD, Rodrigues RDR, Alves SDOC, Rizzo SRCP, Rabello G, Langhi DM. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Anemia tolerance. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S67-S71. [PMID: 38604928 PMCID: PMC11069063 DOI: 10.1016/j.htct.2024.02.018] [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: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/13/2024] Open
Abstract
Anemia is a pathological condition in which the hemoglobin and red blood cell mass decrease; it is mainly defined by the concentration of hemoglobin in the blood. The World Health Organization guidelines establish specific values to define anemia in different population groups. Early detection of anemia can also be a valuable indicator of underlying medical conditions. Clinical studies have explored the relationship between perioperative anemia and morbidity, highlighting the need for more judicious therapeutic strategies, such as the use of Patient Blood Management, which aims to prevent and treat anemia in a personalized and effective way. Patient Blood Management emerges as a promising approach to dealing with anemia, recognizing that its correction through transfusion always carries risks and that personalized prevention and treatment can offer better outcomes for patients.
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Affiliation(s)
- Gil Cunha De Santis
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Lorena Costa
- Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Denise Menezes Brunetta
- Faculdade de Medicina da Universidade Federal do Ceará (FM UFC), Fortaleza, CE, Brazil; Centro de Hematologia e Hemoterapia do Ceará (HEMOCE), Fortaleza, CE, Brazil; Complexo Hospitalar da Universidade Federal do Ceará (EBSERH UFC), Fortaleza, CE, Brazil
| | - Mariana Munari Magnus
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro UNICAMP), Campinas, SP, Brazil
| | - Bruno Deltreggia Benites
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro UNICAMP), Campinas, SP, Brazil
| | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
| | - Dante Mario Langhi
- Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM UNIFESP), São Paulo, SP, Brazil
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10
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Pagano MB, Stanworth SJ, Valentine S, Metcalf R, Wood EM, Pavenski K, Cholette J, So-Osman C, Carson JL. The 2023 AABB international guidelines for red blood cell transfusions: What is new? Transfusion 2024; 64:727-732. [PMID: 38380850 DOI: 10.1111/trf.17764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Affiliation(s)
- Monica B Pagano
- Transfusion Medicine, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust; NHSBT, Oxford, UK
- Radcliffe Department of Medicine, Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ryan Metcalf
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Erica M Wood
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- International Society of Blood Transfusion, Amsterdam, Netherlands
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- International Collaboration for Transfusion Medicine Guidelines, British Columbia, Canada
| | - Jill Cholette
- Department of Pediatrics, University of Rochester, Golisano Children's Hospital, Rochester, New York, USA
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
- European Haematology Association, Transfusion-Specialized Working Group
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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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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12
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Zhu J, Dong Y, Liao P, Yin X, He J, Guo L. Prognostic value of hemoglobin in patients with sepsis: A systematic review and meta-analysis. Heart Lung 2024; 64:93-99. [PMID: 38070279 DOI: 10.1016/j.hrtlng.2023.12.001] [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: 07/23/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 03/18/2024]
Abstract
BACKGROUND Sepsis patients have a high mortality rate and are frequently anemic. The importance of early detection and blood transfusion treatment cannot be overstated. OBJECTIVE A systematic review and meta-analysis of published literature was conducted to evaluate the association between hemoglobin and the prognosis of patients with sepsis. METHODS The PubMed, Embase, Cochrane Library and Chinese Biomedical Literature (CBM) databases were searched from inception to May 21, 2023. Pediatric patients were excluded, and there were no language restrictions. A random effects model was used to calculate pooled odds ratios to assess the relationship between hemoglobin and prognosis in sepsis. RESULTS There were 110,004 patients included in 9 studies, of which 51,568 had a poor prognosis. The results of univariate and multivariate analyzes showed that hemoglobin was associated with the prognosis of patients with sepsis (univariate OR: 1.35, 95 % confidence interval (CI): 1.16-1.58; multivariate OR: 1.26, 95 % CI: 1.13-1.40). Dose-response meta-analysis showed that there was a nonlinear relationship between hemoglobin level and prognosis in patients with sepsis. CONCLUSION The level of hemoglobin at admission is related to the prognosis of patients with sepsis, and decreases in hemoglobin level are associated with an increase in the mortality rate of patients with sepsis. Therefore, early transfusion of red blood cells should be performed in patients with sepsis, and early attention should be given to anemia in patients with sepsis. However, more robust studies are needed to further determine the level of early hemoglobin maintenance in patients with sepsis.
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Affiliation(s)
- Jin Zhu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Yanyan Dong
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Pengda Liao
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, China
| | - Xin Yin
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, China
| | - Jianzhuo He
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, China
| | - Liheng Guo
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, China.
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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [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: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Kosaki Y, Hongo T, Hayakawa M, Kudo D, Kushimoto S, Tagami T, Naito H, Nakao A, Yumoto T. Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial. World J Emerg Surg 2024; 19:1. [PMID: 38167057 PMCID: PMC10763143 DOI: 10.1186/s13017-023-00530-7] [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: 12/04/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels. METHODS We performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups. RESULTS Of the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (β coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (β coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury. CONCLUSIONS Our results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.
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Affiliation(s)
- Yoshinori Kosaki
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, 1-396 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
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15
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Ho I, Kuo M, Hsu P, Lee I, Hsu T, Lin Y, Huang C. The impacts of anemia burden on clinical outcomes in patients with out-of-hospital cardiac arrest. Clin Cardiol 2024; 47:e24175. [PMID: 37872851 PMCID: PMC10777437 DOI: 10.1002/clc.24175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) has low survival rates, and few patients achieve a desirable neurological outcome. Anemia is common among OHCA patients and has been linked to worse outcomes, but its impact following the return of spontaneous circulation (ROSC) is unclear. This study examines the relationship between anemia burden and clinical outcomes in OHCA patients. HYPOTHESIS Higher anemia burden after ROSC may be related to higher mortality and worse neurologic outcomes. METHODS Patients who experienced OHCA and had ROSC were enrolled retrospectively. Anemia burden was defined as the area under curve from the target hemoglobin level over a 72-h period after OHCA. Hemoglobin level was measured at 12-h intervals. The clinical outcomes of the study included mortality and neurological outcomes at Day 30. RESULTS The study enrolled 258 nontraumatic OHCA patients who achieved ROSC between January 2017 and December 2021. Among the 162 patients who survived more than 72 h, a higher anemia burden, specifically target hemoglobin levels below 7 (hazard ratio [HR]: 1.129, 95% confidence interval [CI]: 1.013-1.259, p = .029), 8 (HR: 1.099, 95% CI: 1.014-1.191, p = .021), and 9 g/dL (HR: 1.066, 95% CI: 1.001-1.134, p = .046) was associated with higher 30-day mortality. Additionally, anemia burden with target hemoglobin levels below 7 (HR: 1.129, 95% CI: 1.016-1.248; p = .024) and 8 g/dL (HR: 1.088; 95% CI: 1.008-1.174, p = .031) was linked to worse neurological outcomes. CONCLUSIONS Anemia burden predicts 30-day mortality and neurological outcomes in OHCA patients who survive more than 72 h. Maintaining higher hemoglobin levels within the first 72 h after ROSC may improve short-term outcomes.
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Affiliation(s)
- I‐Wei Ho
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Ming‐Jen Kuo
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Pai‐Feng Hsu
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Healthcare and Services CenterTaipei Veterans General HospitalTaipeiTaiwan
| | - I‐Hsin Lee
- Department of EmergencyTaipei Veterans General HospitalTaipeiTaiwan
| | - Teh‐Fu Hsu
- Department of EmergencyTaipei Veterans General HospitalTaipeiTaiwan
| | - Yenn‐Jiang Lin
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Heart Rhythm CenterTaipei Veterans General HospitalTaipeiTaiwan
| | - Chin‐Chou Huang
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Pharmacology, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
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16
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Ruan X, Wang B, Gao Y, Wu J, Yu X, Liang C, Pan J. Assessing the impact of transfusion thresholds in patients with septic acute kidney injury: a retrospective study. Front Med (Lausanne) 2023; 10:1308275. [PMID: 38193037 PMCID: PMC10772139 DOI: 10.3389/fmed.2023.1308275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/05/2023] [Indexed: 01/10/2024] Open
Abstract
Background Sepsis is a severe condition that often leads to complications such as acute kidney injury, which significantly increases morbidity and mortality rates. Septic AKI (S-AKI) is common in ICU patients and is associated with poor outcomes. However, there is no consensus on the optimal transfusion threshold for achieving the best clinical results. This retrospective study aims to investigate the relationship between different transfusion thresholds during hospitalization and the prognosis of septic AKI. Methods Data from patients with S-AKI was extracted from MIMIC-IV. Based on the lowest hemoglobin level 24 h before transfusion, patients were divided into high-threshold (≥7 g/L) and low-threshold (<7 g/L) groups. We compared the outcomes between these two groups, including hospital and ICU mortality rates as primary outcomes, and 30 days, 60 days, and 90 days mortality rates, as well as duration of stay in ICU and hospital as secondary outcomes. Results A total of 5,654 patients were included in our study. Baseline characteristics differed significantly between the two groups, with patients in the low-threshold group generally being younger and having higher SOFA scores. After performing propensity score matching, no significant differences in survival rates were found between the groups. However, patients in the low-threshold group had a longer overall hospital stay. Conclusion A lower transfusion threshold does not impact the mortality rate in S-AKI patients, but it may lead to a longer hospital stay.
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Affiliation(s)
- Xiangyuan Ruan
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Baoxin Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yifan Gao
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jinmei Wu
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xueshu Yu
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chenglong Liang
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jingye Pan
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, China
- Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, China
- Zhejiang Engineering Research Center for Hospital Emergency and Process Digitization, Wenzhou, China
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17
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Liao R, Liu J, Zhang W, Zheng H, Zhu Z, Sun H, Yu Z, Jia H, Sun Y, Qin L, Yu W, Luo Z, Chen Y, Zhang K, Ma L, Yang H, Wu H, Liu L, Yuan F, Xu H, Zhang J, Zhang L, Liu D, Huang H. Individualized red-cell transfusion strategy for non-cardiac surgery in adults: a randomized controlled trial. Chin Med J (Engl) 2023; 136:2857-2866. [PMID: 37052133 PMCID: PMC10686592 DOI: 10.1097/cm9.0000000000002584] [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: 12/12/2022] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Red-cell transfusion is critical for surgery during the peri-operative period; however, the transfusion threshold remains controversial mainly owing to the diversity among patients. The patient's medical status should be evaluated before making a transfusion decision. Herein, we developed an individualized transfusion strategy using the West-China-Liu's Score based on the physiology of oxygen delivery/consumption balance and designed an open-label, multicenter, randomized clinical trial to verify whether it reduced red cell requirement as compared with that associated with restrictive and liberal strategies safely and effectively, providing valid evidence for peri-operative transfusion. METHODS Patients aged >14 years undergoing elective non-cardiac surgery with estimated blood loss > 1000 mL or 20% blood volume and hemoglobin concentration <10 g/dL were randomly assigned to an individualized strategy, a restrictive strategy following China's guideline or a liberal strategy with a transfusion threshold of hemoglobin concentration <9.5 g/dL. We evaluated two primary outcomes: the proportion of patients who received red blood cells (superiority test) and a composite of in-hospital complications and all-cause mortality by day 30 (non-inferiority test). RESULTS We enrolled 1182 patients: 379, 419, and 384 received individualized, restrictive, and liberal strategies, respectively. Approximately 30.6% (116/379) of patients in the individualized strategy received a red-cell transfusion, less than 62.5% (262/419) in the restrictive strategy (absolute risk difference, 31.92%; 97.5% confidence interval [CI]: 24.42-39.42%; odds ratio, 3.78%; 97.5% CI: 2.70-5.30%; P <0.001), and 89.8% (345/384) in the liberal strategy (absolute risk difference, 59.24%; 97.5% CI: 52.91-65.57%; odds ratio, 20.06; 97.5% CI: 12.74-31.57; P <0.001). No statistically significant differences were found in the composite of in-hospital complications and mortality by day 30 among the three strategies. CONCLUSION The individualized red-cell transfusion strategy using the West-China-Liu's Score reduced red-cell transfusion without increasing in-hospital complications and mortality by day 30 when compared with restrictive and liberal strategies in elective non-cardiac surgeries. TRIAL REGISTRATION ClinicalTrials.gov, NCT01597232.
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Affiliation(s)
- Ren Liao
- Department of Anesthesiology, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Jin Liu
- Department of Anesthesiology, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Hong Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University,Urumqi, Xinjiang 830054, China
| | - Zhaoqiong Zhu
- Department of Anesthesiology, The Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, China
| | - Haorui Sun
- Department of Anesthesiology, Beijing Friendship Hospital of Capital Medical University, Beijing 100069, China
| | - Zhangsheng Yu
- Department of Bioinformatics and Biostatistics, School of Life Science and Biotechnology, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Huiqun Jia
- Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiangzhuang, Hebei 050019, China
| | - Yanyuan Sun
- Department of Anesthesiology, Xijing Hospital of the Fourth Military Medical University, Xi’an, Shaanxi 710032, China
| | - Li Qin
- Department of Transfusion, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Wenli Yu
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin 300192, China
| | - Zhen Luo
- Department of Anesthesiology, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Yanqing Chen
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian 350001, China
| | - Kexian Zhang
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Chengdu, Sichuan 610041, China
| | - Lulu Ma
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100032, China
| | - Hui Yang
- Department of Anesthesiology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Hong Wu
- Department of Hepato-Bilio-Pancreatic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Limin Liu
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Fang Yuan
- Department of Anesthesiology, General Hospital Affiliated to Tianjin Medical University, Tianjin 300052, China
| | - Hongwei Xu
- Department of Anesthesiology, Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianwen Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Lei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University,Urumqi, Xinjiang 830054, China
| | - Dexing Liu
- Department of Anesthesiology, The Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, China
| | - Han Huang
- Department of Anesthesiology and Translational Neuroscience Center, West China Second University Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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Braaten JA, Dillon BS, Wothe JK, Olson CP, Lusczek ER, Sather KJ, Beilman GJ, Brunsvold ME. Extracorporeal Membrane Oxygenation Patient Outcomes Following Restrictive Blood Transfusion Protocol. Crit Care Explor 2023; 5:e1020. [PMID: 38107536 PMCID: PMC10723844 DOI: 10.1097/cce.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES To investigate the effect of a restrictive blood product utilization protocol on blood product utilization and clinical outcomes. DESIGN We retrospectively reviewed all adult extracorporeal membrane oxygenation (ECMO) patients from January 2019 to December 2021. The restrictive protocol, implemented in March 2020, was defined as transfusion of blood products for a hemoglobin level less than 7, platelet levels less than 50, and/or fibrinogen levels less than 100. Subgroup analysis was performed based on the mode of ECMO received: venoarterial ECMO, venovenous ECMO, and ECMO support following extracorporeal cardiopulmonary resuscitation (ECPR). SETTING M Health Fairview University of Minnesota Medical Center. PATIENTS The study included 507 patients. INTERVENTIONS One hundred fifty-one patients (29.9%) were placed on venoarterial ECMO, 70 (13.8%) on venovenous ECMO, and 286 (56.4%) on ECPR. MEASUREMENTS AND MAIN RESULTS For patients on venoarterial ECMO (48 [71.6%] vs. 52 [63.4%]; p = 0.374), venovenous ECMO (23 [63.9%] vs. 15 [45.5%]; p = 0.195), and ECPR (54 [50.0%] vs. 69 [39.2%]; p = 0.097), there were no significant differences in survival on ECMO. The last recorded mean hemoglobin value was also significantly decreased for venoarterial ECMO (8.10 [7.80-8.50] vs. 7.50 [7.15-8.25]; p = 0.001) and ECPR (8.20 [7.90-8.60] vs. 7.55 [7.10-8.88]; p < 0.001) following implementation of the restrictive transfusion protocol. CONCLUSIONS These data suggest that a restrictive transfusion protocol is noninferior to ECMO patient survival. Additional, prospective randomized trials are required for further investigation of the safety of a restrictive transfusion protocol.
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Flint AW, Brady K, Wood EM, Thao LTP, Hammond N, Knowles S, Nangla C, Reade MC, McQuilten ZK. Transfusion practices in intensive care units: An Australian and New Zealand point prevalence study. CRIT CARE RESUSC 2023; 25:193-200. [PMID: 38234319 PMCID: PMC10790088 DOI: 10.1016/j.ccrj.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
Objective To describe current transfusion practices in intensive care units (ICUs) in Australia and New Zealand, compare them against national guidelines, and describe how viscoelastic haemostatic assays (VHAs) are used in guiding transfusion decisions. Design setting and participants Prospective, multicentre, binational point-prevalence study. All adult patients admitted to participating ICUs on a single day in 2021. Main outcome measures Transfusion types, amounts, clinical reasons, and triggers; use of anti-platelet medications, anti-coagulation, and VHA. Results Of 712 adult patients in 51 ICUs, 71 (10%) patients received a transfusion during the 24hr period of observation. Compared to patients not transfused, these patients had higher Acute Physiology and Chronic Health Evaluation II scores (19 versus 17, p = 0.02), a greater proportion were mechanically ventilated (49.3% versus 37.3%, p < 0.05), and more had systemic inflammatory response syndrome (70.4% versus 51.3%, p < 0.01). Overall, 63 (8.8%) patients received red blood cell (RBC) transfusions, 10 (1.4%) patients received platelet transfusions, 6 (0.8%) patients received fresh frozen plasma (FFP), and 5 (0.7%) patients received cryoprecipitate. VHA was available in 42 (82.4%) sites but only used in 6.6% of transfusion episodes when available. Alignment with guidelines was found for 98.6% of RBC transfusions, but only 61.6% for platelet, 28.6% for FFP, and 20% for cryoprecipitate transfusions. Conclusions Non-RBC transfusion decisions are often not aligned with guidelines and VHA is commonly available but rarely used to guide transfusions. Better evidence to guide transfusions in ICUs is needed.
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Affiliation(s)
- Andrew W.J. Flint
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Royal Australian Navy, Australia
- Intensive Care Unit, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Karina Brady
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Health, Clayton, Victoria, Australia
| | - Le Thi Phuong Thao
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Naomi Hammond
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Newtown, NSW, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Serena Knowles
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Newtown, NSW, Australia
| | - Conrad Nangla
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Newtown, NSW, Australia
| | - Michael C. Reade
- The Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care Unit, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Joint Health Command, Australian Defence Force, Canberra, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Zoe K. McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Health, Clayton, Victoria, Australia
| | - The George Institute for Global Health, the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Blood Synergy Program
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Royal Australian Navy, Australia
- Intensive Care Unit, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Monash Health, Clayton, Victoria, Australia
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Newtown, NSW, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
- Joint Health Command, Australian Defence Force, Canberra, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
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20
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Raasveld SJ, de Bruin S, Reuland MC, van den Oord C, Schenk J, Aubron C, Bakker J, Cecconi M, Feldheiser A, Meier J, Müller MCA, Scheeren TWL, McQuilten Z, Flint A, Hamid T, Piagnerelli M, Tomić Mahečić T, Benes J, Russell L, Aguirre-Bermeo H, Triantafyllopoulou K, Chantziara V, Gurjar M, Myatra SN, Pota V, Elhadi M, Gawda R, Mourisco M, Lance M, Neskovic V, Podbregar M, Llau JV, Quintana-Diaz M, Cronhjort M, Pfortmueller CA, Yapici N, Nielsen ND, Shah A, de Grooth HJ, Vlaar APJ. Red Blood Cell Transfusion in the Intensive Care Unit. JAMA 2023; 330:1852-1861. [PMID: 37824112 PMCID: PMC10570913 DOI: 10.1001/jama.2023.20737] [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: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
Importance Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice. Objective To evaluate and describe ICU RBC transfusion practices worldwide. Design, Setting, and Participants International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks. Exposure ICU stay. Main Outcomes and Measures The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused. Results Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL. Conclusions and Relevance RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sanne de Bruin
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Merijn C. Reuland
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Claudia van den Oord
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Amsterdam Public Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Cécile Aubron
- Médecine Intensive Réanimation, CHU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Jan Bakker
- Department of Pulmonary and Critical Care, New York University and Columbia University New York
- Department of Intensive Care Adults, Erasmus MC University Medical Centers, Rotterdam, the Netherlands
- Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maurizio Cecconi
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Aarne Feldheiser
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, EvangKliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, Essen, Germany
| | - Jens Meier
- Department of Anesthesiology and Intensive Care, Kepler University Clinic, Kepler University, Linz, Austria
| | - Marcella C. A. Müller
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Thomas W. L. Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Zoe McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Flint
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tarikul Hamid
- Department of Critical Care, Asgar Ali Hospital, Dhaka, Bangladesh
| | - Michaël Piagnerelli
- Department of Intensive Care, CHU Charleroi Marie Curie, Université Libre de Brussels, Charleroi, Belgium
| | - Tina Tomić Mahečić
- Department of Anesthesiology and Intensive Care, University Clinical Hospital Center Zagreb, Croatia
| | - Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital and Faculty of Medicine in Plzen–Charles University, Plzen, Czech Republic
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care Medicine, Copenhagen University Hospital–Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Vasiliki Chantziara
- Intensive Care Unit, First Department of Respiratory Medicine, National and Kapodistrian University of Athens, Sotiria Chest Hospital, Athens, Greece
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vincenzo Pota
- Department of Child, General and Specialistic Surgery, University of Campania, Luigi Vanvitelli, Naples, Italy
| | | | - Ryszard Gawda
- Department of Anesthesiology and Intensive Care, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Mafalda Mourisco
- Department of Intensive Care, Centro Hospitalar de Entro o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Marcus Lance
- Department of Anesthesiology, Aga Khan University Hospital, Nairobi, Kenya
| | - Vojislava Neskovic
- Department of Anesthesia and Intensive Care, Military Medical Academy Belgrade, Belgrade, Serbia
| | - Matej Podbregar
- Department for Internal Intensive Care, General Hospital Celje, Medical Faculty, University of Ljubljana, Slovenia
| | - Juan V. Llau
- Department of Anesthesiology and Post-surgical Critical Care, University Hospital Doctor Peset, Valencia, Spain
| | | | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Carmen A. Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nihan Yapici
- Department of Anesthesiology and Reanimation, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, University of Health Sciences, Istanbul, Turkey
| | - Nathan D. Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, and Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque
| | - Akshay Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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21
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Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, Cohn CS, Dubon A, Grossman BJ, Gupta GK, Hess AS, Jacobson JL, Kaplan LJ, Lin Y, Metcalf RA, Murphy CH, Pavenski K, Prochaska MT, Raval JS, Salazar E, Saifee NH, Tobian AAR, So-Osman C, Waters J, Wood EM, Zantek ND, Pagano MB. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA 2023; 330:1892-1902. [PMID: 37824153 DOI: 10.1001/jama.2023.12914] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Importance Red blood cell transfusion is a common medical intervention with benefits and harms. Objective To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.
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Affiliation(s)
- Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- NHSBT, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, United Kingdom
| | - Gordon Guyatt
- Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester
| | - Jane Dennis
- Cochrane Injuries Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California, San Francisco
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | | | - Brenda J Grossman
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Gaurav K Gupta
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron S Hess
- Departments of Anesthesiology and Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison
| | - Jessica L Jacobson
- Department of Pathology, New York University Grossman School of Medicine, New York
- NYC Health + Hospitals/Bellevue, New York, New York
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care and Surgical Emergencies, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City
| | - Colin H Murphy
- Pathology Associates of Albuquerque, Albuquerque, New Mexico
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque
| | - Eric Salazar
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan Waters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erica M Wood
- Department of Haematology, Monash Health, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
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22
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Yang P, Yuan J, Yu L, Yu J, Zhang Y, Yuan Z, Chen L, Zhang X, Tang X, Chen Q. Clinical significance of hemoglobin level and blood transfusion therapy in elderly sepsis patients: A retrospective analysis. Am J Emerg Med 2023; 73:27-33. [PMID: 37579529 DOI: 10.1016/j.ajem.2023.08.005] [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: 02/06/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023] Open
Abstract
INTRODUCTION The clinical significance of hemoglobin level and blood transfusion therapy in elderly sepsis patients remains controversial. The study investigated the relationship between mortality, hemoglobin levels, and blood transfusion in elderly sepsis patients. METHODS Elderly sepsis patients were included in the Marketplace for Medical Information in Intensive Care (MIMIC-IV) database. A multivariate regression model analyzed the relationship between the Hb level and the 28-day mortality risk. Logistic Multivariate analysis, Propensity Matching (PSM) analysis, an Inverse Probabilities Weighting (IPW) model and doubly robust estimation were applied to analyze the 28-day mortality risk between transfused and non-transfused patients in Hb at 7-8 g/dL, 8-9 g/dL, 9-10 g/dL, and 10-11 g/dL groups. RESULTS 7473 elderly sepsis patients were enrolled in the study. The Hb level in the ICU and the 28-day mortality risk of patients with sepsis shared a non-linear relationship. The patients with Hb levels of <10 g/dL(p < 0.05) and > 15 g/dL(p < 0.05) within 24 h had a high mortality risk in multivariate analysis. In the Hb level 7-8 g/dL and 8-9 g/dL subgroup, the Multivariate analysis (p < 0.05), PSM (p < 0.05), IPW (p < 0.05) and doubly robust estimation (p < 0.05) suggested that blood transfusion could reduce the mortality risk. In the subgroup with a Hb level of 10-11 g/dL, IPW (p < 0.05) and doubly robust estimation (p < 0.05) suggested that blood transfusion could increase the mortality risk of elderly sepsis patients. CONCLUSION A non-linear relationship between the Hb level and the 28-day mortality risk and Hb levels of <10 g/dL and > 15 g/dL may increase the mortality risk, and blood transfusion with a Hb level of <9 g/dL may minimize mortality risk in elderly sepsis patients.
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Affiliation(s)
- Penglei Yang
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Jun Yuan
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Lina Yu
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Jiangquan Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou 225009, Jiangsu Province, China
| | - Ying Zhang
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Zhou Yuan
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Lianxin Chen
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Xiaoli Zhang
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Xun Tang
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China
| | - Qihong Chen
- Department of Critical Care Medicine, Jiangdu People's Hospital Affiliated to Yangzhou University, Yangzhou 225200, China.
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23
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DeCarlo C, Mohebali J, Dua A, Conrad MF, Mohapatra A. Preoperative Anemia Is Associated With Postoperative Renal Failure After Elective Open Aortic Repair. J Surg Res 2023; 291:187-194. [PMID: 37442045 DOI: 10.1016/j.jss.2023.05.033] [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: 07/06/2022] [Revised: 03/23/2023] [Accepted: 05/15/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Preoperative anemia has been consistently shown to be a risk factor for acute kidney injury (AKI) after cardiac surgery. However, this association has not been examined in the open abdominal aortic aneurysm repair (OAR) population and is the subject of this analysis. METHODS Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried for patients undergoing OAR from 2013 to 2019. Anemia was defined according to World Health Organization Guidelines: Hematocrit<36% for women or <39% for men. Primary endpoint was 30-day AKI. Anemia's effect on AKI was determined using inverse probability weighted logistic regression. RESULTS There were 2275 OAR; mean age was 70.9 ± 8.2 y; 24.0% were women. Anemia was present in 498 (26.3%) patients; 165 (7.6%) had a hematocrit<33% and 8 (0.35%) had a hematocrit<24%. Differences in patient factor were nonsignificant after weighting. Any degree of postoperative AKI was more common in the anemia group (11.2% vs 5.1%; unweighted P < 0.001), as was AKI requiring hemodialysis (7.7% vs 3.2%; unweighted P < 0.001). In the weighted multivariable analysis, anemia was independently associated with postoperative AKI (odds ratio 1.51; 95% confidence interval: 1.01-2.26; P = 0.042) while controlling for age and operative factors. Patients with postoperative AKI were significantly more likely to die postoperatively than those without (26.1% vs 1.9%; <0.001). CONCLUSIONS Preoperative anemia was independently associated with post-OAR AKI after propensity weighting and controlling for operative factors. AKI is a major source of morbidity and mortality in these patients, and, if time permits, preoperative correction of anemia or its underlying cause should be considered in high-risk patients.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark F Conrad
- Division of Vascular Surgery, St Elizabeth's Hospital, Brighton, Massachusetts
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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24
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Shudo Y, Cheng N, He H, Rosenberg C, Hiesinger W, Hadhazy E, Shepard J, Krishna P, Resnik J, Fong R, Hill C, Hsu JL, Maggio PM, Chang SI, Boyd JH, Woo YJ. A value-based approach to optimize red blood cell transfusion in patients receiving extracorporeal membrane oxygenation. Perfusion 2023; 38:1682-1687. [PMID: 36148806 DOI: 10.1177/02676591221128138] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The risk, cost, and adverse outcomes associated with packed red blood cell (RBC) transfusions in patients with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) have raised concerns regarding the overutilization of RBC products. It is, therefore, necessary to establish optimal transfusion criteria and protocols for patients supported with ECMO. The goal of this study was to establish specific criteria for RBC transfusions in patients undergoing ECMO. METHODS This was a retrospective cohort study conducted at Stanford University Hospital. Data on RBC utilization during the entire hospital stay were obtained, which included patients aged ≥18 years who received ECMO support between 1 January 2017, and 30 June 2020 (n = 281). The primary outcome was in-hospital mortality. RESULTS Hemoglobin (HGB) levels >10 g/dL before transfusion did not improve in-hospital survival. Therefore, we revised the HGB threshold to ≤10 g/dL to guide transfusion in patients undergoing ECMO. To validate this intervention, we prospectively compared the pre- and post-intervention cohorts for in-hospital mortality. Post-intervention analyses found 100% compliance for all eligible records and a decrease in the requirement for RBC transfusion by 1.2 units per patient without affecting the mortality. CONCLUSIONS As an institution-driven value-based approach to guide transfusion in patients undergoing ECMO, we lowered the threshold HGB level. Validation of this revised intervention demonstrated excellent compliance and reduced the need for RBC transfusion while maintaining the clinical outcome. Our findings can help reform value-based healthcare in this cohort while maintaining the outcome.
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Affiliation(s)
- Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Nathalie Cheng
- Quality Patient Safety & Clinical Effectiveness, Stanford Health Care, Stanford, CA, USA
| | - Hao He
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Corinne Rosenberg
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Eric Hadhazy
- Quality Patient Safety & Clinical Effectiveness, Stanford Health Care, Stanford, CA, USA
| | - John Shepard
- Quality Patient Safety & Clinical Effectiveness, Stanford Health Care, Stanford, CA, USA
| | - Purnima Krishna
- Quality Patient Safety & Clinical Effectiveness, Stanford Health Care, Stanford, CA, USA
| | - Josh Resnik
- Perfusion Services, Stanford Health Care, Stanford, CA, USA
| | - Robyn Fong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles Hill
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joe L Hsu
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul M Maggio
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Sang-Ick Chang
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jack H Boyd
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Fasano RM, Doctor A, Stowell SR, Spinella PC, Carson JL, Maier CL, Josephson CD, Triulzi DJ. Optimizing RBC Transfusion Outcomes in Patients with Acute Illness and in the Chronic Transfusion Setting. Transfus Med Rev 2023; 37:150758. [PMID: 37743191 DOI: 10.1016/j.tmrv.2023.150758] [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: 06/14/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023]
Abstract
Red blood cell (RBC) transfusion is a common clinical intervention used to treat patients with acute and chronic anemia. The decision to transfuse RBCs in the acute setting is based on several factors but current clinical studies informing optimal RBC transfusion decision making (TDM) are largely based upon hemoglobin (Hb) level. In contrast to transfusion in acute settings, chronic RBC transfusion therapy has several different purposes and is associated with distinct transfusion risks such as iron overload and RBC alloimmunization. Consequently, RBC TDM in the chronic setting requires optimizing the survival of transfused RBCs in order to reduce transfusion exposure over the lifespan of an individual and the associated transfusion complications mentioned. This review summarizes the current medical literature addressing optimal RBC-TDM in the acute and chronic transfusion settings and discusses the current gaps in knowledge which need to be prioritized in future national and international research initiatives.
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Affiliation(s)
- Ross M Fasano
- Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA.
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine and Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sean R Stowell
- Joint Program in Transfusion Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip C Spinella
- Departments of Surgery and Critical Care Medicine, Pittsburgh University, Pittsburgh, PA, USA
| | - Jeffrey L Carson
- Division of General Internal Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Cheryl L Maier
- Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Cassandra D Josephson
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Darrell J Triulzi
- Vitalant and Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
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Raasveld SJ, Karami M, Schenk J, Dos Reis Miranda D, Mandigers L, Dauwe DF, De Troy E, Pappalardo F, Fominskiy E, van den Bergh WM, Oude Lansink-Hartgring A, van der Velde F, Maas JJ, van de Berg P, de Haan M, Donker DW, Meuwese CL, Taccone FS, Peluso L, Lorusso R, Delnoij TSR, Scholten E, Overmars M, Ivančan V, Bojčić R, de Metz J, van den Bogaard B, de Bakker M, Reddi B, Hermans G, Broman LM, Henriques JPS, Vlaar APJ. Transfusion of red blood cells in venoarterial extracorporeal membrane oxygenation: A multicenter retrospective observational cohort study. Transfusion 2023; 63:1809-1820. [PMID: 37668074 DOI: 10.1111/trf.17505] [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: 03/15/2023] [Revised: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Evidence-based recommendations for transfusion in patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) are scarce. The current literature is limited to single-center studies with small sample sizes, therefore complicating generalizability. This study aims to create an overview of red blood cell (RBC) transfusion in VA ECMO patients. METHODS This international mixed-method study combined a survey with a retrospective observational study in 16 centers. The survey inventoried local transfusion guidelines. Additionally, retrospective data of all adult patients with a VA ECMO run >24 h (January 2018 until July 2019) was collected of patient, ECMO, outcome, and daily transfusion parameters. All patients that received VA ECMO for primary cardiac support were included, including surgical (i.e., post-cardiotomy) and non-surgical (i.e., myocardial infarction) indications. The primary outcome was the number of RBC transfusions per day and in total. Univariable logistic regressions and a generalized linear mixed model (GLMM) were performed to assess factors associated with RBC transfusion. RESULTS Out of 419 patients, 374 (89%) received one or more RBC transfusions. During a median ECMO run of 5 days (1st-3rd quartile 3-8), patients received a median total of eight RBC units (1st-3rd quartile 3-17). A lower hemoglobin (Hb) prior to ECMO, longer ECMO-run duration, and hemorrhage were associated with RBC transfusion. After correcting for duration and hemorrhage using a GLMM, a different transfusion trend was found among the regimens. No unadjusted differences were found in overall survival between either transfusion status or the different regimens, which remained after adjustment for potential confounders. CONCLUSION RBC transfusion in patients on VA ECMO is very common. The sum of RBC transfusions increases rapidly after ECMO initiation, and is dependent on the Hb threshold applied. This study supports the rationale for prospective studies focusing on indications and thresholds for RBC transfusion.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, the Netherlands
| | - Mina Karami
- Department of Cardiology, Amsterdam University Medical Centers, Location Academic Medical Centers, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Location AMC, Amsterdam Public Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Loes Mandigers
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dieter F Dauwe
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Erwin De Troy
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Allesandria, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Pablo van de Berg
- Adult Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Maarten de Haan
- Department of Extracorporeal Circulation, Catharina hospital Eindhoven, Eindhoven, the Netherlands
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Christiaan L Meuwese
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Roberto Lorusso
- Cardiothoracic surgery, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Martijn Overmars
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Višnja Ivančan
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Robert Bojčić
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | | | - Martin de Bakker
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Benjamin Reddi
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska, University Hospital, Stockholm, Sweden
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, Location Academic Medical Centers, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, the Netherlands
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Chander S, Kumari R, Sadarat F, Luhana S. The Evolution and Future of Intensive Care Management in the Era of Telecritical Care and Artificial Intelligence. Curr Probl Cardiol 2023; 48:101805. [PMID: 37209793 DOI: 10.1016/j.cpcardiol.2023.101805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
Critical care practice has been embodied in the healthcare system since the institutionalization of intensive care units (ICUs) in the late '50s. Over time, this sector has experienced many changes and improvements in providing immediate and dedicated healthcare as patients requiring intensive care are often frail and critically ill with high mortality and morbidity rates. These changes were aided by innovations in diagnostic, therapeutic, and monitoring technologies, as well as the implementation of evidence-based guidelines and organizational structures within the ICU. In this review, we examine these changes in intensive care management over the past 40 years and their impact on the quality of care available to patients. Moreover, the current state of intensive care management is characterized by a multidisciplinary approach and the use of innovative technologies and research databases. Advancements such as telecritical care and artificial intelligence are being increasingly explored, especially since the COVID-19 pandemic, to reduce the length of hospitalization and ICU mortality. With these advancements in intensive care and ever-changing patient needs, critical care experts, hospital managers, and policymakers must also explore appropriate organizational structures and future enhancements within the ICU.
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Affiliation(s)
- Subhash Chander
- Department of Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY.
| | - Roopa Kumari
- Department of Internal Medicine, Mount Sinai Morningside and West, New York, NY
| | - Fnu Sadarat
- Department of Internal Medicine, University of Buffalo, NY, USA
| | - Sindhu Luhana
- Department of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan
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Litton E. Treating intensive care anaemia to improve patient outcomes. Anaesthesia 2023; 78:1203-1205. [PMID: 37450345 DOI: 10.1111/anae.16098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Affiliation(s)
- E Litton
- School of Medicine, University of Western Australia, Crawley, WA, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
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Messmer A, Pietsch U, Siegemund M, Buehler P, Waskowski J, Müller M, Uehlinger DE, Hollinger A, Filipovic M, Berger D, Schefold JC, Pfortmueller CA. Protocolised early de-resuscitation in septic shock (REDUCE): protocol for a randomised controlled multicentre feasibility trial. BMJ Open 2023; 13:e074847. [PMID: 37734896 PMCID: PMC11148668 DOI: 10.1136/bmjopen-2023-074847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Fluid overload is associated with excess mortality in septic shock. Current approaches to reduce fluid overload include restrictive administration of fluid or active removal of accumulated fluid. However, evidence on active fluid removal is scarce. The aim of this study is to assess the efficacy and feasibility of an early de-resuscitation protocol in patients with septic shock. METHODS All patients admitted to the intensive care unit (ICU) with a septic shock are screened, and eligible patients will be randomised in a 1:1 ratio to intervention or standard of care. INTERVENTION Fluid management will be performed according to the REDUCE protocol, where resuscitation fluid will be restricted to patients showing signs of poor tissue perfusion. After the lactate has peaked, the patient is deemed stable and assessed for active de-resuscitation (signs of fluid overload). The primary objective of this study is the proportion of patients with a negative cumulative fluid balance at day 3 after ICU. Secondary objectives are cumulative fluid balances throughout the ICU stay, number of patients with fluid overload, feasibility and safety outcomes and patient-centred outcomes. The primary outcome will be assessed by a logistic regression model adjusting for the stratification variables (trial site and chronic renal failure) in the intention-to-treat population. ETHICS AND DISSEMINATION The study was approved by the respective ethical committees (No 2020-02197). The results of the REDUCE trial will be published in an international peer-reviewed medical journal regardless of the results. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT04931485.
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Affiliation(s)
- Anna Messmer
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Urs Pietsch
- Department of operative Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Philipp Buehler
- Department of Intensive Care Medicine, Cantonal Hospital Winterthu, Winterthur, Switzerland
| | - Jan Waskowski
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Dominik E Uehlinger
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Miodrag Filipovic
- Department of operative Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - David Berger
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Joerg C Schefold
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Carmen A Pfortmueller
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [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: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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Adkins BD, Murfin R, Luu HS, Noland DK. Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion. Vox Sang 2023; 118:746-752. [PMID: 37431735 DOI: 10.1111/vox.13497] [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: 05/03/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Providing red blood cell (RBC) transfusion to paediatric patients with a haemoglobin (Hb) level of <7 g/dL is the current best practice, but it is often difficult to ensure appropriateness of RBC transfusion on a health system level. Electronic health record (EHR) clinical decision support systems have been shown to be effective in encouraging providers to transfuse at appropriate Hb thresholds. We present our experience with an interruptive best practice alert (BPA) at a paediatric healthcare system. MATERIALS AND METHODS An interruptive BPA requiring physician response was implemented in our EHR (Epic Systems Corp., Verona, WI, USA) in 2018 based on Hb thresholds for inpatients. The threshold was initially <8 g/dL and later changed to <7 g/dL in 2019. We assessed total activations, number of RBC transfusions and hospital metrics through 2022 compared to the 2 years prior to implementation. RESULTS The BPA activated 6956 times over 4 years, slightly less than 5/day, and the success rate, with no RBC transfusions within 24 h of order attempt, was 14.5% (1012/6956). There was a downward trend in the number of total RBC transfusions and RBC transfusions per admission after implementation, non-significant (p = 0.41 and p = >0.99). The annual case mix index was similar over the years evaluated. The estimated cost savings based on acquisition costs for RBC units were 213,822 USD or about $51,891 per year. CONCLUSION BPA implementation led to sustained change in RBC transfusion towards best practice, and there were long-term savings in RBC expenditure.
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Roberta Murfin
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Hung S Luu
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Daniel K Noland
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
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Mladinov D, Isaza E, Gosling AF, Clark AL, Kukreja J, Brzezinski M. Perioperative Fluid Management. Anesthesiol Clin 2023; 41:613-629. [PMID: 37516498 DOI: 10.1016/j.anclin.2023.03.001] [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: 07/31/2023]
Abstract
The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the elderly are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the elderly. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, CWN-L1, Boston, MA 02115, USA
| | - Erin Isaza
- University of California, San Francisco, School of Medicine, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Andre F Gosling
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845D, Birmingham, AL 35249, USA
| | - Adrienne L Clark
- Department of Anesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Marek Brzezinski
- Department of Anesthesia and Perioperative Care, University of California, VA Medical Center-San Francisco, 4150 Clement Street, San Francisco CA 94121, USA.
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Mustahsin M, Maitra S, Anand RK, Soneja M, Madan K, Darlong V, Baidya DK. Transfusion trigger in the critically ill with sepsis or septic shock: A prospective study. Indian J Med Res 2023; 158:276-283. [PMID: 37815070 PMCID: PMC10720963 DOI: 10.4103/ijmr.ijmr_329_22] [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: 02/07/2022] [Indexed: 10/11/2023] Open
Abstract
Background & objectives Current practice around transfusion trigger in critically ill sepsis patients is not clear. Moreover, any association of haemoglobin trigger and other transfusion parameters such as age of red blood cells (RBCs) at transfusion and number of units of RBCs transfused with mortality and other adverse outcomes need further assessment. Methods In this prospective study, patients aged 18-70 yr and admitted to intensive care with a diagnosis of sepsis were included (n=108). Baseline demographic, clinical and laboratory parameters were noted and various transfusion data, i.e., haemoglobin trigger, number of units of RBCs and the age of RBCs were recorded. Following outcome data were collected: 28 and 90 day mortality, duration of mechanical ventilation, vasopressor therapy, intensive care unit (ICU) and hospital stay and requirement of renal replacement therapy. Results Of the total 108 participants, 78 (72.2%) survived till 28 days and 66 (61.1%) survived till 90 days. Transfusion trigger was 6.9 (6.7-7.1) g/dl [median (interquartile range)]. On multivariable logistic regression analysis, acute physiology and chronic health evaluation (APACHE) II [adjusted odds ratio (aOR) (95% confidence interval {CI}): 0.86 (0.78, 0.96); P=0.005], cumulative fluid balance (CFB) [aOR (95% CI): 0.99 (0.99, 0.99); P=0.005] and admission platelet count [aOR (95% CI): 1.69 (1.01, 2.84); P=0.043] were the predictors of 28 day mortality [model area under the receiver operating characteristics (AUROC) 0.81]. APACHE II [aOR (95% CI): 0.88 (0.81, 0.97); P=0.013], CFB [a OR (95% CI): 0.99977 (0.99962, 0.99993); P=0.044] and transfusion trigger [aOR (95% CI): 3 (1.07, 8.34); P=0.035] were the predictors of 90 day mortality (model AUROC: 0.82). Interpretation & conclusions In sepsis, patients admitted to the ICU, current practice suggests transfusion trigger is below 7 g/dl and it does not affect any adverse outcome including 28 day mortality.
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Affiliation(s)
- Mohd. Mustahsin
- Department of Emergency Medicine & Critical Care, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India
- Department of Anaesthesiology, Pain Medicine & Critical Care, New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, New Delhi, India
| | - Rahul Kumar Anand
- Department of Anaesthesiology, Pain Medicine & Critical Care, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vanlal Darlong
- Department of Anaesthesiology, Pain Medicine & Critical Care, New Delhi, India
| | - Dalim Kumar Baidya
- Department of Anaesthesiology, Pain Medicine & Critical Care, New Delhi, India
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Rondinelli MB, Weltert LP, Ruocco G, Ornelli M, Delle Femmine PF, De Rosa A, Pierelli L, Felici N. Patient Blood Management in Microsurgical Procedures for Reconstructive Surgery. Diagnostics (Basel) 2023; 13:2758. [PMID: 37685296 PMCID: PMC10486619 DOI: 10.3390/diagnostics13172758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 09/10/2023] Open
Abstract
Introduction: The main purpose of reconstructive surgery (RS) is to restore the integrity of soft tissues damaged by trauma, surgery, congenital deformity, burns, or infection. Microsurgical techniques consist of harvesting tissues that are separated from the vascular sources of the donor site and anastomosed to the vessels of the recipient site. In these procedures, there are some preoperative modifiable factors that have the potential to influence the outcome of the flap transfer and its anastomosis. The management of anemia, which is always present in the postoperative period and plays a decisive role in the implantation of the flap, covers significant importance, and is associated with clinical and laboratory settings of chronic inflammation. Methods: Chronic inflammatory anemia (ACD) is a constant condition in patients who have undergone RS and correlates with the perfusion of the free flap. The aim of this treatment protocol is to reduce the transfusion rate by maintaining both a good organ perfusion and correction of the patient's anemic state. From January 2017 to September 2019, we studied 16 patients (16 males, mean age 38 years) who underwent microsurgical procedures for RS. Their hemoglobin (Hb) levels, corpuscular indexes, transferrin saturation (TSAT) ferritin concentrations and creatinine clearance were measured the first day after surgery (T0), after the first week (T1), and after five weeks (T2). At T0, all the patients showed low hemoglobin levels (average 7.4 g/dL, STD 0.71 range 6.2-7.4 g dL-1), with an MCV of 72, MCH of 28, MCHC of 33, RDW of 16, serum iron of 35, ferritin of 28, Ret% of 1.36, TRF of 277, creatinine clearance of 119 and high ferritin levels (range 320-560 ng mL-1) with TSAT less than 20%. All the patients were assessed for their clinical status, medical history and comorbidities before the beginning of the therapy. Results: A collaboration between the two departments (Department of Transfusion Medicine and Department of Reconstructive Surgery) resulted in the application of a therapeutic protocol with erythropoietic stimulating agents (ESAs) (Binocrit 6000 UI/week) and intravenous iron every other day, starting the second day after surgery. Thirteen patients received ESAs and FCM (ferric carboxymaltose, 500-1000 mg per session), three patients received ESAs and iron gluconate (one vial every other day). No patients received blood transfusions. No side effects were observed, and most importantly, no limb or flap rejection occurred. Conclusions: Preliminary data from our protocol show an optimal therapeutic response, notwithstanding the very limited scientific literature and data available in this specific surgical field. The enrollment of further patients will allow us to validate this therapeutic protocol with statistically sound data.
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Affiliation(s)
| | - Luca Paolo Weltert
- Department of Medical Statistics, Saint Camillus International University of Health and Medical Sciences (UniCamillus), 00131 Rome, Italy
| | - Giovanni Ruocco
- Department of Reconstructive Surgery, San Camillo-Forlanini Hospital, 00152 Rome, Italy (N.F.)
| | - Matteo Ornelli
- Department of Reconstructive Surgery, San Camillo-Forlanini Hospital, 00152 Rome, Italy (N.F.)
| | | | - Alessandro De Rosa
- Department of Transfusion Medicine, San Camillo-Forlanini Hospital, 00152 Rome, Italy (L.P.)
| | - Luca Pierelli
- Department of Transfusion Medicine, San Camillo-Forlanini Hospital, 00152 Rome, Italy (L.P.)
- Department of Experimental Medicine, La Sapienza University, 00161 Rome, Italy
| | - Nicola Felici
- Department of Reconstructive Surgery, San Camillo-Forlanini Hospital, 00152 Rome, Italy (N.F.)
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Hayakawa M, Tagami T, Kudo D, Ono K, Aoki M, Endo A, Yumoto T, Matsumura Y, Irino S, Sekine K, Ushio N, Ogura T, Nachi S, Irie Y, Hayakawa K, Ito Y, Okishio Y, Muronoi T, Kosaki Y, Ito K, Nakatsutsumi K, Kondo Y, Ueda T, Fukuma H, Saisaka Y, Tominaga N, Kurita T, Nakayama F, Shibata T, Kushimoto S. The Restrictive Red Blood Cell Transfusion Strategy for Critically Injured Patients (RESTRIC) trial: a cluster-randomized, crossover, non-inferiority multicenter trial of restrictive transfusion in trauma. J Intensive Care 2023; 11:34. [PMID: 37488591 PMCID: PMC10364403 DOI: 10.1186/s40560-023-00682-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. METHODS This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7-9 or 10-12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. RESULTS The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49-2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. CONCLUSIONS Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. TRIAL REGISTRATION NUMBER umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.
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Affiliation(s)
- Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan.
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kota Ono
- Ono Biostat Consulting, Tokyo, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akira Endo
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Centre, Chiba, Japan
| | - Shiho Irino
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Noritaka Ushio
- Department of Emergency and Critical Care Medicine, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takayuki Ogura
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Centre, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Sho Nachi
- Advanced Critical Care Centre, Gifu University Hospital, Gifu, Japan
| | - Yuhei Irie
- Department of Emergency and Critical Care Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Katsura Hayakawa
- Advanced Emergency and Critical Care Centre, Saitama Red Cross Hospital, Saitama, Japan
| | - Yusuke Ito
- Senri Critical Care Medical Centre, Saiseikai Senri Hospital, Suita, Japan
| | - Yuko Okishio
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tomohiro Muronoi
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Yoshinori Kosaki
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kaori Ito
- Department of Surgery, Division of Acute Care Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Keita Nakatsutsumi
- Trauma and Acute Critical Care Centre, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Taichiro Ueda
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Hiroshi Fukuma
- Senshu Trauma and Critical Care Centre, Rinku General Medical Centre, Izumisano, Japan
| | - Yuichi Saisaka
- Emergency and Critical Care Centre, Kochi Health Sciences Centre, Kochi, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takeo Kurita
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Fumihiko Nakayama
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tama, Japan
| | - Tomotaka Shibata
- Advanced Trauma, Emergency and Critical Care Centre, Oita University Hospital, Yufu, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Sekeres MA, Kim N, DeZern AE, Norsworthy KJ, Garcia JS, de Claro RA, Theoret MR, Jen EY, Ehrlich LA, Zeidan AM, Komrokji RS. Considerations for Drug Development in Myelodysplastic Syndromes. Clin Cancer Res 2023; 29:2573-2579. [PMID: 36688922 PMCID: PMC10349686 DOI: 10.1158/1078-0432.ccr-22-3348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/07/2022] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
Myelodysplastic syndromes (MDS) have historically been challenging diseases for drug development due to their biology, preclinical modeling, and the affected patient population. In April 2022, the FDA convened a panel of regulators and academic experts in MDS to discuss approaches to improve MDS drug development. The panel reviewed challenges in MDS clinical trial design and endpoints and outlined considerations for future trial design in MDS to facilitate drug development to meaningfully meet patient needs. Challenges for defining clinical benefit in patients with MDS include cumbersome response criteria, standardized transfusion thresholds, and application and validation of patient reported outcome instruments. Clinical trials should reflect the biology of disease evolution, the advanced age of patients with MDS, and how patients are treated in real-world settings to maximize the likelihood of identifying active drugs. In patients with lower-risk disease, response criteria for anemic patients should be based on baseline transfusion dependency, improvement in symptoms, and quality of life. For higher-risk patients with MDS, trials should include guidance to prevent dose reductions or delays that could limit efficacy, specify minimal durations of treatment (in the absence of toxicity or progression), and have endpoints focused on overall survival and durable responses. MDS trials should be designed from the outset to allow the practicable application of new therapies in this high-needs population, with drugs that can be administered and tolerated in community settings, and with endpoints that meaningfully improve patients' lives over existing therapies.
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Affiliation(s)
- Mikkael A. Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Nina Kim
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Kelly J. Norsworthy
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | | | - R. Angelo de Claro
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Marc R. Theoret
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, MD
| | - Emily Y. Jen
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Lori A. Ehrlich
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Cancer Center, Yale University, New Haven, CT
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Sugita S, Ishikawa M, Sakuma T, Iizuka M, Hanai S, Sakamoto A. Intraoperative serum lactate levels as a prognostic predictor of outcome for emergency abdominal surgery: a retrospective study. BMC Surg 2023; 23:162. [PMID: 37328824 DOI: 10.1186/s12893-023-02075-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND The relationship between intraoperative lactate levels and prognosis after emergency gastrointestinal surgery remains unclear. The purpose of this study was to investigate the prognostic value of intraoperative lactate levels for predicting in-hospital mortality, and to examine intraoperative hemodynamic managements. METHODS We conducted a retrospective observational study of emergency GI surgeries performed at our institution between 2011 and 2020. The study group comprised patients admitted to intensive care units postoperatively, and whose intraoperative and postoperative lactate levels were available. Intraoperative peak lactate levels (intra-LACs) were selected for analysis, and in-hospital mortality was set as the primary outcome. The prognostic value of intra-LAC was assessed using logistic regression and receiver operating characteristic (ROC) curve analysis. RESULTS Of the 551 patients included in the study, 120 died postoperatively. Intra-LAC in the group who survived and the group that died was 1.80 [interquartile range [IQR], 1.19-3.01] mmol/L and 4.22 [IQR, 2.15-7.13] mmol/L (P < 0.001), respectively. Patients who died had larger volumes of red blood cell (RBC) transfusions and fluid administration, and were administered higher doses of vasoactive drugs. Logistic regression analysis showed that intra-LAC was an independent predictor of postoperative mortality (odds ratio [OR] 1.210, 95% CI 1.070 -1.360, P = 0.002). The volume of RBCs, fluids transfused, and the amount of vasoactive agents administered were not independent predictors. The area under the curve (AUC) of the ROC curve for intra-LAC for in-hospital mortality was 0.762 (95% confidence interval [CI], 0.711-0.812), with a cutoff value of 3.68 mmol/L by Youden index. CONCLUSIONS Intraoperative lactate levels, but not hemodynamic management, were independently associated with increased in-hospital mortality after emergency GI surgery.
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Affiliation(s)
- Shinji Sugita
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.
- Department of Anesthesiology, Nippon Medical School Musashi-Kosugi Hospital, 1-383 Kosugi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa, 211-8533, Japan.
| | - Masashi Ishikawa
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Takahiro Sakuma
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Masumi Iizuka
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
- Department of Anesthesia, Urasoe General Hospital, 4-16-1 Iso, Urasoe-shi, Okinawa, 901-2132, Japan
| | - Sayako Hanai
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
- Department of Anesthesiology, Keiyu Hospital, 3-7-3 Minatomirai, Nishi-ku, Yokohama-shi, Kanagawa, 220-8521, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
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Mistry N, Richardson V, Carey E, Porter S, Pincus S, Novins-Montague S, Elmer M, Lin CT, Ho PM, Anstett T. General improvements versus interruptive or non-interruptive alerts in the blood order set: study protocol for a randomized control trial to improve packed red blood cell utilization. Trials 2023; 24:314. [PMID: 37158929 PMCID: PMC10165805 DOI: 10.1186/s13063-023-07319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 04/20/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Blood transfusions can serve as a life-saving treatment, but inappropriate blood product transfusions can result in patient harm and excess costs for health systems. Despite published evidence supporting restricted packed red blood cell (pRBC) usage, many providers transfuse outside of guidelines. Here, we report a novel prospective, randomized control trial to increase guideline-concordant pRBC transfusions comparing three variations of clinical decision support (CDS) in the electronic health record (EHR). METHODS All inpatient providers at University of Colorado Hospital (UCH) who order blood transfusions were randomized in a 1:1:1 fashion to the three arms of the study: (1) general order set improvements, (2) general order set improvements plus non-interruptive in-line help text alert, and (3) general order set improvements plus interruptive alert. Transfusing providers received the same randomized order set changes for 18 months. The primary outcome of this study is the guideline-concordant rate of pRBC transfusions. The primary objective of this study is to compare the group using the new interface (arm 1) versus the two groups using the new interface with interruptive or non-interruptive alerts (arms 2 and 3, combined). The secondary objectives compare guideline-concordant transfusion rates between arm 2 and arm 3 as well as comparing all of arms of the study in aggregate to historical controls. This trial concluded after 12 months on April 5, 2022. DISCUSSION CDS tools can increase guideline-concordant behavior. This trial will examine three different CDS tools to determine which type is most effective at increasing guideline-concordant blood transfusions. TRIAL REGISTRATION Registered on ClinicalTrials.gov 3/20/21, NCT04823273 . Approved by University of Colorado Institutional Review Board (19-0918), protocol version 1 4/19/2019, approved 4/30/2019.
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Affiliation(s)
- Neelam Mistry
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, 12401 East 17Th Avenue, Mailstop F-782, Aurora, CO, 80045, USA.
| | - Vanessa Richardson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- The NavLab, an Adult and Child Consortium of Outcome Research and Delivery Science (ACCORDS) Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Evan Carey
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- The NavLab, an Adult and Child Consortium of Outcome Research and Delivery Science (ACCORDS) Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Samuel Porter
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, 12401 East 17Th Avenue, Mailstop F-782, Aurora, CO, 80045, USA
| | - Sharon Pincus
- The NavLab, an Adult and Child Consortium of Outcome Research and Delivery Science (ACCORDS) Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sylvie Novins-Montague
- The NavLab, an Adult and Child Consortium of Outcome Research and Delivery Science (ACCORDS) Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Elmer
- The NavLab, an Adult and Child Consortium of Outcome Research and Delivery Science (ACCORDS) Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chen-Tan Lin
- Division of Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - P Michael Ho
- The NavLab, an Adult and Child Consortium of Outcome Research and Delivery Science (ACCORDS) Program, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tyler Anstett
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, 12401 East 17Th Avenue, Mailstop F-782, Aurora, CO, 80045, USA
- The NavLab, an Adult and Child Consortium of Outcome Research and Delivery Science (ACCORDS) Program, University of Colorado School of Medicine, Aurora, CO, USA
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Kampman JM, Sperna Weiland NH. Anaesthesia and environment: impact of a green anaesthesia on economics. Curr Opin Anaesthesiol 2023; 36:188-195. [PMID: 36700462 PMCID: PMC9973446 DOI: 10.1097/aco.0000000000001243] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The excessive growth of the health sector has created an industry that, while promoting health, is now itself responsible for a significant part of global environmental pollution. The health crisis caused by climate change urges us to transform healthcare into a sustainable industry. This review aims to raise awareness about this issue and to provide practical and evidence-based recommendations for anaesthesiologists.
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Affiliation(s)
| | - Nicolaas H. Sperna Weiland
- Amsterdam UMC location University of Amsterdam, Anaesthesiology
- Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam, The Netherlands
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Worku ET, Win AM, Parmar D, Anstey C, Shekar K. Haematological Trends and Transfusion during Adult Extracorporeal Membrane Oxygenation: A Single Centre Study. J Clin Med 2023; 12:2629. [PMID: 37048711 PMCID: PMC10095131 DOI: 10.3390/jcm12072629] [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: 02/11/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
The temporal trends in haematological parameters and their associations with blood product transfusion requirements in patients supported with extracorporeal membrane oxygenation (ECMO) are poorly understood. We performed a retrospective data analysis to better understand the behaviour of haematological and coagulation parameters and their associations with transfusion requirements during ECMO. METHODS Patient demographics, haematological and coagulation parameters, plasma haemoglobin and fibrinogen concentrations, platelet count, the international normalised ratio (INR), the activated partial thromboplastin time (APTT), and blood product transfusion data from 138 patients who received ECMO in a single high-volume centre were analysed. RESULTS Ninety-two patients received venoarterial (VA) ECMO and 46 patients received venovenous (VV) ECMO. The median (IQR) duration of VA, and VV ECMO was 8 (5-13) days and 13 (8-23) days, respectively. There were significant reductions in haemoglobin, the platelet count, and the fibrinogen concentration upon initiation of ECMO. On average, over time, patients on VV ECMO had platelet counts 44 × 109/L higher than those on VA ECMO (p ≤ 0.001). Fibrinogen and APTT did not vary significantly based on the mode of ECMO (p = 0.55 and p = 0.072, respectively). A platelet count < 50 × 109/L or a fibrinogen level < 1.8 g/L was associated with 50% chance of PRBC transfusion, regardless of the ECMO type, and packed red blood cell (PRBC) transfusion was more common with VA ECMO. APTT was predictive of the transfusion requirement, and the decrement in APTT was discriminatory between VVECMO survivors and nonsurvivors. CONCLUSION ECMO support is associated with reductions in haemoglobin, platelet count, and fibrinogen. Patients supported with VA ECMO are more likely to receive a PRBC transfusion compared to those on VV ECMO. Thrombocytopaenia, hypofibrinogenaemia, and anticoagulation effect the likelihood of requiring PRBC transfusion. Further research is needed to define optimal blood management during ECMO, including appropriate transfusion triggers and the anticoagulation intensity.
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Affiliation(s)
- Elliott T. Worku
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
| | - April M. Win
- Intensive Care Unit, The Townsville Hospital, Townsville, QLD 4810, Australia
| | - Dinesh Parmar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
| | - Chris Anstey
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
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41
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Kougias P, Mi Z, Zhan M, Carson JL, Dosluoglu H, Nelson P, Sarosi GA, Arya S, Norman LE, Sharath S, Scrymgeour A, Ollison J, Calais LA, Biswas K. Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial. Contemp Clin Trials 2023; 126:107095. [PMID: 36690072 DOI: 10.1016/j.cct.2023.107095] [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: 10/11/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events. METHODS A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year. RESULTS The primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups. CONCLUSIONS The TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms. TRIAL REGISTRATION http://clinicaltrials.gov identifier: NCT03229941.
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Affiliation(s)
- Panos Kougias
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America.
| | - Zhibao Mi
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Min Zhan
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Jeffrey L Carson
- Division of General Internal Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
| | - Hasan Dosluoglu
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo/VA Western NY Healthcare System, Buffalo, NY, United States of America
| | - Peter Nelson
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, United States of America
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, General Surgery Section, Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, United States of America
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Vascular Section, Surgery Service Line, Palo Alto Veterans Affairs Medical Center, Palo Alto, CA, United States of America
| | - L Erin Norman
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Sherene Sharath
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America
| | - Alexandra Scrymgeour
- Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, United States of America
| | - Jade Ollison
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America
| | - Lawrence A Calais
- Cooperative Studies Program Site Monitoring, Auditing, and Resource Team (SMART), Albuquerque, NM, United States of America
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
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Kiyatkin ME, Mladinov D, Jarzebowski ML, Warner MA. Patient Blood Management, Anemia, and Transfusion Optimization Across Surgical Specialties. Anesthesiol Clin 2023; 41:161-174. [PMID: 36871997 PMCID: PMC10066799 DOI: 10.1016/j.anclin.2022.10.003] [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] [Indexed: 03/07/2023]
Abstract
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.
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Affiliation(s)
- Michael E Kiyatkin
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mary L Jarzebowski
- Department of Anesthesiology, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI 48109, USA
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, 200 1st Street, Rochester, MN 55905, USA
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Carson JL, Brooks MM, Chaitman BR, Alexander JH, Goodman SG, Bertolet M, Abbott JD, Cooper HA, Rao SV, Triulzi DJ, Fergusson DA, Kostis WJ, Noveck H, Simon T, Steg PG, DeFilippis AP, Goldsweig AM, Lopes RD, White H, Alsweiler C, Morton E, Hébert PC. Rationale and design for the myocardial ischemia and transfusion (MINT) randomized clinical trial. Am Heart J 2023; 257:120-129. [PMID: 36417955 PMCID: PMC9928777 DOI: 10.1016/j.ahj.2022.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND Accumulating evidence from clinical trials suggests that a lower (restrictive) hemoglobin threshold (<8 g/dL) for red blood cell (RBC) transfusion, compared with a higher (liberal) threshold (≥10 g/dL) is safe. However, in anemic patients with acute myocardial infarction (MI), maintaining a higher hemoglobin level may increase oxygen delivery to vulnerable myocardium resulting in improved clinical outcomes. Conversely, RBC transfusion may result in increased blood viscosity, vascular inflammation, and reduction in available nitric oxide resulting in worse clinical outcomes. We hypothesize that a liberal transfusion strategy would improve clinical outcomes as compared to a more restrictive strategy. METHODS We will enroll 3500 patients with acute MI (type 1, 2, 4b or 4c) as defined by the Third Universal Definition of MI and a hemoglobin <10 g/dL at 144 centers in the United States, Canada, France, Brazil, New Zealand, and Australia. We randomly assign trial participants to a liberal or restrictive transfusion strategy. Participants assigned to the liberal strategy receive transfusion of RBCs sufficient to raise their hemoglobin to at least 10 g/dL. Participants assigned to the restrictive strategy are permitted to receive transfusion of RBCs if the hemoglobin falls below 8 g/dL or for persistent angina despite medical therapy. We will contact each participant at 30 days to assess clinical outcomes and at 180 days to ascertain vital status. The primary end point is a composite of all-cause death or recurrent MI through 30 days following randomization. Secondary end points include all-cause mortality at 30 days, recurrent adjudicated MI, and the composite outcome of all-cause mortality, nonfatal recurrent MI, ischemia driven unscheduled coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), or readmission to the hospital for ischemic cardiac diagnosis within 30 days. The trial will assess multiple tertiary end points. CONCLUSIONS The MINT trial will inform RBC transfusion practice in patients with acute MI.
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Affiliation(s)
| | | | | | | | - Shaun G Goodman
- St. Michael's Hospital, University of Toronto, Toronto Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Marnie Bertolet
- University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - J Dawn Abbott
- Warren Alpert Medical School. Brown University, Providence, RI
| | | | - Sunil V Rao
- Durham VA Medical Center, Durham, NC; NYU Langone Health, New York, NY
| | | | | | | | - Helaine Noveck
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | | | | | | | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil; Duke Clinical Research Institute, Durham, NC
| | - Harvey White
- Green Lane Clinical Coordinating Centre Ltd, Auckland, New Zealand
| | | | | | - Paul C Hébert
- Centre de Recherche du Centre Hosp. Universitaire de Montréal, Montréal, Québec, Canada
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Tonna JE. Patients receiving ECMO are special, but still only need a haemoglobin concentration of 7g/dL. THE LANCET. RESPIRATORY MEDICINE 2023; 11:215-217. [PMID: 36240835 PMCID: PMC9991993 DOI: 10.1016/s2213-2600(22)00367-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery and Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT 84132, USA.
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Martucci G, Schmidt M, Agerstrand C, Tabatabai A, Tuzzolino F, Giani M, Ramanan R, Grasselli G, Schellongowski P, Riera J, Hssain AA, Duburcq T, Gorjup V, De Pascale G, Buabbas S, Gannon WD, Jeon K, Trethowan B, Fanelli V, Chico JI, Balik M, Broman LM, Pesenti A, Combes A, Ranieri MV, Foti G, Buscher H, Tanaka K, Lorusso R, Arcadipane A, Brodie D, Arcadipane A, Pesenti A, Grasselli G, Brioni M, De Pascale G, Montini L, Giani M, Foti G, Bosa L, Curcio P, Fanelli V, Garofalo E, Martin-Villen L, Garcìa-Álvarez R, Lopez Sanchez M, Principe N, Chica Saez V, Chico JI, Gomez V, Colomina-Climent J, Riera J, Pacheco AF, Gorjup V, Goutay J, Thibault D, Szułdrzyński K, Eller P, Lobmeyr E, Schellongowski P, Schmidt M, Combes A, Lorusso R, Mariani S, Ranieri MV, Suk P, Maly M, Balik M, Forestier J, Broman LM, Rizzo M, Tuzzolino F, Tanaka K, Holsworth T, Trethowan B, Serra A, Agerstrand C, Brodie D, Cavayas YA, Tabatabai A, Menaker J, Galvagno S, Gannon WD, Rice TW, Grandin WE, Nunez J, Cheplic C, Ramanan R, Rivosecchi R, Cho YJ, Buabbas S, Jeon K, Kwan MC, Sallam H, Villanueva JA, Aliudin J, Ait Hssain A, Hoshino K, Hara Y, Ramanathan K, Maclaren G, Buscher H. Transfusion practice in patients receiving VV ECMO (PROTECMO): a prospective, multicentre, observational study. THE LANCET. RESPIRATORY MEDICINE 2023; 11:245-255. [PMID: 36240836 DOI: 10.1016/s2213-2600(22)00353-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) packed red blood cell (PRBC) transfusion thresholds are usually higher than in other patients who are critically ill. Available guidelines suggest a restrictive approach, but do not provide specific recommendations on the topic. The main aim of this study was, in a short timeframe, to describe the actual values of haemoglobin and the rate and the thresholds for transfusion of PRBC during VV ECMO. METHODS PROTECMO was a multicentre, prospective, cohort study done in 41 ECMO centres in Europe, North America, Asia, and Australia. Consecutive adult patients with acute respiratory distress syndrome (ARDS) who were receiving VV ECMO were eligible for inclusion. Patients younger than 18 years, those who were not able to provide informed consent when required, and patients with an ECMO stay of less than 24 h were excluded. Our main aim was to monitor the daily haemoglobin concentration and the value at the point of PRBC transfusion, as well as the rate of transfusions. The practice in different centres was stratified by continent location and case volume per year. Adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for baseline and time varying confounding. FINDINGS Between Dec 1, 2018, and Feb 22, 2021, 604 patients were enrolled (431 [71%] men, 173 [29%] women; mean age 50 years [SD 13·6]; and mean haemoglobin concentration at cannulation 10·9 g/dL [2·4]). Over 7944 ECMO days, mean haemoglobin concentration was 9·1 g/dL (1·2), with lower concentrations in North America and high-volume centres. PRBC were transfused on 2432 (31%) of days on ECMO, and 504 (83%) patients received at least one PRBC unit. Overall, mean pretransfusion haemoglobin concentration was 8·1 g/dL (1·1), but varied according to the clinical rationale for transfusion. In a time-dependent Cox model, haemoglobin concentration of less than 7 g/dL was consistently associated with higher risk of death in the intensive care unit compared with other higher haemoglobin concentrations (hazard ratio [HR] 2·99 [95% CI 1·95-4·60]); PRBC transfusion was associated with lower risk of death only when transfused when haemoglobin concentration was less than 7 g/dL (HR 0·15 [0·03-0·74]), although no significant effect in reducing mortality was reported for transfusions for other haemoglobin classes (7·0-7·9 g/dL, 8·0-9·9 g/dL, or higher than 10 g/dL). INTERPRETATION During VV ECMO, there was no universally accepted threshold for transfusion, but PRBC transfusion was invariably associated with lower mortality only when done with haemoglobin concentration of less than 7 g/dL. FUNDING Extracorporeal Life Support Organization.
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Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy.
| | - Matthieu Schmidt
- INSERM 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Cara Agerstrand
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, NY, USA
| | - Ali Tabatabai
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Fabio Tuzzolino
- Statistics and Data Management Services, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Marco Giani
- Ospedale San Gerardo, Università degli Studi Di Milano-Bicocca, Monza, Italy
| | - Raj Ramanan
- Department of Critical Care, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Jordi Riera
- Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Shock Organ Dysfunction and Resuscitation, Vall d'Hebron Institut de Recerca, Barcelona, Spain; Centro de Investigacion en Red de Enfermedades Respiratorias Instituto de Salud Carlos III, Barcelona, Spain
| | | | - Thibault Duburcq
- Centre Hospitalier Regional Universitaire Lille, Hôpital Roger Salengro, Lille, France
| | | | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sarah Buabbas
- Kuwait Extracorporeal Life Support Program, Jaber Al-Ahmad Alsabah Hospital, Kuwait City, Kuwait
| | - Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyeongman Jeon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Brian Trethowan
- Meijer Heart Center Butterworth Hospital, Spectrum Health, Grand Rapids, MI, USA
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Juan I Chico
- Critical Care Department, Alvaro Cunqueiro University Hospital, Vigo, Spain
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Medical Faculty, General University Hospital, Prague, Czech Republic
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Antonio Pesenti
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Alain Combes
- INSERM 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Giuseppe Foti
- Ospedale San Gerardo, Università degli Studi Di Milano-Bicocca, Monza, Italy
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Kenichi Tanaka
- The University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Daniel Brodie
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, NY, USA
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Lindén A, Fisher J, Lilja G, Olsen MH, Sjövall F, Jungner M, Spångfors M, Samuelsson L, Oras J, Linder A, Unden J, Kander T, Lipcsey M, Nielsen N, Jakobsen JC, Bentzer P. Protocolised reduction of non-resuscitation fluids versus usual care in patients with septic shock (REDUSE): a protocol for a multicentre feasibility trial. BMJ Open 2023; 13:e065392. [PMID: 36854601 PMCID: PMC9980317 DOI: 10.1136/bmjopen-2022-065392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION Administration of large volumes of fluids is associated with poor outcome in septic shock. Recent data suggest that non-resuscitation fluids are the major source of fluids in the intensive care unit (ICU) patients suffering from septic shock. The present trial is designed to test the hypothesis that a protocol targeting this source of fluids can reduce fluid administration compared with usual care. METHODS AND ANALYSIS The design will be a multicentre, randomised, feasibility trial. Adult patients admitted to ICUs with septic shock will be randomised within 12 hours of admission to receive non-resuscitation fluids either according to a restrictive protocol or to receive usual care. The healthcare providers involved in the care of participants will not be blinded. The participants, outcome assessors at the 6-month follow-up and statisticians will be blinded. Primary outcome will be litres of fluids administered within 3 days of randomisation. Secondary outcomes will be proportion of randomised participants with outcome data on all-cause mortality; days alive and free of mechanical ventilation within 90 days of inclusion; any acute kidney injury and ischaemic events in the ICU (cerebral, cardiac, intestinal or limb ischaemia); proportion of surviving randomised patients who were assessed by European Quality of Life 5-Dimensions 5-Level questionnaire and Montreal Cognitive Assessment; proportion of all eligible patients who were randomised and proportion of participants experiencing at least one protocol violation. ETHICS AND DISSEMINATION Ethics approval has been obtained in Sweden. Results of the primary and secondary outcomes will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT05249088.
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Affiliation(s)
- Anja Lindén
- Anesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Jane Fisher
- Anesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Fredrik Sjövall
- Intensive and Perioperative Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Malmö, Sweden
| | - Mårten Jungner
- Intensive and Perioperative Care, Department of Clinical Sciences Malmö, Skane University Hospital, Lund University, Malmö, Sweden
| | - Martin Spångfors
- Department of Anesthesiology and Intensive Care, Kristianstad Hospital, Central Hospital in Kristianstad, Kristianstad, Sweden
| | - Line Samuelsson
- Department of Anesthesiology and Intensive Care, Östersund Hospital, Ostersund, Sweden
| | - Jonatan Oras
- Department of Anesthesiology and Intensive Care Medicine, University of Gothenburg, Goteborg, Sweden
| | - Adam Linder
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johan Unden
- Department of Operation and Intensive Care, Halland Hospital Halmstad, Halmstad, Sweden
| | - T Kander
- Intensive and Perioperative Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Miklós Lipcsey
- Anesthesiology and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Clinical Sciences, Uppsala University, Uppsala, Sweden
| | - Niklas Nielsen
- Anesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter Bentzer
- Anesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Helsingborg, Sweden
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Babu S, Sreedhar R, Munaf M, Gadhinglajkar SV. Sepsis in the Pediatric Cardiac Intensive Care Unit: An Updated Review. J Cardiothorac Vasc Anesth 2023; 37:1000-1012. [PMID: 36922317 DOI: 10.1053/j.jvca.2023.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
Sepsis remains among the most common causes of mortality in children with congenital heart disease (CHD). Extensive literature is available regarding managing sepsis in pediatric patients without CHD. Because the cardiovascular pathophysiology of children with CHD differs entirely from their typical peers, the available diagnosis and management recommendations for sepsis cannot be implemented directly in children with CHD. This review discusses the risk factors, etiopathogenesis, available diagnostic tools, resuscitation protocols, and anesthetic management of pediatric patients suffering from various congenital cardiac lesions. Further research should focus on establishing a standard guideline for managing children with CHD with sepsis and septic shock admitted to the intensive care unit.
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Affiliation(s)
- Saravana Babu
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India.
| | - Rupa Sreedhar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Mamatha Munaf
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Shrinivas V Gadhinglajkar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
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Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit. J Clin Med 2023; 12:jcm12041304. [PMID: 36835840 PMCID: PMC9965353 DOI: 10.3390/jcm12041304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/21/2023] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Acutely ill patients treated with blood transfusion (BT) have unfavorable prognoses. Nevertheless, data regarding outcomes in patients treated with BT admitted into a contemporary tertiary care medical center intensive cardiac care unit (ICCU) are limited. The current study aimed to assess the mortality rate and outcomes of patients treated with BT in a modern ICCU. METHODS Prospective single center study where we evaluated mortality, in the short and long term, of patients treated with BT between the period of January 2020 and December 2021 in an ICCU. OUTCOMES A total of 2132 consecutive patients were admitted to the ICCU during the study period and were followed-up for up to 2 years. In total, 108 (5%) patients were treated with BT (BT-group) during their admission, with 305 packed cell units. The mean age was 73.8 ± 14 years in the BT-group vs. 66.6 ± 16 years in the non-BT (NBT) group, p < 0.0001. Females were more likely to receive BT as compared with males (48.1% vs. 29.5%, respectively, p < 0.0001). The crude mortality rate was 29.6% in the BT-group and 9.2% in the NBT-group, p < 0.0001. Multivariate Cox analysis found that even one unit of BT was independently associated with more than two-fold the mortality rate [HR = 2.19 95% CI (1.47-3.62)] as compared with the NBT-group, p < 0.0001]. Receiver operating characteristic (ROC) curve was plotted for multivariable analysis and showed area under curve (AUC) of 0.8 [95% CI (0.760-0.852)]. CONCLUSIONS BT continues to be a potent and independent predictor for both short- and long-term mortality even in a contemporary ICCU, despite the advanced technology, equipment and delivery of care. Further considerations for refining the strategy of BT administration in ICCU patients and guidelines for different subsets of high-risk patients may be warranted.
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Prescott LS, Vergote I, Sun CC, Bodurka DC, Coleman RL. Transfusion use and effect on progression-free, overall survival, and quality of life in upfront treatment of advanced epithelial ovarian cancer: evaluation of the European Organization for Research and Treatment EORTC-55971 Cohort. Int J Gynecol Cancer 2023; 33:1-9. [PMID: 36356982 PMCID: PMC10046328 DOI: 10.1136/ijgc-2022-003947] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The impact of blood transfusion on ovarian cancer survival is uncertain. OBJECTIVE To investigate whether peri-operative blood transfusion negatively impacted progression-free survival, overall survival, and quality of life in patients with advanced ovarian cancer. METHODS We performed an ancillary analysis of the European Organization for Research and Treatment (EORTC) 55971 phase III trial, in which patients were randomized to primary debulking surgery versus neoadjuvant chemotherapy. Patients included in the per-protocol analysis were categorized by receipt of a transfusion. RESULTS 612 of 632 (97%) of patients had adequate data for analysis. Of those, 323 (53%) received a transfusion. The transfusion cohort was more likely to have had better Word Health Organization (WHO) performance status, serous histology, undergone primary debulking surgery, and received more aggressive surgery, with higher rates of no gross residual disease. Median overall survival was 34.0 vs 35.2 months in the no transfusion and transfusion cohorts (p=0.97). The adjusted HR for death was 1.18 (95% CI 0.94 to 1.48) in favor of the transfusion cohort. Median progression-free survival was 13.6 vs 12.6 months in the no transfusion and transfusion cohorts (p=0.96). The adjusted HR for progression was 1.14 (95% CI 0.91 to 1.43). There were no significant differences in global quality of life, fatigue, dyspnea, or physical functioning between the two cohorts at baseline or at any of the four assessment times. Grade 3 and 4 surgical site infections were more common in the transfusion cohort. CONCLUSION Transfusion did not negatively impact progression-free survival or overall survival; however, it was associated with increased peri-operative morbidity without improvements in quality of life.
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Affiliation(s)
- Lauren Shore Prescott
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane C Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Russell L, Weihe S, Madsen EK, Hvas CL, Leistner JW, Michelsen J, Brøchner AC, Bastiansen A, Nielsen FM, Meier N, Andreasen AS, Ribergaard N, Rasmussen BS, Sølling CG, Buck DL, Bundgaard H, Pedersen HS, Darfelt IS, Poulsen LM, Ibsen M, Plovsing RR, Sigurdsson ST, Iversen S, Hildebrandt T, Mohr T, Espelund US, Jørgensen V, Haase N, Perner A. Thromboembolic and bleeding events in ICU patients with COVID-19: A nationwide, observational study. Acta Anaesthesiol Scand 2023; 67:76-85. [PMID: 36263897 PMCID: PMC9874434 DOI: 10.1111/aas.14157] [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: 08/13/2022] [Revised: 10/08/2022] [Accepted: 10/13/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intensive care unit (ICU) patients with Coronavirus disease 2019 (COVID-19) have an increased risk of thromboembolic complications. We describe the occurrence of thromboembolic and bleeding events in all ICU patients with COVID-19 in Denmark during the first and second waves of the pandemic. METHODS This was a sub-study of the Danish Intensive Care Covid database, in which all patients with SARS-CoV-2 admitted to Danish ICUs from 10th March 2020 to 30th June 2021 were included. We registered coagulation variables at admission, and all thromboembolic and bleeding events, and the use of heparins during ICU stay. Variables associated with thrombosis and bleeding and any association with 90-day mortality were estimated using Cox regression analyses. RESULTS We included 1369 patients in this sub-study; 158 (12%, 95% confidence interval 10-13) had a thromboembolic event in ICU and 309 (23%, 20-25) had a bleeding event, among whom 81 patients (6%, 4.8-7.3) had major bleeding. We found that mechanical ventilation and increased D-dimer were associated with thrombosis and mechanical ventilation, low platelet count and presence of haematological malignancy were associated with bleeding. Most patients (76%) received increased doses of thromboprophylaxis during their ICU stay. Thromboembolic events were not associated with mortality in adjusted analysis (hazard ratio 1.35 [0.91-2.01, p = .14], whereas bleeding events were 1.55 [1.18-2.05, p = .002]). CONCLUSIONS Both thromboembolic and bleeding events frequently occurred in ICU patients with COVID-19. Based on these data, it is not apparent that increased doses of thromboprophylaxis were beneficial.
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Affiliation(s)
- Lene Russell
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Sarah Weihe
- Department of AnaesthesiologyZealand University HospitalRoskildeDenmark
| | - Emilie Kabel Madsen
- Department of Anaesthesiology and Intensive CareAarhus University HospitalAarhusDenmark
| | | | - Jens Wolfgang Leistner
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Jens Michelsen
- Department of Anaesthesiology and Intensive CareOdense University HospitalOdenseDenmark
| | - Anne Craveiro Brøchner
- Department of Anaesthesiology and Intensive CareUniversity Hospital of Southern DenmarkKoldingDenmark
| | - Anders Bastiansen
- Department of Anaesthesiology and Intensive CareBispebjerg HospitalCopenhagenDenmark
| | | | - Nick Meier
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | | | - Niels‐Erik Ribergaard
- Department of Anaesthesiology and Intensive CareHjørring Regional HospitalHjørringDenmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive CareAalborg University HospitalAalborgDenmark
| | | | - David Levarett Buck
- Department of Anaesthesiology and Intensive CareHolbæk HospitalHolbækDenmark
| | - Helle Bundgaard
- Department of Anaesthesiology and Intensive CareRanders Regional HospitalRandersDenmark
| | - Helle Scharling Pedersen
- Department of Anaesthesiology and Intensive CareNykøbing Falster HospitalNykøbing FalsterDenmark
| | - Iben Strøm Darfelt
- Department of Anaesthesiology and Intensive CareRegionshospitalet GødstrupHerningDenmark
| | | | - Michael Ibsen
- Department of Anaesthesiology and Intensive CareNorth Zealand HospitalHillerødDenmark
| | - Ronni R. Plovsing
- Department of Anaesthesiology and Intensive CareHvidovre HospitalHvidovreDenmark
| | | | - Susanne Iversen
- Department of Anaesthesiology and Intensive CareSlagelse HospitalSlagelseDenmark
| | - Thomas Hildebrandt
- Department of Anaesthesiology and Intensive CareZealand University HospitalRoskildeDenmark
| | - Thomas Mohr
- Department of Anaesthesiology and Intensive CareGentofte HospitalGentofteDenmark
| | | | - Vibeke Jørgensen
- Department of Cardiothoracic Anaesthesiology, RigshospitaletCopenhagenDenmark
| | - Nicolai Haase
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Anders Perner
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
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