1
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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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2
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Ali S, Roubos S, Hoeks SE, Verbrugge SJC, Koopman-van Gemert AWMM, Stolker RJ, van Lier F. Perioperative transfusion study (PETS): Does a liberal transfusion protocol improve outcome in high-risk cardiovascular patients undergoing non-cardiac surgery? A randomised controlled pilot study. Transfus Med 2024. [PMID: 38890740 DOI: 10.1111/tme.13058] [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: 03/25/2024] [Revised: 05/07/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Small studies have shown that patients with advanced coronary artery disease might benefit from a more liberal blood transfusion strategy. The goal of this pilot study was to test the feasibility of a blood transfusion intervention in a group of vascular surgery patients who have elevated cardiac troponins in rest. METHODS We conducted a single-centre, randomised controlled pilot study. Patients with a preoperative elevated high-sensitive troponin T undergoing non-cardiac vascular surgery were randomised between a liberal transfusion regime (haemoglobin >10.4 g/dL) and a restrictive transfusion regime (haemoglobin 8.0-9.6 g/dL) during the first 3 days after surgery. The primary outcome was defined as a composite endpoint of all-cause mortality, myocardial infarction or unscheduled coronary revascularization. RESULTS In total 499 patients were screened; 92 were included and 50 patients were randomised. Postoperative haemoglobin was different between the intervention and control group; 10.6 versus 9.8, 10.4 versus 9.4, 10.9 versus 9.4 g/dL on day one, two and three respectively (p < 0.05). The primary outcome occurred in four patients (16%) in the liberal transfusion group and in two patients (8%) in control group. CONCLUSION This pilot study shows that the studied transfusion protocol was able to create a clinically significant difference in perioperative haemoglobin levels. Randomisation was possible in 10% of the screened patients. A large definitive trial should be possible to provide evidence whether a liberal transfusion strategy could decrease the incidence of postoperative myocardial infarction in high risk surgical patients.
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Affiliation(s)
- Samir Ali
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Steven Roubos
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sanne E Hoeks
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Serge J C Verbrugge
- Department of Anaesthesiology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Robert Jan Stolker
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Felix van Lier
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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3
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Wang YY, Chou YC, Tsai YH, Chang CW, Chen YC, Tai TW. Unplanned emergency department visits within 90 days of hip hemiarthroplasty for osteoporotic femoral neck fractures: Reasons, risks, and mortalities. Osteoporos Sarcopenia 2024; 10:66-71. [PMID: 39035225 PMCID: PMC11260006 DOI: 10.1016/j.afos.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/12/2024] [Accepted: 05/15/2024] [Indexed: 07/23/2024] Open
Abstract
Objectives Bipolar hemiarthroplasty is commonly performed to treat displaced femoral neck fractures in osteoporotic patients. This study aimed to assess the occurrence and outcomes of unplanned return visits to the emergency department (ED) within 90 days following bipolar hemiarthroplasty for displaced femoral neck fractures. Methods The clinical data of 1322 consecutive patients who underwent bipolar hemiarthroplasty for osteoporotic femoral neck fractures at a tertiary medical center were analyzed. Data from the patients' electronic medical records, including demographic information, comorbidities, and operative details, were collected. The risk factors and mortality rates were analyzed. Results Within 90 days after surgery, 19.9% of patients returned to the ED. Surgery-related reasons accounted for 20.2% of the patient's returns. Older age, a high Charlson comorbidity index score, chronic kidney disease, and a history of cancer were identified as significant risk factors for unplanned ED visits. Patients with uncemented implants had a significantly greater risk of returning to the ED due to periprosthetic fractures than did those with cemented implants (P = 0.04). Patients who returned to the ED within 90 days had an almost fivefold greater 1-year mortality rate (15.2% vs 3.1%, P < 0.001) and a greater overall mortality rate (26.2% vs 10.5%, P < 0.001). Conclusions This study highlights the importance of identifying risk factors for unplanned ED visits after bipolar hemiarthroplasty, which may contribute to a better prognosis. Consideration should be given to the use of cemented implants for hemiarthroplasty, as uncemented implants are associated with a greater risk of periprosthetic fractures.
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Affiliation(s)
- Yang-Yi Wang
- Department of Orthopedic Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Yi-Chuan Chou
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, 701, Taiwan
| | - Yuan-Hsin Tsai
- Department of Orthopedic Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan
- Tissue Engineering and Regenerative Medicine, National Chung Hsing University, Taichung, 402, Taiwan
| | - Chih-Wei Chang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Chen Chen
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Wei Tai
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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4
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Aziz MA, Bojja S, Aziz AA, Javed N, Patel H. Gastrointestinal Bleeding in Patients With Acute Ischemic Stroke: A Literature Review. Cureus 2024; 16:e53210. [PMID: 38425599 PMCID: PMC10902729 DOI: 10.7759/cureus.53210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Stroke is an infarction of the central nervous system (brain, spinal cord, or retina) that results from a disruption in cerebral blood flow either due to ischemia or hemorrhage. Complications of acute stroke are common and include pneumonia, urinary tract infection, myocardial infarction, deep vein thrombosis, and pulmonary embolism, among several others, all of which increase the risk of poor clinical outcomes. Gastrointestinal bleeding is a well-known complication that can occur during the acute phase of stroke. In this review, we have summarized the existing data regarding the incidence, pathophysiology, risk factors, morbidity, mortality, and management strategies for gastrointestinal bleeding in patients with acute ischemic stroke.
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Affiliation(s)
| | - Srikaran Bojja
- Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Ahmed Ali Aziz
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Nismat Javed
- Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Harish Patel
- Gastroenterology and Hepatology, BronxCare Health System, New York City, USA
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Yusop MF, Tahir NM, Azim SMSS, Kamaruzaman AA, Hata NRM, Kugaan A, Osman MF, Yazid TNT, Mokhtar S, Omar H, Amir AS. Intraoperative blood loss and blood transfusion requirement among liver transplant recipients: A national single-center experience 2020. Asian J Transfus Sci 2023; 17:251-255. [PMID: 38274975 PMCID: PMC10807514 DOI: 10.4103/ajts.ajts_38_21] [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: 03/25/2021] [Revised: 08/25/2021] [Accepted: 08/29/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Liver transplantation (LT) is a complicated surgical procedure with high risk for massive intraoperative blood loss due to pre-existing coagulopathy, portosystemic shunts with collateral circulations, and splenomegaly. The transfusion service will direct most of their resources toward LT programs with great impact on cost. The purpose of this study was to evaluate single center transfusion strategies and to identify the risk factors associated with the intraoperative blood loss and blood transfusion. METHODS The study includes 18 patients who underwent LT at Hospital Selayang between January 2020 and December 2020. Retrospective analysis of data included preoperative assessment of coagulopathy, intraoperative blood loss, and blood component transfusion. RESULTS The mean age in the study group was 36.4 ± 12.68 years. The mean intraoperative blood loss was 4450 ± 1646 ml requiring 4.17 ± 3.3 packed red blood cell (PRBC) units, 7.56 ± 5.5 platelet units, and 9.50 ± 6.0 fresh-frozen plasma units. The independent risk factor for high blood loss (HBL) group was lower preoperative platelet count and it is statistically significant (P = 0.024). The HBL group is associated with higher usage of PRBC (P = 0.024) and platelet units (P = 0.031) and it is statistically significant. The length of stay (LOS) in intensive care unit (ICU) averaging 8.6 ± 4.95 days, and there is no significant differences comparing the HBL and LBL group (P = 0.552). The mortality <90 days for all recipients was 22.2%. CONCLUSION The preoperative platelet count for is the most important factor associated with HBL in LT procedure. The usage of PRBC and platelet units was statistically higher in the HBL group. Comparing HBL and LBL patients, there is no difference in terms of the LOS in ICU postoperatively. A larger sample size would be needed in view of relatively small sample size.
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Affiliation(s)
- Mohd Faeiz Yusop
- Department of Pathology, Hospital Selayang, Selangor, Ministry of Health, Malaysia
| | | | | | | | - Nur Raihan Mohd Hata
- Department of Pathology, Hospital Selayang, Selangor, Ministry of Health, Malaysia
| | - Arvend Kugaan
- Department of Pathology, Hospital Selayang, Selangor, Ministry of Health, Malaysia
| | - Mohd Fairuz Osman
- Department of Pathology, Hospital Selayang, Selangor, Ministry of Health, Malaysia
| | | | - Suryati Mokhtar
- Department of Hepatobiliary, Hospital Selayang, Selangor, Ministry of Health, Malaysia
| | - Haniza Omar
- Department of Hepatology, Hospital Selayang, Selangor, Ministry of Health, Malaysia
| | - Ahmad Suhaimi Amir
- Department of Anaesthesiology and Intensive Care Unit, Hospital Selayang, Selangor, Ministry of Health, Malaysia
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6
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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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7
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Tian Y, Li Y, Sun S, Dong Y, Tian Z, Zhan L, Wang X. Effects of urban particulate matter on the quality of erythrocytes. CHEMOSPHERE 2023; 313:137560. [PMID: 36526140 DOI: 10.1016/j.chemosphere.2022.137560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/20/2022] [Accepted: 12/12/2022] [Indexed: 06/17/2023]
Abstract
With the acceleration of industrialisation and urbanisation, air pollution has become a serious global concern as a hazard to human health, with urban particulate matter (UPM) accounting for the largest share. UPM can rapidly pass into and persist within systemic circulation. However, few studies exist on whether UPM may have any impact on blood components. In this study, UPM standards (SRM1648a) were used to assess the influence of UPM on erythrocyte quality in terms of oxidative and metabolic damage as well as phagocytosis by macrophages in vitro and clearance in vivo. Our results showed that UPM had weak haemolytic properties. It can oxidise haemoglobin and influence the oxygen-carrying function, redox balance, and metabolism of erythrocytes. UPM increases the content of reactive oxygen species (ROS) and decreases antioxidant function according to the data of malonaldehyde (MDA), glutathione (GSH), and glucose 6 phosphate dehydrogenase (G6PDH). UPM can adhere to or be internalised by erythrocytes at higher concentrations, which can alter their morphology. Superoxide radicals produced in the co-incubation system further disrupted the structure of red blood cell membranes, thereby lowering the resistance to the hypotonic solution, as reflected by the osmotic fragility test. Moreover, UPM leads to an increase in phosphatidylserine exposure in erythrocytes and subsequent clearance by the mononuclear phagocytic system in vivo. Altogether, this study suggests that the primary function of erythrocytes may be affected by UPM, providing a warning for erythrocyte quality in severely polluted areas. For critically ill patients, transfusion of erythrocytes with lesions in morphology and function will have serious clinical consequences, suggesting that potential risks should be considered during blood donation screening. The current work expands the scope of blood safety studies.
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Affiliation(s)
- Yaxian Tian
- Institute of Health Service and Transfusion Medicine, Beijing, 100850, China; Department of Central Laboratory, Liaocheng People's Hospital, Liaocheng, 252000, Shandong Province, China; School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, 271016, China
| | - Yuxuan Li
- Institute of Health Service and Transfusion Medicine, Beijing, 100850, China
| | - Sujing Sun
- Institute of Health Service and Transfusion Medicine, Beijing, 100850, China
| | - Yanrong Dong
- Institute of Health Service and Transfusion Medicine, Beijing, 100850, China
| | - Zhaoju Tian
- School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, 271016, China.
| | - Linsheng Zhan
- Institute of Health Service and Transfusion Medicine, Beijing, 100850, China.
| | - Xiaohui Wang
- Institute of Health Service and Transfusion Medicine, Beijing, 100850, China.
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8
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Kang SH, Moon JY, Kim SH, Sung JH, Kim IJ, Lim SW, Cha DH, Kim WJ. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes in Koreans. Medicine (Baltimore) 2022; 101:e32579. [PMID: 36596077 PMCID: PMC9803465 DOI: 10.1097/md.0000000000032579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Anemia is a well-known risk factor for cardiovascular disease. However, there are limited data on whether anemia on admission is a long-term prognostic factor in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention. We sought to evaluate the prevalence and prognostic consequences of anemia in patients with ACS treated with percutaneous coronary intervention in Korea. We retrospectively enrolled 1930 consecutive patients. Among the anemic population (hemoglobin [Hb] < 13 g/dL in men, and < 12 g/dL in women), we classified patients with Hb ≥ 7 g/dL, <10 d/dL as moderate anemia, other cases classified as mild anemia. Among patients with normal hemoglobin levels, we classified those with Hb > 16.5 g/dL in men, and > 16.0 g/dL in women, as having high hemoglobin. We examined the relationship between anemia with all-cause mortality and secondary outcomes - including cardiovascular mortality, myocardial infarction, stroke, and repeat revascularization. We classified 3.3%, 21.5%, and 5.3% of patients as moderate anemia, mild anemia, and high hemoglobin, respectively. During a median follow-up of 67.2 (interquartile range; 46.8-88.5) months, 74 (3.8%) patients died. Compared with patients with normal hemoglobin, we detected a significantly increased risk for all-cause mortality in patients with anemia (adjusted hazard ratios for moderate and mild anemia, respectively: 8.26 [95% confidence interval: 3.98-17.15], P < .001 and 2.60 [1.54-4.40], P < .001). Among patients with ACS, anemia is prevalent and is strongly associated with increased mortality and cardiovascular events. Clinical trials will prospectively evaluate the efficacy of treatment for anemia on the outcomes of patients with ACS.
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Affiliation(s)
- Se Hun Kang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jae Youn Moon
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sang Hoon Kim
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jung Hoon Sung
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - In Jai Kim
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sang Wook Lim
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Dong Hun Cha
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Won-Jang Kim
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- * Correspondence: Won-Jang Kim, Department of cardiology, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundgang-gu, Seongnam-si, Gyeonggi-do 13496, Korea (e-mail: )
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9
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Nakamura M, Yaku H, Ako J, Arai H, Asai T, Chikamori T, Daida H, Doi K, Fukui T, Ito T, Kadota K, Kobayashi J, Komiya T, Kozuma K, Nakagawa Y, Nakao K, Niinami H, Ohno T, Ozaki Y, Sata M, Takanashi S, Takemura H, Ueno T, Yasuda S, Yokoyama H, Fujita T, Kasai T, Kohsaka S, Kubo T, Manabe S, Matsumoto N, Miyagawa S, Mizuno T, Motomura N, Numata S, Nakajima H, Oda H, Otake H, Otsuka F, Sasaki KI, Shimada K, Shimokawa T, Shinke T, Suzuki T, Takahashi M, Tanaka N, Tsuneyoshi H, Tojo T, Une D, Wakasa S, Yamaguchi K, Akasaka T, Hirayama A, Kimura K, Kimura T, Matsui Y, Miyazaki S, Okamura Y, Ono M, Shiomi H, Tanemoto K. JCS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J 2022; 86:477-588. [DOI: 10.1253/circj.cj-20-1282] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Kozuma
- Department of Internal Medicine, Teikyo University Faculty of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | | | - Hirofumi Takemura
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kanazawa University
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Institute of Community Medicine, Niigata University Uonuma Kikan Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital
| | | | - Shigeru Miyagawa
- Frontier of Regenerative Medicine, Graduate School of Medicine, Osaka University
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Toho University
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
| | - Hiromasa Otake
- Department of Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken-ichiro Sasaki
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science
| | - Masao Takahashi
- Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | | | - Taiki Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kindai University
| | | | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Skoog H, Chisolm P, Altonji SJ, Moore L, Carroll WR, Richman J, Greene B, Grayson JW. Moving to a more restrictive transfusion protocol: Outcomes in head and neck free flap surgery. Am J Otolaryngol 2022; 43:103268. [PMID: 34695698 DOI: 10.1016/j.amjoto.2021.103268] [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: 09/23/2021] [Accepted: 10/14/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine if a more restrictive transfusion protocol results in increased rates of adverse flap outcomes in patients undergoing free tissue transfer. MATERIALS AND METHODS Mixed retrospective and prospective cohort study. Patients who underwent surgery before the protocol change were collected retrospectively. Patients who underwent surgery after the protocol change were collected prospectively. RESULTS Of the 460 patients who underwent free tissue transfer, 116 patients in the pre-change cohort (N = 211) underwent transfusion (54.98%) and 78 in the post-change cohort(N = 249) (31.33%) (p < 0.001). The mean number of units transfused was 1.55 + 2.00 in the pre-change cohort, and 0.78 + 1.51 in the post-change cohort (p < 0.001). When separated temporally, the pre-change cohort received significantly more blood transfusions than the post-change cohort in the operating room (33.65% vs 18.07%) (p < 0.01), within 72 h of surgery (35.55% vs 15.66%) (p < 0.001), and after 72 h after surgery to discharge (16.59% vs 8.03%) (p = 0.018017). The rate of flap failure was 6.70% in the pre-change cohort, and 5.31% in the post-change cohort (p = 0.67). In a logistic regression model controlling for potential confounders, transfusion protocol was not significantly associated with flap failure (OR = 1.1080, 95% CI: 0.48-2.54). There were no significant differences between cohorts for medical morbidity, ICU transfer, or death. CONCLUSION Our data support the conclusion that patients undergoing free tissue transfer to the head and neck can be transfused following the same protocols as other patients, without increasing the rate of flap failure or other morbidities. LEVEL OF EVIDENCE 3 (mixed retrospective, prospective cohort study).
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Affiliation(s)
- Hunter Skoog
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America.
| | - Paul Chisolm
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - Samuel J Altonji
- Duke University, Department of Head and Neck Surgery and Communication Sciences, Durham, NC, United States of America
| | - Lindsay Moore
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - William R Carroll
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - Joshua Richman
- University of Alabama Birmingham, Department of Surgery, Birmingham, AL, United States of America
| | - Benjamin Greene
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - Jessica W Grayson
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
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11
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Ally SA, Foy M, Sood A, Gonzalez M. Preoperative risk factors for postoperative pneumonia following primary Total Hip and Knee Arthroplasty. J Orthop 2021; 27:17-22. [PMID: 34456526 PMCID: PMC8379351 DOI: 10.1016/j.jor.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/15/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA. METHODS Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA. RESULTS Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA. CONCLUSION This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.
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Affiliation(s)
- Syeda Akila Ally
- Department of Orthopaedic Surgery, University of Illinois, 835 S. Wolcott Avenue, Chicago, IL, 60612, United States
| | - Michael Foy
- Department of Orthopaedic Surgery, University of Illinois, 835 S. Wolcott Avenue, Chicago, IL, 60612, United States
| | - Anshum Sood
- Department of Orthopaedic Surgery, University of Illinois, 835 S. Wolcott Avenue, Chicago, IL, 60612, United States
| | - Mark Gonzalez
- Department of Orthopaedic Surgery, University of Illinois, 835 S. Wolcott Avenue, Chicago, IL, 60612, United States
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12
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Sharma YP, Kaur N, Kasinadhuni G, Batta A, Chhabra P, Verma S, Panda P. Anemia in heart failure: still an unsolved enigma. Egypt Heart J 2021; 73:75. [PMID: 34453627 PMCID: PMC8403217 DOI: 10.1186/s43044-021-00200-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/02/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Anemia affects one-third of heart failure patients and is associated with increased morbidity and mortality. Despite being one of the commonest comorbidities associated with heart failure, there is a significant knowledge gap about management of anemia in the setting of heart failure due to conflicting evidence from recent trials. MAIN BODY The etiology of anemia in heart failure is multifactorial, with absolute and functional iron deficiency, decreased erythropoietin levels and erythropoietin resistance, inflammatory state and heart failure medications being the important causative factors. Anemia adversely affects the already compromised hemodynamics in heart failure, besides being commonly associated with more comorbidities and more severe disease. Though low hemoglobin levels are associated with poor outcomes, the correction of anemia has not been consistently associated with improved outcomes. Parenteral iron improves the functional capacity in iron deficient heart failure patients, the effects are independent of hemoglobin levels, and also the evidence on hard clinical outcomes is yet to be ascertained. CONCLUSION Despite all the research, anemia in heart failure remains an enigma. Perhaps, anemia is a marker of severe disease, rather than the cause of poor outcome in these patients. In this review, we discuss the current understanding of anemia in heart failure, its management and the newer therapies being studied.
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Affiliation(s)
- Yash Paul Sharma
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, Sector-12, Chandigarh, India
| | - Navjyot Kaur
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, Sector-12, Chandigarh, India
| | - Ganesh Kasinadhuni
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, Sector-12, Chandigarh, India
| | - Akash Batta
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, Sector-12, Chandigarh, India
| | - Pulkit Chhabra
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, Sector-12, Chandigarh, India
| | - Samman Verma
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, Sector-12, Chandigarh, India
| | - Prashant Panda
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, Sector-12, Chandigarh, India.
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13
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Jentzer JC, Lawler PR, Katz JN, Wiley BM, Murphree DH, Bell MR, Barsness GW, Kor DJ. Red blood cell transfusion threshold and mortality in cardiac intensive care unit patients. Am Heart J 2021; 235:24-35. [PMID: 33497698 DOI: 10.1016/j.ahj.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 01/21/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND The benefit of red blood cell (RBC) transfusion in anemic critically-ill patients with cardiovascular disease is uncertain, as is the optimal threshold at which RBC transfusion should be considered. We sought to examine the association between RBC transfusion and mortality stratified by nadir Hgb level and admission diagnosis among cardiac intensive care unit (CICU) patients. METHODS Retrospective single-center cohort of 11,754 CICU patients admitted between 2007 and 2018. The association between RBC transfusion and hospital mortality at each nadir Hgb (<8 g/dL, 8-9.9 g/dL, ≥10 g/dL) was assessed using multivariable logistic regression adjusted for the propensity to receive RBC transfusion. RESULTS The study population had a mean age of 68±15 years, including 38% females; 1,134 (11.4%) received RBC transfusion. Admission diagnoses included: acute coronary syndrome , 42%; heart failure, 50%; cardiac arrest , 12%; and cardiogenic shock , 12%. Patients who received RBC transfusion had higher crude hospital mortality (19% vs. 8%, P<.001). RBC transfusion was associated with lower adjusted hospital mortality in patients with nadir Hgb <8 g/dL after propensity adjustment, including subgroups with acute coronary syndrome, cardiac arrest, or cardiogenic shock (all P <.01). RBC transfusion was not associated with lower adjusted hospital mortality in any subgroup of patients with nadir Hgb ≥8 g/dL. CONCLUSIONS These observational data suggest the use of a Hgb threshold <8 g/dL for RBC transfusion in most CICU patients, although we could not exclude a potential benefit of RBC transfusion at a nadir Hgb of 8 to 9.9 g/dL; we did not observe any benefit from RBC transfusion at a nadir Hgb ≥10 g/dL.
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14
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Ducrocq G, Calvo G, González-Juanatey JR, Durand-Zaleski I, Avendano-Sola C, Puymirat E, Lemesle G, Arnaiz JA, Martínez-Sellés M, Rousseau A, Cachanado M, Vicaut E, Silvain J, Karam C, Danchin N, Simon T, Steg PG. Restrictive vs liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia: Rationale and design of the REALITY trial. Clin Cardiol 2021; 44:143-150. [PMID: 33405291 PMCID: PMC7852166 DOI: 10.1002/clc.23453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 01/28/2023] Open
Abstract
Background Anemia is common in patients with acute myocardial infarction (AMI), and is an independent predictor of mortality. The optimal transfusion strategy in these patients is unclear. Hypothesis We hypothesized that a “restrictive” transfusion strategy (triggered by hemoglobin ≤8 g/dL) is clinically noninferior to a “liberal” transfusion strategy (triggered by hemoglobin ≤10 g/dL), but is less costly. Methods REALITY is an international, randomized, multicenter, open‐label trial comparing a restrictive vs a liberal transfusion strategy in patients with AMI and anemia. The primary outcome is the incremental cost‐effectiveness ratio (ICER) at 30 days, using the primary composite clinical outcome of major adverse cardiovascular events (MACE; comprising all‐cause death, nonfatal stroke, nonfatal recurrent myocardial infarction, or emergency revascularization prompted by ischemia) as the effectiveness criterion. Secondary outcomes include the ICER at 1 year, and MACE (and its components) at 30 days and at 1 year. Results The trial aimed to enroll 630 patients. Based on estimated event rates of 11% in the restrictive group and 15% in the liberal group, this number will provide 80% power to demonstrate clinical noninferiority of the restrictive group, with a noninferiority margin corresponding to a relative risk equal to 1.25. The sample size will also provide 80% power to show the cost‐effectiveness of the restrictive strategy at a threshold of €50 000 per quality‐adjusted life year. Conclusions REALITY will provide important guidance on the management of patients with AMI and anemia.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Gonzalo Calvo
- Àrea del Medicament Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - José Ramón González-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Cristina Avendano-Sola
- Clinical Pharmacology Service, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Etienne Puymirat
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, Institut Pasteur de Lille, Inserm U1011, F-59000 Lille, France; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Joan Albert Arnaiz
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV; Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Alexandra Rousseau
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Marine Cachanado
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Eric Vicaut
- AP-HP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, AP-HP, INSERM UMRS 1166, Paris, France
| | - Carma Karam
- Cardiology Department, Ambroise Paré Hospital, AP-HP, Boulogne, University of Versailles-Saint Quentin en Yvelines, Boulogne-Billancourt, France
| | - Nicolas Danchin
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris, France
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.,Royal Brompton Hospital, Imperial College, London, UK
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15
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Wax MK. Taking an Idea from Inception to Innovation: Evolution in Restrictive Transfusion Criteria. Facial Plast Surg 2020; 36:681-683. [PMID: 33368121 DOI: 10.1055/s-0040-1721111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Innovation in surgical care is a complex procedure. When you reflect on how your practice has changed, whether it be 5 years or over decades, it can be enlightening to not only see the change but also conceptualize how it came about. Examining one's practice as part of Pittsburgh Sleep Quality Index or as a result of reading the literature, attending a meeting, or some other educational activity can lead one to question if there is a better method available. In this manuscript, I will describe how outside influences initiated a paradigm shift that ultimately benefited patient care, the system, and my practice. The methodology has been used over the course of my career to influence and modulate practice patterns.
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Affiliation(s)
- Mark K Wax
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon
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16
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When to transfuse your acute care patient? A narrative review of the risk of anemia and red blood cell transfusion based on clinical trial outcomes. Can J Anaesth 2020; 67:1576-1594. [DOI: 10.1007/s12630-020-01763-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/07/2020] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
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17
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Moretti K, Marqués CG, Garbern S, Mbanjumucyo G, Uwamahoro C, Beaudoin FL, Amanullah S, Gjelsvik A, Aluisio AR. Transfusion, mortality and hemoglobin level: Associations among emergency department patients in Kigali, Rwanda. Afr J Emerg Med 2020; 10:68-73. [PMID: 32612911 PMCID: PMC7320208 DOI: 10.1016/j.afjem.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/06/2020] [Accepted: 01/09/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda. METHODS This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013-16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL. RESULTS Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p = 0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51-3.21) as compared to those ≤5.0 mg/dL. CONCLUSIONS No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice.
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Affiliation(s)
- Katelyn Moretti
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
- Brown University School of Public Health, Providence, USA
| | | | - Stephanie Garbern
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
| | - Gabin Mbanjumucyo
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
- Service d'Aide Médicale Urgente, Kigali, Rwanda
| | - Chantal Uwamahoro
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
- Service d'Aide Médicale Urgente, Kigali, Rwanda
| | - Francesca L Beaudoin
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
| | - Siraj Amanullah
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
| | - Annie Gjelsvik
- Brown University School of Public Health, Providence, USA
| | - Adam R Aluisio
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
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18
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Yao RQ, Ren C, Zhang ZC, Zhu YB, Xia ZF, Yao YM. Is haemoglobin below 7.0 g/dL an optimal trigger for allogenic red blood cell transfusion in patients admitted to intensive care units? A meta-analysis and systematic review. BMJ Open 2020; 10:e030854. [PMID: 32029484 PMCID: PMC7045194 DOI: 10.1136/bmjopen-2019-030854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES We employed a comprehensive systematic review and meta-analysis to assess benefits and risks of a threshold of haemoglobin level below 7 g/dL versus liberal transfusion strategy among critically ill patients, and even patients with septic shock. DESIGN Systematic review and meta-analysis. DATA SOURCES We performed systematical searches for relevant randomised controlled trials (RCTs) in the Cochrane Library, EMBASE and PubMed databases up to 1 September 2019. ELIGIBILITY CRITERIA RCTs among adult intensive care unit (ICU) patients comparing 7 g/dL as restrictive strategy with liberal transfusion were incorporated. DATA EXTRACTION AND SYNTHESIS The clinical outcomes, including short-term mortality, length of hospital stay, length of ICU stay, myocardial infarction (MI) and ischaemic events, were screened and analysed after data collection. We applied odds ratios (ORs) to analyse dichotomous outcomes and standardised mean differences (SMDs) to analyse continuous outcomes with fixed or random effects models based on heterogeneity evaluation for each outcome. RESULTS Eight RCTs with 3415 patients were included. Compared with a more liberal threshold, a red blood cell (RBC) transfusion threshold <7 g/dL haemoglobin showed no significant difference in short-term mortality (OR: 0.90, 95% CI: 0.67 to 1.21, p=0.48, I2=53%), length of hospital stay (SMD: -0.11, 95% CI: -0.30 to 0.07, p=0.24, I2=71%), length of ICU stay (SMD: -0.03, 95% CI: -0.14 to 0.08, p=0.54, I2=0%) or ischaemic events (OR: 0.80, 95% CI: 0.43 to 1.48, p=0.48, I2=51%). However, we found that the incidence of MI (OR: 0.54, 95% CI: 0.30 to 0.98, p=0.04, I2=0%) was lower in the group with the threshold <7 g/dL than that with the more liberal threshold. CONCLUSIONS An RBC transfusion threshold <7 g/dL haemoglobin is incapable of decreasing short-term mortality in ICU patients according to currently published evidences, while it might have potential role in reducing MI incidence.
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Affiliation(s)
- Ren-Qi Yao
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Chao Ren
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Zi-Cheng Zhang
- Department of Orthopedics, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Yi-Bing Zhu
- Department of Critical Care Medicine, Beijing Fuxing Hospital, Capital Medical University, Beijing, China
| | - Zhao-Fan Xia
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Yong-Ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
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Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R. Restrictive Transfusion Strategy and Clinical Decision Support Practices for Reducing RBC Transfusion Overuse. Am J Clin Pathol 2019; 152:544-557. [PMID: 31305890 DOI: 10.1093/ajcp/aqz070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Assess support for the effectiveness of two separate practices, restrictive transfusion strategy and computerized physician order entry/clinical decision support (CPOE/CDS) tools, in decreasing RBC transfusions in adult surgical and nonsurgical patients. METHODS Following the Centers for Disease Control and Prevention Laboratory Medicine Best Practice (LMBP) Systematic Review (A-6) method, studies were assessed for quality and evidence of effectiveness in reducing the percentage of patients transfused and/or units of blood transfused. RESULTS Twenty-five studies on restrictive transfusion practice and seven studies on CPOE/CDS practice met LMBP inclusion criteria. The overall strength of the body of evidence of effectiveness for restrictive transfusion strategy and CPOE/CDS was rated as high. CONCLUSIONS Based on these procedures, adherence to an institutional restrictive transfusion strategy and use of CPOE/CDS tools for hemoglobin alerts or reminders of the institution's restrictive transfusion policies are effective in reducing RBC transfusion overuse.
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Affiliation(s)
| | | | - Aaron Alford
- National Network of Public Health Institutes, Washington, DC
| | | | - Aryeh Shander
- Englewood Hospital and Medical Center, Englewood, NJ
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20
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Rayes HA, Vallabhajosyula S, Barsness GW, Anavekar NS, Go RS, Patnaik MS, Kashani KB, Jentzer JC. Association between anemia and hematological indices with mortality among cardiac intensive care unit patients. Clin Res Cardiol 2019; 109:616-627. [PMID: 31535171 PMCID: PMC7224152 DOI: 10.1007/s00392-019-01549-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/11/2019] [Indexed: 12/22/2022]
Abstract
Background Anemia and elevated red cell distribution width (RDW) or mean corpuscular volume (MCV) are associated with an adverse prognosis in patients with cardiovascular disease and critical illness. Limited data exist regarding these associations in unselected cardiac intensive care unit (CICU) patients. Methods Retrospective cohort study of CICU patients between January 1, 2007, and December 31, 2015, with a hemoglobin (Hb) level measured at admission. Multivariable regression was performed to determine predictors of hospital mortality, and Kaplan–Meier analysis was used to determine post-discharge survival. Results We included 9644 patients with a mean age of 67.5 ± 15.1 years, including 3604 (37.4%) females. The median (IQR) values of Hb, MCV and RDW were 12.2 g/dL (10.6, 13.7), 90.7 fL (87.3, 94.2) fL, and 14.1% (13.3, 15.8), respectively. Anemia (admission Hb < 12 g/dL) was present in 4434 (46%) patients. A total of 845 (8.8%) patients died in the hospital. Patients with anemia had higher hospital mortality (11.3% vs. 6.6%, unadjusted OR 1.82, 95% CI 1.58–2.10, p < 0.001). After multivariable regression, admission Hb and MCV were not significantly associated with hospital mortality (both p > 0.1), while admission RDW (adjusted OR 1.12 per 1%, 95% CI 1.07–1.18, p < 0.001) was significantly associated with hospital mortality. Hospital survivors with lower Hb, higher MCV, or higher RDW had lower post-discharge survival. Conclusion Elevated RDW on admission was independently associated with higher hospital mortality in CICU patients. These data emphasize the importance of hematologic abnormalities for mortality risk stratification in CICU populations. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-019-01549-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hamza A Rayes
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Saraschandra Vallabhajosyula
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ronald S Go
- Division of Hematology and Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mrinal S Patnaik
- Division of Hematology and Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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21
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Brady JS, Desai SV, Crippen MM, Eloy JA, Gubenko Y, Baredes S, Park RCW. Association of Anesthesia Duration With Complications After Microvascular Reconstruction of the Head and Neck. JAMA FACIAL PLAST SU 2019; 20:188-195. [PMID: 28983575 DOI: 10.1001/jamafacial.2017.1607] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking. Objective To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck. Design, Setting, and Participants The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016. Exposures Microvascular reconstructive surgery of the head and neck. Main Outcomes and Measures Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality. Results A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16). Conclusions and Relevance Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery. Level of Evidence 3.
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Affiliation(s)
- Jacob S Brady
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Stuti V Desai
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Meghan M Crippen
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark.,Department of Ophthalmology, Rutgers New Jersey Medical School, Newark
| | - Yuriy Gubenko
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
| | - Richard Chan Woo Park
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
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22
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Is A Hemoglobin Concentration As Low As 7 g/dL Adequate For All Critically Ill Patients With Sepsis? Legitimate Doubts Remain! Crit Care Med 2019; 45:2101-2102. [PMID: 29148987 DOI: 10.1097/ccm.0000000000002739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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23
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Affiliation(s)
- Mohammed Ezzat Moemen
- Department of Anaesthesia and Intensive Care
Faculty of Medicine
Zagazig University
Zagazig Egypt
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24
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Chan CH, Ziyadi GM, Zuhdi MA. Adverse Outcomes of Perioperative Red Blood Cell Transfusions in Coronary Artery Bypass Grafting in Hospital Universiti Sains Malaysia. Malays J Med Sci 2019; 26:49-63. [PMID: 31303850 PMCID: PMC6613466 DOI: 10.21315/mjms2019.26.3.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/03/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Perioperative red blood cell (RBC) transfusion in coronary artery bypass grafting (CABG) has both benefits and harms. Our aim was to study the association between perioperative RBC transfusion and its adverse outcomes. METHODS This was a retrospective study of patients who underwent isolated CABG in Hospital Universiti Sains Malaysia, Kelantan, Malaysia, from 1 January 2013 until 31 December 2017. Data were collected from medical records, and comparisons were made between patients who received perioperative RBC transfusions and those who did not have adverse outcomes after CABG. RESULTS A total of 108 patients who underwent isolated CABG were included in our study, and 78 patients received perioperative RBC transfusions. Patients who received perioperative RBC transfusions compared to those who did not were significantly more likely to develop prolonged ventilatory support (21.8% versus 0%, P = 0.003), cardiac morbidity (14.1% versus 0%, P = 0.032), renal morbidity (28.2% versus 3.3%, P = 0.005) and serious infection (20.5% versus 3.3%, P = 0.037). With each unit of packed RBC transfusions, there was a significantly increased risk of prolonged ventilatory support (adjusted odds ratio [AOR] = 1.45; 95% confidence interval [CI] = 1.20-1.77; P < 0.001), cardiac morbidity (AOR =1.40; 95%CI = 1.01-1.79; P = 0.007), renal morbidity (AOR = 1.23; 95%CI = 1.03-1.45; P = 0.019) and serious infection (AOR = 1.31; 95%CI = 1.07-1.60; P = 0.009). CONCLUSION Perioperative RBC transfusion in isolated CABG patients is associated with increased risks of developing adverse events such as prolonged ventilatory support, cardiac morbidity, renal morbidity and serious infection.
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Affiliation(s)
- Choon Hua Chan
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Ghazali Mohamad Ziyadi
- Unit of Cardiothoracic Surgery, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Mamat Ahmad Zuhdi
- Unit of Cardiothoracic Surgery, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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25
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Taneja A, El-Bakoury A, Khong H, Railton P, Sharma R, Johnston KD, Puloski S, Smith C, Powell J. Association between Allogeneic Blood Transfusion and Wound Infection after Total Hip or Knee Arthroplasty: A Retrospective Case-Control Study. J Bone Jt Infect 2019; 4:99-105. [PMID: 31192107 PMCID: PMC6536767 DOI: 10.7150/jbji.30636] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
Background: To assess using a retrospective case control study, whether patients undergoing primary, elective total hip or knee arthroplasty who receive blood transfusion have a higher rate of post-operative infection compared to those who do not. Materials and Methods: Data on elective primary total hip or knee arthroplasty patients, including patient characteristics, co-morbidities, type and duration of surgery, blood transfusion, deep and superficial infection was extracted from the Alberta Bone and Joint Health Institute (ABJHI). Logistic regression analysis was used to compare deep infection and superficial infection in blood-transfused and non-transfused cohorts. Results: Of the 27892 patients identified, 3098 (11.1%) received blood transfusion (TKA 9.7%; THA 13.1%). Overall, the rate of superficial infection (SI) was 0.5% and deep infection (DI) was 1.1%. The infection rates in the transfused cohort were SI 1.0% and DI 1.6%, and in the non-transfused cohort were SI 0.5% and DI 1.0%. The transfused cohort had an increased risk of superficial infection (adjusted odds ratio (OR) 1.9 [95% CI 1.2-2.9, p-value 0.005]) as well as deep infection (adjusted OR 1.6 [95% CI 1.1-2.2, p-value 0.008]). Conclusion: The odds of superficial and deep wound infection are significantly increased in primary, elective total hip and knee arthroplasty patients who receive blood transfusion compared to those who did not. This study can potentially help in reducing periprosthetic hip or knee infections.
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Affiliation(s)
- Ashish Taneja
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Ahmed El-Bakoury
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.,University of Alexandria, Egypt
| | - Hoa Khong
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Pam Railton
- Alberta Health Services, Calgary, Alberta, Canada
| | - Rajrishi Sharma
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.,McCaig Institute for Bone and Joint Health
| | - Kelly Dean Johnston
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Shannon Puloski
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Christopher Smith
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - James Powell
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
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26
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Guedeney P, Sorrentino S, Claessen B, Mehran R. The link between anemia and adverse outcomes in patients with acute coronary syndrome. Expert Rev Cardiovasc Ther 2019; 17:151-159. [DOI: 10.1080/14779072.2019.1575729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul Guedeney
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
- Institut de Cardiologie, Sorbonne Université, ACTION Study group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Sabato Sorrentino
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
- Division of cardiology, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Bimmer Claessen
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
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27
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Huang D, Chen C, Ming Y, Liu J, Zhou L, Zhang F, Yan M, Du L. Risk of massive blood product requirement in cardiac surgery: A large retrospective study from 2 heart centers. Medicine (Baltimore) 2019; 98:e14219. [PMID: 30702577 PMCID: PMC6380710 DOI: 10.1097/md.0000000000014219] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Cardiac surgery under cardiopulmonary bypass (CPB) accounts for most consumption of red blood cells (RBCs). Identifying risk factors for massive red blood cell transfusion (MRT) in cardiac surgery may help to reduce this consumption.We retrospectively analyzed 8238 patients who underwent valve surgery and/or coronary artery bypass grafting (CABG) under CPB at 2 major heart centers in China. Uni- and multivariate logistic regression was carried out to assess whether risk factors for MRT (defined as receiving at least 4 units RBCs) varied with type of cardiac surgery.A total of 1691 patients (21%) received at least 4 units RBCs (6.77 ± 4.78 units per person). This MRT group consumed 70% of the total units of allogeneic RBCs in the study. MRT incidence was 2-fold higher among patients undergoing CABG with or without valve surgery than among patients undergoing valve surgery alone. Multivariate logistic analysis identified the following MRT risk factors common to valve surgery alone, CABG alone, and their combination: female sex, older age, renal dysfunction, lower body mass index, lower preoperative hemoglobin, and longer CPB. Several independent MRT risk factors were also identified specific to valve surgery: active endocarditis, nonatrial fibrillation, smaller left atrium diameter, abnormal international normalized ratio, and repeat surgery.Different types of cardiac surgery share several, but not all, MRT risk factors. This study may help guide the prediction and management of patients at higher MRT risk.
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Affiliation(s)
- Dou Huang
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Changwei Chen
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jing Liu
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Li Zhou
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Fengjiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lei Du
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
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28
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Daly DJ, Myles PS, Smith JA, Knight JL, Clavisi O, Bain DL, Glew R, Gibbs NM, Merry AF. Anticoagulation, bleeding and blood transfusion practices in Australasian cardiac surgical practice. Anaesth Intensive Care 2019; 35:760-8. [DOI: 10.1177/0310057x0703500516] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We surveyed contemporary Australasian cardiac surgical and anaesthetic practice, focusing on antiplatelet and antifibrinolytic therapies and blood transfusion practices. The cohort included 499 sequential adult cardiac surgical patients in 12 Australasian teaching hospitals. A total of 282 (57%) patients received red cell or component transfusion. The median (IQR) red cell transfusion threshold haemogloblin levels were 66 (61-73) g/l intraoperative^ and 79 (74-85) g/l postoperatively. Many (40%) patients had aspirin within five days of surgery but this was not associated with blood loss or transfusion; 15% had Clopidogrel within seven days of surgery. In all, 30 patients (6%) required surgical re-exploration for bleeding. Factors associated with transfusion and excessive bleeding include pre-existing renal impairment, preoperative Clopidogrel therapy, and complex or emergency surgery. Despite frequent (67%) use of antifibrinolytic therapy, there was a marked variability in red cell transfusion rates between centres (range 17 to 79%, P <0.001). This suggests opportunities for improvement in implementation of guidelines and effective blood-sparing interventions. Many patients presenting for surgery receive antiplatelet and/or antifibrinolytic therapy, yet the subsequent benefits and risks remain unclear.
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Affiliation(s)
- D. J. Daly
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria
| | - P. S. Myles
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria
| | - J. A. Smith
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Cardiothoracic Surgery Unit, Monash Medical Centre and Professor, Department of Surgery, Monash University, Clayton and Steering Committee, ASCTS Victorian Cardiac Surgery Database, Victoria
| | - J. L. Knight
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Head, Cardiac Services, Flinders Medical Centre and Associate Professor, Department of Surgery, Flinders University, Bedford Park, South Australia
| | - O. Clavisi
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- ANZCA Trials Group, Australian and New Zealand College of Anaesthetists, Melbourne, Victoria
| | - D. L. Bain
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria
| | - R. Glew
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Green Lane Department Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - N. M. Gibbs
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - A. F. Merry
- Cardiothoracic Units, Alfred Hospital; Austin Health, Monash Medical Centre, Melbourne; Geelong Hospital, Geelong; St. Vincent's Hospital, Fitzroy, Victoria; Royal Perth Hospital, Perth; Sir Charles Gairdner Hospital, Nedlands, Western Australia; Flinders Medical Centre, Bedford Park, South Australia, Royal North Shore, Westmead Hospital, Sydney, New South Wales, Australia; Auckland City Hospital, Auckland, New Zealand and Prince of Wales Hospital, Shatin, New Territories, Hong Kong
- Green Lane Department Anaesthesia, Auckland City Hospital and Professor of Anaesthesiology, University of Auckland, Auckland, New Zealand
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29
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Khasne RW, Kulkarni PA, Kulkarni AP. Landmark Papers on Blood and Component Transfusion Therapy in the Critically Ill: A Critical Analysis. Indian J Crit Care Med 2019; 23:S207-S211. [PMID: 31656380 PMCID: PMC6785815 DOI: 10.5005/jp-journals-10071-23254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
How to cite this article: Khasne RW, Kulkarni PA, Kulkarni AP. Landmark Papers on Blood and Component Transfusion Therapy in the Critically Ill: A Critical Analysis. Indian J Crit Care Med 2019;23(Suppl 3):S207–S211.
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Affiliation(s)
| | - Pradnya Atul Kulkarni
- Blood Bank, Department of Pathology, KJ Somaiya Hospital, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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30
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Levy JH, Steiner ME. How to interpret recent restrictive transfusion trials in cardiac surgery: More new data or new more data? J Thorac Cardiovasc Surg 2018; 157:1038-1040. [PMID: 30527721 DOI: 10.1016/j.jtcvs.2018.10.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC.
| | - Marie E Steiner
- Department of Hematology and Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minn
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31
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Mincu RI, Rassaf T, Totzeck M. Red blood cell transfusion in patients with ST-elevation myocardial infarction-a meta-analysis of more than 21,000 patients. Neth Heart J 2018; 26:454-460. [PMID: 30039381 PMCID: PMC6115305 DOI: 10.1007/s12471-018-1137-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Red blood cell transfusion remains controversial in patients with acute coronary syndromes and particularly in patients with ST-elevation myocardial infarction (STEMI). METHODS We systematically searched PubMed, Cochrane, EMBASE, and Web of Science for studies published until January 2017 describing the outcomes in patients with STEMI who received red blood cell transfusion, compared with patients who did not. RESULTS A total of 21,770 patients with STEMI from 5 cohort studies were included in the meta-analysis, 984 (4.5%) received red blood cell transfusion and 20,786 (95.4%) did not. Red blood cell transfusion was associated with a higher risk of in-hospital and long-term mortality, emergency repeated percutaneous coronary intervention (PCI), reinfarction rate, stroke rate, and heart failure. The group with red blood cell transfusion had a slightly higher incidence of diabetes mellitus and hypertension, but a lower incidence of smoking. The two groups had the same incidence of prior myocardial infarction, prior coronary artery bypass graft surgery and malignancy. Prior heart failure, prior stroke and prior PCI were more frequent in the group that had received red blood cell transfusion. The mean nadir haemoglobin was 8.5 ± 0.1 g/dl in the group with red blood cell transfusion and 12.5 ± 0.4 g/dl in the control group, p < 0.001. CONCLUSIONS Red blood cell transfusion increases the morbidity and mortality in patients with STEMI. This difference could not be explained by the higher morbidity in the red blood cell transfusion group alone. Further randomised controlled trials are required to provide a reliable haemoglobin threshold for these patients.
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Affiliation(s)
- R I Mincu
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany.,University and Emergency Hospital, Cardiac Research Unit, 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania
| | - T Rassaf
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany
| | - M Totzeck
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany.
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A practical guide on how to handle patients with bleeding events while on oral antithrombotic treatment. Neth Heart J 2018; 26:341-351. [PMID: 29740754 PMCID: PMC5968004 DOI: 10.1007/s12471-018-1117-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bleeding is a feared complication in patients who are treated with antithrombotic therapy (oral anticoagulation or antiplatelet therapy). Management of antithrombotic therapy after bleeding poses a dilemma where restarting the crucial medication could lead to recurrent bleeding, while interrupting or even discontinuing treatment could increase the thrombotic risk. In this review, we provide recommendations regarding the treatment of patients with a bleeding event while on oral antithrombotic therapy, based on the literature and expert opinion.
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Cortés-Puch I, Wiley BM, Sun J, Klein HG, Welsh J, Danner RL, Eichacker PQ, Natanson C. Risks of restrictive red blood cell transfusion strategies in patients with cardiovascular disease (CVD): a meta-analysis. Transfus Med 2018; 28:335-345. [PMID: 29675833 DOI: 10.1111/tme.12535] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 01/28/2023]
Abstract
AIM To evaluate the risks of restrictive red blood cell transfusion strategies (haemoglobin 7-8 g dL-1 ) in patients with and without known cardiovascular disease (CVD). BACKGROUND Recent guidelines recommend restrictive strategies for CVD patients hospitalised for non-CVD indications, patients without known CVD and patients hospitalised for CVD corrective procedures. METHODS/MATERIALS Database searches were conducted through December 2017 for randomised clinical trials that enrolled patients with and without known CVD, hospitalised either for CVD-corrective procedures or non-cardiac indications, comparing effects of liberal with restrictive strategies on major adverse coronary events (MACE) and death. RESULTS In CVD patients not undergoing cardiac interventions, a liberal strategy decreased (P = 0·01) the relative risk (95% CI) (RR) of MACE [0·50 (0·29-0·86)] (I2 = 0%). Among patients without known CVD, the incidence of MACE was lower (1·7 vs 3·9%), and the effect of a liberal strategy on MACE [0·79, (0·39-1·58)] was smaller and non-significant but not different from CVD patients (P = 0·30). Combining all CVD and non-CVD patients, a liberal strategy decreased MACE [0·59, (0·39-0·91); P = 0·02]. Conversely, among studies reporting mortality, a liberal strategy decreased mortality in CVD patients (11·7% vs·13·3%) but increased mortality (19·2% vs 18·0%) in patients without known CVD [interaction P = 0·05; ratio of RR 0·73, (0·53-1·00)]. A liberal strategy also did not benefit patients undergoing cardiac surgery; data were insufficient for percutaneous cardiac procedures. CONCLUSIONS In patients hospitalised for non-cardiac indications, liberal transfusion strategies are associated with a decreased risk of MACE in both those with and without known CVD. However, this only provides a survival benefit to CVD patients not admitted for CVD-corrective procedures.
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Affiliation(s)
- I Cortés-Puch
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - B M Wiley
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - J Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - H G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - J Welsh
- National Institutes of Health Library, National Institutes of Health, Bethesda, Maryland, USA
| | - R L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - P Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - C Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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Shehata N, Whitlock R, Fergusson DA, Thorpe KE, MacAdams C, Grocott HP, Rubens F, Fremes S, Lellouche F, Bagshaw S, Royse A, Rosseel PM, Hare G, Medicis ED, Hudson C, Belley-Cote E, Bainbridge D, Kent B, Shaw A, Byrne K, Syed S, Royse CF, McGuiness S, Hall J, Mazer CD. Transfusion Requirements in Cardiac Surgery III (TRICS III): Study Design of a Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2018; 32:121-129. [DOI: 10.1053/j.jvca.2017.10.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Indexed: 11/11/2022]
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Kim K, Choi HS, Chung SP, Kwon WY. Septic Shock. ESSENTIALS OF SHOCK MANAGEMENT 2018. [PMCID: PMC7121676 DOI: 10.1007/978-981-10-5406-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
For more than 20 years, sepsis has been defined as symptoms associated with the response to microorganism infection, which was more specifically called systemic inflammatory response syndrome (SIRS). With the evidence of organ failure, it was called severe sepsis, and this could lead to hypotension (septic shock). However, with the deep understanding of the pathophysiology of sepsis, sepsis has been known as both inflammatory and anti-inflammatory. Additionally, the classic use of SIRS could lead to overestimation of sepsis. For example, usual common cold could be identified as sepsis in classic definition. With this background, new sepsis definition, Sepsis 3, was introduced and sepsis was defined as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” The management of sepsis has been changed dramatically, with the development of Surviving Sepsis Campaign, which substantially increased the survival of sepsis. However, this is not with the help of a new drug, but the implementation of a treatment system. Unfortunately, no specific drug for sepsis has survived in clinical use even though many candidate drugs have been successfully investigated in preclinical setting, and this leads to the new approach to the sepsis.
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Torella F, Haynes SL, Bennett J, Sewell D, McCollum CN. Can Hospital Transfusion Committees Change Transfusion Practice? J R Soc Med 2017; 95:450-2. [PMID: 12205210 PMCID: PMC1279992 DOI: 10.1177/014107680209500907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Blood and blood products are commonly over-used in hospital practice. We investigated whether the introduction of a red-cell transfusion trigger (haemoglobin <8 g dL–1) influenced transfusion practice in surgery. Coronary artery bypass grafts (CABGs, n=400), total hip replacements (n=107), colectomies (n=85) and transurethral prostatectomies (TURPs, n=158) were reviewed over two periods of six months, before and after the introduction of the policy by the local hospital transfusion committee. After introduction of the policy, the proportion of patients transfused fell from 57% to 45% with CABGs (P=0.02) and from 52% to 26% with hip replacements (P=0.006); for colectomies and TURPs there was no change. Hospital stay did not increase in any of the groups. In the second period, haemoglobin concentration on discharge was lower after total hip replacement, by a mean (95% CI) of 0.7 (0.3–1.2) g dL–1 (P=0.002) and after colectomy, by a mean of 0.6 (0.1–1.1) g dL–1 (P=0.03). Although other factors cannot be excluded, we suggest that the reductions in red-cell transfusion were in large part attributable to the new transfusion policy.
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Affiliation(s)
- Francesco Torella
- Academic Surgery Unit, Education and Research Centre, South Manchester University Hospital, Southmoor Road, Manchester M23 9LT, UK.
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Gandhi SJ, Hagans I, Nathan K, Hunter K, Roy S. Prevalence, Comorbidity and Investigation of Anemia in the Primary Care Office. J Clin Med Res 2017; 9:970-980. [PMID: 29163729 PMCID: PMC5687900 DOI: 10.14740/jocmr3221w] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/23/2017] [Indexed: 01/17/2023] Open
Abstract
Background Anemia has a myriad of causes and its prevalence is growing. Anemia is associated with increased all-cause hospitalization and mortality in community-dwelling individuals above age 65 years. Our aim was to determine the prevalence and severity of anemia in adult patients in our primary care office and to determine the relationship between anemia and medical comorbidities. Methods Electronic medical records of 499 adult patients in our suburban internal medicine office were reviewed who had had at least one hemoglobin value and did not undergo moderate to high-risk surgery in the preceding 30 days. Results About one-fifth (21.1%) of the patients had anemia. The mean age of patients with anemia was 62.6 years. Among all patients with anemia, 20.3% were males and 79.6% were females. Of these patients, 60.1% had mild anemia (hemoglobin 11 - 12.9 g/dL) and 39.8% had moderate anemia (hemoglobin 8 - 10.9 g/dL). For every year of increase in age, there was 1.8% increased odds of having anemia. African-American race had 5.2 times greater odds of having anemia than the Caucasian race. Hispanic race had 3.2 times greater odds of having anemia compared to the Caucasian race. Patients with anemia had a greater average number of comorbidities compared to patients without anemia (1.74 and 0.96, respectively; P < 0.05). There was a statistically greater percentage of patients with essential hypertension, hypothyroidism, chronic kidney disease, malignancy, rheumatologic disease, congestive heart failure, and coronary artery disease in the anemic population as compared to the non-anemic population. Of the patients, 41% with mild anemia and 62% with moderate anemia underwent additional diagnostic studies. Of the patients, 14.8% had resolution of anemia without therapy in 1 year, 15.7% were on iron replacement therapy, and 6.5% were on cobalamin therapy. No specific etiology of anemia was found in 24% of patients. Conclusion A higher prevalence of anemia was associated with advancing age, African-American and Hispanic ethnicity, and comorbidities, such as essential hypertension, hypothyroidism, chronic kidney disease, malignancy, rheumatologic disease, congestive heart failure, and coronary artery disease. It is important to be aware of the demographic factors and their relationship to anemia in primary care.
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Affiliation(s)
- Shivani Jatin Gandhi
- Department of Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Iris Hagans
- Department of Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Karim Nathan
- Department of Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Krystal Hunter
- Cooper Research Institute, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Satyajeet Roy
- Department of Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
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Kumar MA, Levine J, Faerber J, Elliott JP, Winn HR, Doerfler S, Le Roux P. The Effects of Red Blood Cell Transfusion on Functional Outcome after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 108:807-816. [PMID: 29038077 DOI: 10.1016/j.wneu.2017.09.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. OBJECTIVE To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. METHODS A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. RESULTS Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65). CONCLUSIONS Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Levine
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Faerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Paul Elliott
- Colorado Neurological Institute, Englewood, Colorado, USA
| | - H Richard Winn
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Le Roux
- Brain and Spine Center and Lankenau Institute of Medical Research Lankenau Medical Center, Wynnewood, Pennsylvania, USA.
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Napolitano LM. Anemia and Red Blood Cell Transfusion: Advances in Critical Care. Crit Care Clin 2017; 33:345-364. [PMID: 28284299 DOI: 10.1016/j.ccc.2016.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Anemia is common in the intensive care unit (ICU), resulting in frequent administration of red blood cell (RBC) transfusions. Significant advances have been made in understanding the pathophysiology of anemia in the ICU, which is anemia of inflammation. This anemia is related to high hepcidin concentrations resulting in iron-restricted erythropoiesis, and decreased erythropoietin concentrations. A new hormone (erythroferrone) has been identified, which mediates hepcidin suppression to allow increased iron absorption and mobilization from iron stores. RBC transfusions are most commonly administered to ICU patients for treatment of anemia. All strategies to reduce anemia in the ICU should be implemented.
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Affiliation(s)
- Lena M Napolitano
- Division of Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery], Department of Surgery, University of Michigan Health System, University Hospital, Room 1C340-UH, 1500 East Medical Drive, SPC 5033, Ann Arbor, MI 48109-5033, USA.
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Evidence-Based Red Blood Cell Transfusion Practices in Cardiac Surgery. Transfus Med Rev 2017; 31:230-235. [DOI: 10.1016/j.tmrv.2017.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/21/2017] [Accepted: 06/17/2017] [Indexed: 01/28/2023]
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Delaney M, Stark PC, Suh M, Triulzi DJ, Hess JR, Steiner ME, Stowell CP, Sloan SR. Massive Transfusion in Cardiac Surgery: The Impact of Blood Component Ratios on Clinical Outcomes and Survival. Anesth Analg 2017; 124:1777-1782. [PMID: 28333704 DOI: 10.1213/ane.0000000000001926] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac surgery is the most common setting for massive transfusion in medically advanced countries. Studies of massive transfusion after injury suggest that the ratios of administered plasma and platelets (PLT) to red blood cells (RBCs) affect mortality. Data from the Red Cell Storage Duration Study (RECESS), a large randomized trial of the effect of RBC storage duration in patients undergoing complex cardiac surgery, were analyzed retrospectively to investigate the association between blood component ratios used in massively transfused patients and subsequent clinical outcomes. METHODS Massive transfusion was defined as those who had ≥6 RBC units or ≥8 total blood components. For plasma, high ratio was defined as ≥1 plasma unit:1 RBC unit. For PLT transfusion, high ratio was defined as ≥0.2 PLT doses:1 RBC unit; PLT dose was defined as 1 apheresis PLT or 5 whole blood PLT equivalents. The clinical outcomes analyzed were mortality and the change in the Multiple Organ Dysfunction Score (ΔMODS) comparing the preoperative score with the highest composite score through the earliest of death, discharge, or day 7. Outcomes were compared between patients transfused with high and low ratios. Linear and Cox regression were used to explore relationships between predictors and continuous outcomes and time to event outcomes. RESULTS A total of 324 subjects met the definition of massive transfusion. In those receiving high plasma:RBC ratio, the mean (SE) 7- and 28-day ΔMODS was 1.24 (0.45) and 1.26 (0.56) points lower, (P = .007 and P = .024), respectively, than in patients receiving lower ratios. In patients receiving high PLT:RBC ratio, the mean (SE) 7- and 28-day ΔMODS were 1.55 (0.53) and 1.49 (0.65) points lower (P = .004 and P = .022), respectively. Subjects who received low-ratio plasma:RBC transfusion had excess 7-day mortality compared with those who received high ratio (7.2% vs 1.7%, respectively, P = .0318), which remained significant at 28 days (P = .035). The ratio of PLT:RBCs was not associated with differences in mortality. CONCLUSIONS This analysis found that in complex cardiac surgery patients who received massive transfusion, there was an association between the composition of blood products used and clinical outcomes. Specifically, there was less organ dysfunction in those who received high-ratio transfusions (plasma:RBCs and PLT:RBCs), and lower mortality in those who received high-ratio plasma:RBC transfusions.
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Affiliation(s)
- Meghan Delaney
- From the *Medical Division and Department of Laboratory Medicine, University of Washington, Seattle, Washington; †Center for Epidemiological and Statistical Research, New England Research Institutes (Data Coordinating Center), Watertown, Massachusetts; ‡Division of Transfusion Medicine, Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania; §Harborview Medical Center, Department of Laboratory Medicine and Division of Hematology, University of Washington, Seattle, Washington; ‖Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; ¶Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and #Department of Laboratory Medicine, Boston Children's Hospital and Department of Pathology, Harvard Medical School, Boston, Massachusetts
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Osborne Z, Hanson K, Brooke BS, Schermerhorn M, Henke P, Faizer R, Schanzer A, Goodney P, Bower T, DeMartino RR. Variation in Transfusion Practices and the Association with Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative. Ann Vasc Surg 2017; 46:1-16. [PMID: 28689939 DOI: 10.1016/j.avsg.2017.06.154] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Blood transfusions are associated with adverse events. We examined perioperative transfusion practices and associated complications following open vascular procedures nationwide in the Vascular Quality Initiative (VQI). METHODS Adults undergoing open abdominal aortic aneurysm repair (OAR) and lower extremity arterial bypass (Bypass) within VQI (2003-2016) were identified. All emergent cases, patients with preoperative hemoglobin <7 g/dL, preoperative hospitalization >1 day, or a return to operating room during the index hospitalization were excluded. Units of red blood cells transfused were the primary outcome. Secondary outcomes were postoperative myocardial infarction (MI) and death. Patient, center, and procedural factors were evaluated. Multivariable mixed effects negative binomial regression and multivariable logistic regression were performed. RESULTS We identified 24,131 procedures (OAR 3885, 16.1%; Bypass 20,246, 83.9%) among 22,532 patients (10.1% had >1 procedure). Overall, 37.5% of OAR and 19.5% of Bypass were transfused. Transfusion rates varied across estimated blood loss quartiles and across various preoperative hemoglobin levels. The overall rate of postoperative MI and death was 4.0% and 1.8% for OAR, and 2.2% and 0.7% for Bypass, respectively. In univariate and multivariable analysis, transfusions were associated with an increased risk of postoperative MI and death. A mixed effects negative binomial model demonstrated variation in transfusions across centers (P < 0.001). Female gender and preoperative anemia were significantly associated with transfusions. CONCLUSIONS Blood transfusions are variable across centers in VQI. Transfusions are associated with a higher postoperative MI and death after OAR and Bypass. Efforts to reduce transfusion may focus on center variability, gender, and preoperative anemia.
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Affiliation(s)
- Zachary Osborne
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Kristine Hanson
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Benjamin S Brooke
- Section of Vascular Surgery, The University of Utah School of Medicine, Salt Lake City, UT
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Peter Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Rumi Faizer
- Division of Vascular Surgery, University of Minnesota, Minneapolis, MN
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts Medical Center, Worcester, MA
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, NH
| | - Thomas Bower
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Choi YJ, Kim SO, Sim JH, Hahm KD. Postoperative Anemia Is Associated with Acute Kidney Injury in Patients Undergoing Total Hip Replacement Arthroplasty: A Retrospective Study. Anesth Analg 2017; 122:1923-8. [PMID: 26451518 DOI: 10.1213/ane.0000000000001003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Chronic and acute anemia are both correlated with an increased risk of injury to major organs, such as the brain, heart, and kidney. We evaluated the association between postoperative anemia (hemoglobin [Hb] < 10 g/dL) and acute kidney injury (AKI) in patients undergoing total hip replacement arthroplasty (THRA). METHODS Patients who underwent THRA between January 2005 and February 2013 were retrospectively reviewed. We divided patients into 2 groups: Hb < 10 (n = 938) and Hb ≥ 10 (n = 1529). They were then categorized according to changes in plasma creatinine concentration within 48 hours of THRA using Acute Kidney Injury Network criteria. To evaluate the association between postoperative anemia and postoperative AKI, an inverse-probability-of-treatment weighted method was used and both univariate and multivariable analyses were performed. RESULTS Postoperative anemia was significantly associated with postoperative AKI (multivariate odds ratio, 2.036; 95% confidence interval, 1.369-3.028; P < 0.001; inverse probability-of-treatment weighted odds ratio, 1.817; 95% confidence interval, 1.169-2.826; P = 0.011). In patients with a normal glomerular filtration rate, postoperative AKI was also related to postoperative anemia (P = 0.010). CONCLUSIONS Postoperative anemia was associated with postoperative AKI after THRA. Although our study was limited by its retrospective design, our observation suggests that postoperative anemia may play a role in postoperative AKI.
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Affiliation(s)
- Yoon Ji Choi
- From the *Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea; and Departments of †Clinical Epidemiology and Biostatistics and ‡Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Outcomes of Protocol-Driven Care of Critically Ill Severely Anemic Patients for Whom Blood Transfusion Is Not an Option. Crit Care Med 2017; 44:1109-15. [PMID: 26807684 DOI: 10.1097/ccm.0000000000001599] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To compare the outcomes of severely anemic critically ill patients for whom transfusion is not an option ("bloodless" patients) with transfused patients. DESIGN Cohort study with propensity score matching. SETTING ICU of a referral center. PATIENTS One hundred seventy-eight bloodless and 441 transfused consecutive severely anemic, critically ill patients, admitted between May 1996 and April 2011, and having at least one hemoglobin level less than or equal to 8 g/dL within 24 hours of ICU admission. Patients with diagnosis of brain injury, acute myocardial infarction, or status postcardiac surgery were excluded. INTERVENTIONS Allogeneic RBC transfusion during ICU stay. MEASUREMENTS AND MAIN RESULTS Primary outcome was in-hospital mortality. Other outcomes were ICU mortality, readmission to ICU, new electrocardiographic or cardiac enzyme changes suggestive of cardiac ischemia or injury, and new positive blood culture result. Transfused patients were older, had higher hemoglobin level at admission, and had higher Acute Physiology and Chronic Health Evaluation II score. Hospital mortality rates were 24.7% in bloodless and 24.5% in transfused patients (odds ratio, 1.01; 95% CI, 0.68-1.52; p = 0.95). Adjusted odds ratio of hospital mortality was 1.52 (95% CI, 0.95-2.43; p = 0.08). No significant difference in ICU readmission or positive blood culture results was observed. Analysis of propensity score-matched cohorts provided similar results. CONCLUSIONS Overall risk of mortality in severely anemic critically ill bloodless patients appeared to be comparable with transfused patients, albeit the latter group had older age and higher Acute Physiology and Chronic Health Evaluation II score. Use of a protocol to manage anemia in these patients in a center with established patient blood management and bloodless medicine and surgery programs is feasible and likely to contribute to improved outcome, whereas more studies are needed to better delineate the impact of such programs.
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Myles P, Bellomo R, Corcoran T, Forbes A, Wallace S, Peyton P, Christophi C, Story D, Leslie K, Serpell J, McGuinness S, Parke R. Restrictive versus liberal fluid therapy in major abdominal surgery (RELIEF): rationale and design for a multicentre randomised trial. BMJ Open 2017; 7:e015358. [PMID: 28259855 PMCID: PMC5353290 DOI: 10.1136/bmjopen-2016-015358] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The optimal intravenous fluid regimen for patients undergoing major abdominal surgery is unclear. However, results from many small studies suggest a restrictive regimen may lead to better outcomes. A large, definitive clinical trial evaluating perioperative fluid replacement in major abdominal surgery, therefore, is required. METHODS/ANALYSIS We designed a pragmatic, multicentre, randomised, controlled trial (the RELIEF trial). A total of 3000 patients were enrolled in this study and randomly allocated to a restrictive or liberal fluid regimen in a 1:1 ratio, stratified by centre and planned critical care admission. The expected fluid volumes in the first 24 hour from the start of surgery in restrictive and liberal groups were ≤3.0 L and ≥5.4 L, respectively. Patient enrolment is complete, and follow-up for the primary end point is ongoing. The primary outcome is disability-free survival at 1 year after surgery, with disability defined as a persistent (at least 6 months) reduction in functional status using the 12-item version of the World Health Organisation Disability Assessment Schedule. ETHICS/DISSEMINATION The RELIEF trial has been approved by the responsible ethics committees of all participating sites. Participant recruitment began in March 2013 and was completed in August 2016, and 1-year follow-up will conclude in August 2017. Publication of the results of the RELIEF trial is anticipated in early 2018. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier NCT01424150.
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Affiliation(s)
- Paul Myles
- Alfred Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Monash University, Melbourne, Victoria, Australia
- Austin Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Tomas Corcoran
- University of Western Australia, Melbourne, Victoria, Australia
| | | | - Sophie Wallace
- Alfred Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | | | - Chris Christophi
- Austin Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - David Story
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Kate Leslie
- Monash University, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jonathan Serpell
- Alfred Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
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Abstract
Transfusion of red blood cells (RBCs) is a balance between providing benefit for patients while avoiding risks of transfusion. Randomized, controlled trials of restrictive RBC transfusion practices have shown equivalent patient outcomes compared with liberal transfusion practices, and meta-analyses have shown improved in-hospital mortality, reduced cardiac events, and reduced bacterial infections. This body of level 1 evidence has led to substantial, improved blood utilization and reduction of inappropriate blood transfusions with implementation of clinical decision support via electronic medical records, along with accompanying educational initiatives.
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Affiliation(s)
- Lawrence Tim Goodnough
- Department of Pathology, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA.
| | - Anil K Panigrahi
- Department of Pathology, Stanford University, Stanford, CA, USA; Department of Anesthesiology, Stanford University, Stanford, CA, USA
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Menendez ME, Lu N, Huybrechts KF, Ring D, Barnes CL, Ladha K, Bateman BT. Variation in Use of Blood Transfusion in Primary Total Hip and Knee Arthroplasties. J Arthroplasty 2016; 31:2757-2763.e2. [PMID: 27325367 DOI: 10.1016/j.arth.2016.05.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/22/2016] [Accepted: 05/09/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is growing clinical and policy emphasis on minimizing transfusion use in elective joint arthroplasty, but little is known about the degree to which transfusion rates vary across US hospitals. This study aimed to assess hospital-level variation in use of allogeneic blood transfusion in patients undergoing elective joint arthroplasty and to characterize the extent to which variability is attributable to differences in patient and hospital characteristics. METHODS The study population included 228,316 patients undergoing total knee arthroplasty (TKA) at 922 hospitals and 88,081 patients undergoing total hip arthroplasty (THA) at 606 hospitals from January 1, 2009 to December 31, 2011 in the Nationwide Inpatient Sample database, a 20% stratified sample of US community hospitals. RESULTS The median hospital transfusion rates were 11.0% (interquartile range, 3.5%-18.5%) in TKA and 15.9% (interquartile range, 5.4%-26.2%) in THA. After fully adjusting for patient- and hospital-related factors using mixed-effects logistic regression models, the average predicted probability of blood transfusion use in TKA was 6.3%, with 95% of the hospitals having a predicted probability between 0.37% and 55%. For THA, the average predicted probability of blood transfusion use was 9.5%, with 95% of the hospitals having a predicted probability between 0.57% and 66%. Hospital transfusion rates were inversely associated with hospital procedure volume and directly associated with length of stay. CONCLUSION The use of blood transfusion in elective joint arthroplasty varied widely across US hospitals, largely independent of patient case-mix and hospital characteristics.
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Affiliation(s)
- Mariano E Menendez
- Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Na Lu
- Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Massachusetts; Rheumatology Allergy and Immunology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Karim Ladha
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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48
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Goldhammer JE, Kohl BA. Coexisting Cardiac and Hematologic Disorders. Anesthesiol Clin 2016; 34:659-668. [PMID: 27816126 DOI: 10.1016/j.anclin.2016.06.003] [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: 10/20/2022]
Abstract
Patients with concomitant cardiac and hematologic disorders presenting for noncardiac surgery are challenging. Anemic patients with cardiac disease should be approached in a methodical fashion. Transfusion triggers and target should be based on underlying symptomatology. The approach to anticoagulation management in patients with artificial heart valves, cardiac devices, or severe heart failure in the operative setting must encompass a complete understanding of the rationale of a patient's therapy as well as calculate the risk of changing this regimen. This article focuses common disorders and discusses strategies to optimize care in patients with coexisting cardiac and hematologic disease.
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Affiliation(s)
- Jordan E Goldhammer
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, 111 South 11th Street, Philadelphia, PA 19107, USA.
| | - Benjamin A Kohl
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, 111 South 11th Street, Philadelphia, PA 19107, USA
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Carroll I, Mount T, Atkinson D. Myocardial infarction in intensive care units: A systematic review of diagnosis and treatment. J Intensive Care Soc 2016; 17:314-325. [PMID: 28979516 PMCID: PMC5624468 DOI: 10.1177/1751143716656642] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Patients in the intensive care unit are vulnerable to myocardial injury from a variety of causes, both ischaemic and non-ischaemic. It is challenging for ICU clinicians to apply the conventional guidance concerning diagnosis and treatment. We conducted this review to examine the evidence concerning diagnosis and treatment of myocardial infarction in the ICU. METHODS A systematic review was performed to identify relevant studies. RESULTS 19 studies concerning use of ECG, cardiac enzymes, echocardiography and angiography were identified. 4 studies considered treatment of myocardial infarction. CONCLUSIONS Regular 12 lead ECG or 12 lead ECG monitoring is more sensitive than 2 lead monitoring, regular measurement of cardiac enzymes is more sensitive than when provoked by symptoms. Coronary angiography rarely identifies treatable lesions, without regional wall motion abnormality on echocardiography. Evidence relating to treatment was limited. A potential strategy to diagnose myocardial infarctions in the ICU is proposed.
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Affiliation(s)
- Iain Carroll
- Adult Critical Care Unit, Royal London Hospital, London, UK
| | - Thomas Mount
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dougal Atkinson
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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50
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Muszynski JA, Spinella PC, Cholette JM, Acker JP, Hall MW, Juffermans NP, Kelly DP, Blumberg N, Nicol K, Liedel J, Doctor A, Remy KE, Tucci M, Lacroix J, Norris PJ. Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness. Transfusion 2016; 57:195-206. [PMID: 27696473 DOI: 10.1111/trf.13855] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/01/2016] [Accepted: 08/15/2016] [Indexed: 02/06/2023]
Abstract
Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care Medicine, Canadian Blood Services, Edmonton, Alberta, Canada.,The Research Institute, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Philip C Spinella
- Department of Pediatrics, Division Pediatric Critical Care, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Jill M Cholette
- Pediatric Critical Care and Cardiology, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Jason P Acker
- Centre for Innovation, Canadian Blood Services.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Mark W Hall
- Division of Critical Care Medicine, Canadian Blood Services, Edmonton, Alberta, Canada.,The Research Institute, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Daniel P Kelly
- Division of Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Neil Blumberg
- Transfusion Medicine/Blood Bank and Clinical Laboratories, Departments of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer Liedel
- Pediatric Critical Care Medicine, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Allan Doctor
- Departments of Pediatrics and Biochemistry, Washington University in St Louis, St Louis, Missouri
| | - Kenneth E Remy
- Department of Pediatrics, Division Pediatric Critical Care, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Marisa Tucci
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Philip J Norris
- Blood Systems Research Institute.,Departments of Laboratory Medicine and Medicine, University of California, San Francisco, San Francisco, California
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