1
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Scheiderer AN, Shachner TR, Rains AW, Heidel RE, Clark CT. Blasting the myth of predictive INR changes related to plasma transfusion: an academic institution's experience. Hematol Transfus Cell Ther 2023; 45:1-6. [PMID: 34052196 PMCID: PMC9938493 DOI: 10.1016/j.htct.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/30/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Plasma transfusion is a common therapeutic strategy used to lower international normalized ratio (INR) values in the non-emergent setting. However, due to lack of evidence of its efficacy, standardized guidelines for this practice have not been well established. METHODS This retrospective observational cohort study analyzed 276 inpatient encounters that involved plasma transfusions focusing on change in INR values from pre- to post-transfusion, with respect to the following predictor variables: vitamin K co-administration, number of plasma units transfused, order indication and body mass index (BMI). RESULTS The overall average change in the INR was 1.35. Patients who received vitamin K showed an average change of 2.51, while patients that did not receive vitamin K demonstrated an average change of 0.70. Increased numbers of plasma units transfused showed benefit up to three-unit orders. Greater decreases in the INR were observed for patients requiring plasma for anticoagulation reversal or active bleeding. There was no significant difference in the change in INR based on the BMI. By multivariate and regression analyses, the stepwise addition of each successive predictor variable demonstrated an increase in the shared variance in the outcome of the post-transfusion INR: the pre-transfusion INR and vitamin K co-administration alone was not significant (p = 0.45); the additional number of plasma units transfused was significant (R² = 0.13, p < 0.001), and; the subsequent additional plasma order indications (R² = 0.19, p < 0.001) and BMI (R² = 0.18, p < 0.001) were increasingly significant. CONCLUSION Taking into consideration the combination of multiple predictive factors may aid in a more efficient use of plasma products.
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Affiliation(s)
- Ashley N. Scheiderer
- Corresponding author at: Ashley N. Scheiderer, 1924 Alcoa Hwy, Knoxville, TN 37920, Office phone: (865) 305-8944, Fax number: (865) 305-6866.
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2
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Holmqvist J, Brynolf A, Zhao J, Halmin M, Hollenberg J, Mårtensson J, Bell M, Block L, Edgren G. Patterns and determinants of blood transfusion in intensive care in Sweden between 2010 and 2018: A nationwide, retrospective cohort study. Transfusion 2022; 62:1188-1198. [PMID: 35638740 PMCID: PMC9328318 DOI: 10.1111/trf.16942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
Background Intensive care unit (ICU) patients are transfused with blood products for a number of reasons, from massive ongoing hemorrhage, to mild anemia following blood sampling, combined with bone marrow depression due to critical illness. There's a paucity of data on transfusions in ICUs and most studies are based on audits or surveys. The aim of this study was to provide a complete picture of ICU‐related transfusions in Sweden. Methods We conducted a register based retrospective cohort study with data on all adult patient admissions from 82 of 84 Swedish ICUs between 2010 and 2018, as recorded in the Swedish Intensive Care Register. Transfusions were obtained from the SCANDAT‐3 database. Descriptive statistics were computed, characterizing transfused and nontransfused patients. The distribution of blood use comparing different ICUs was investigated by computing the observed proportion of ICU stays with a transfusion, as well as the expected proportion. Results In 330,938 ICU episodes analyzed, at least one transfusion was administered for 106,062 (32%). For both red‐cell units and plasma, the fraction of patients who were transfused decreased during the study period from 31.3% in 2010 to 24.6% in 2018 for red‐cells, and from 16.6% in 2010 to 9.4% in 2018 for plasma. After adjusting for a range of factors, substantial variation in transfusion frequency remained, especially for plasma units. Conclusion Despite continuous decreases in utilization, transfusions remain common among Swedish ICU patients. There is considerable unexplained variation in transfusion rates. More research is needed to establish stronger critiera for when to transfuse ICU patients.
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Affiliation(s)
- Jacob Holmqvist
- Department of Anaestesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Anne Brynolf
- Department of Medicine, Solna, Clinical Epidemiology Division, Stockholm, Sweden
| | - Jingcheng Zhao
- Department of Medicine, Solna, Clinical Epidemiology Division, Stockholm, Sweden
| | - Märit Halmin
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Center for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Johan Mårtensson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Max Bell
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Linda Block
- Department of Anaestesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Gustaf Edgren
- Department of Medicine, Solna, Clinical Epidemiology Division, Stockholm, Sweden.,Department of Cardiology, Södersjukhuset, Stockholm, Sweden
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3
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Mo YD, Delaney M. Transfusion in Pediatric Patients: Review of Evidence-Based Guidelines. Clin Lab Med 2021; 41:1-14. [PMID: 33494878 DOI: 10.1016/j.cll.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Children require transfusion of blood components for a vast array of medical conditions, including acute hemorrhage, hematologic and nonhematologic malignancies, hemoglobinopathy, and allogeneic and autologous stem cell transplant. Evidence-based literature on pediatric transfusion practices is limited, particularly for non-red blood cell products, and many recommendations are extrapolated from studies in adult populations. Recognition of these knowledge gaps has led to increasing numbers of clinical trials focusing on children and establishment of pediatric transfusion working groups in recent years. This article reviews existing literature on pediatric transfusion therapy within the larger context of analogous data in adult populations.
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Affiliation(s)
- Yunchuan Delores Mo
- Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA.
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA
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4
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Larsson L, Sandgren P, Ohlsson S, Derving J, Friis-Christensen T, Daggert F, Frizi N, Reichenberg S, Chatellier S, Diedrich B, Antovic J, Larsson S, Uhlin M. Non-phthalate plasticizer DEHT preserves adequate blood component quality during storage in PVC blood bags. Vox Sang 2020; 116:60-70. [PMID: 32918773 DOI: 10.1111/vox.12982] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/02/2020] [Accepted: 07/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Commercial blood bags are predominantly made of polyvinyl chloride (PVC) plasticized with di(2-ethylhexyl) phthalate (DEHP). DEHP is favourable for storage of red blood cells (RBC). Historically, removal of DEHP from blood bags has been linked to unacceptable haemolysis levels. Oncoming regulatory restrictions for DEHP due to toxicity concerns increase the urgency to replace DEHP without compromising RBC quality. Di(2-ethylhexyl) terephthalate (DEHT) is one suggested substitute. The aim of this study was to compare PVC-DEHT to PVC-DEHP blood bags using additive solutions saline-adenine-glucose-mannitol (SAGM) and phosphate-adenine-glucose-guanosine-saline-mannitol (PAGGSM), to determine whether DEHT can maintain acceptable component quality. MATERIALS AND METHODS RBC concentrates (N = 64), platelet concentrates (N = 16) and fresh frozen plasma (N = 32) were produced from whole blood collected into either DEHT or DEHP plasticized systems. Using a pool-and-split study design, pairs of identical RBC content were created within each plasticizer arm and assigned either SAGM or PAGGSM. Storage effects were assessed weekly for 49 days (RBC), 7 days (platelets) and before/after freezing (plasma). RESULTS Though haemolysis was slightly higher in DEHT, all study arms remained below half of the European limit 0·8%. K+ was lower in DEHT than in DEHP independent of additive solution. The metabolic parameters were not influenced by choice of plasticizer. Platelet activation/metabolism and plasma content were similarly preserved. CONCLUSION Our study demonstrates that the plasticizer DEHT provides adequate blood component quality. We propose DEHT as a strong future candidate for replacement of DEHP in blood bags.
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Affiliation(s)
- Linda Larsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Per Sandgren
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Ohlsson
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Julia Derving
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | | | - Beatrice Diedrich
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jovan Antovic
- Department of Coagulation Research, Institute for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Stella Larsson
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Uhlin
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
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5
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Mansi ET, Waldrop JE, Davidow EB. Retrospective evaluation of the indications, safety and effects of fresh frozen plasma transfusions in 36 cats (2014-2018). J Feline Med Surg 2020; 22:696-704. [PMID: 31576775 PMCID: PMC10814499 DOI: 10.1177/1098612x19876728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The goals of this study were to classify the indications, risks, effects on coagulation times and outcomes of cats receiving fresh frozen plasma (FFP) transfusions in clinical practice. METHODS This was a retrospective study of FFP transfusions administered in two referral hospitals from 2014 to 2018. Transfusion administration forms and medical records were reviewed. Information was collected on indication, underlying condition, coagulation times and signs of transfusion reactions. Seven-day outcomes after FFP administration were also evaluated when available. RESULTS Thirty-six cats received 54 FFP transfusions. Ninety-four percent of cats were administered FFP for treatment of a coagulopathy. Twenty cats had paired coagulation testing before and after FFP administration. Eighteen of these cats had improved coagulation times after receiving 1-3 units of FFP. Eight of the 36 cats had probable transfusion reactions (14.8% of 54 FFP transfusions). These reactions included respiratory signs (n = 4), fever (n = 2) and gastrointestinal signs (n = 2). Five of the eight cats with probable reactions had received packed red blood cells contemporaneously. Overall mortality rate during hospitalization was 29.7%, with 52.8% (n = 19/36) of cats confirmed to be alive 7 days after discharge. CONCLUSIONS AND RELEVANCE This retrospective study shows that FFP transfusions improve coagulation times in cats. Transfusion reactions are a risk, and risk-benefit ratios must be measured prior to administration and possible reactions monitored. In the study cats, the FFP transfusions appeared to be a tolerable risk given the benefit to prolonged coagulation times.
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Affiliation(s)
- Elizabeth T Mansi
- Emergency and Critical Care Service, BluePearl Veterinary Partners, Seattle, WA, USA
| | - Jennifer E Waldrop
- Emergency and Critical Care Service, BluePearl Veterinary Partners, Seattle, WA, USA
| | - Elizabeth B Davidow
- Emergency and Critical Care Service, BluePearl Veterinary Partners, Seattle, WA, USA
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6
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Al Khan S, Rosinski K, Petraszko T, Dawe P, Hwang BW, Sham L, Hudoba M, Roland K, Shih AW. Reducing AB plasma utilisation through the AB plasma appropriateness index. Transfus Med 2019; 29:381-388. [PMID: 31576629 DOI: 10.1111/tme.12632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/17/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We hypothesised that there was inappropriate group AB plasma used in our hospital, identifiable by a novel key quality indicator (KQI) and mitigable through massive transfusion protocol (MTP) modification. BACKGROUND Group AB plasma is a scarce resource strained by increasing usage worldwide when used as universal donor plasma in non-group AB patients. To reduce inappropriate use and to promote benchmarking to the best practice, we developed the AB plasma appropriateness index (ABAI). ABAI is the ratio of AB plasma transfused to group AB or unknown blood group patients to all AB plasma utilised, where values closer to 1 are better. METHODS Data collected included AB plasma disposition by blood group, indications for transfusion, total blood utilisation, patient clinical characteristics and outcomes. ABAI during a 12-month period was retrospectively assessed, which led to implementation of pre-thawed group A plasma instead of group AB plasma for trauma patients starting in July 2017. RESULTS The ABAI retrospectively showed inappropriate use in non-group AB patients in our hospital, the majority used to avoid expiry after thaw. When comparing 1-year pre- and post-implementation periods, ABAI improved from 0·464 to 0·900 (P < 0·0001). After exclusion of therapeutic plasma exchange, ABAI still improved (0·486-0·720, P < 0·0001). No differences in the length of stay or mortality associated in 32 patients receiving group A plasma for emergency release were observed. CONCLUSION The ABAI is a novel KQI to indicate inappropriate AB plasma usage for quality improvement. This led to thawed A plasma use for MTPs, reducing inappropriate AB plasma usage.
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Affiliation(s)
- S Al Khan
- Blood Bank Services, Directorate General of Specialized Medical Care, Ministry of Health, Muscat, Oman
| | - K Rosinski
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - T Petraszko
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Canadian Blood Services, Vancouver, British Columbia, Canada
| | - P Dawe
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.,Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - B W Hwang
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - L Sham
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - M Hudoba
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - K Roland
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - A W Shih
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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7
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Lehot JJ, Clec’h C, Bonhomme F, Brauner M, Chemouni F, de Mesmay M, Gayat E, Guidet B, Hejblum G, Hernu R, Jauréguy F, Martin C, Rousson R, Samama M, Schwebel C, Van de Putte H, Lemiale V, Ausset S. Pertinence de la prescription des examens biologiques et de la radiographie thoracique en réanimation RFE commune SFAR-SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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8
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Rajadhyaksha GC, Meah A. Spectrum of Diseases/conditions Exhibiting Hemostatic Abnormalities in Patients Admitted to a Medical Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2018; 22:711-717. [PMID: 30405281 PMCID: PMC6201640 DOI: 10.4103/ijccm.ijccm_505_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background and Aims: In a medical intensive care unit (MICU), many patients develop hemostatic abnormalities, ranging from abnormal clotting tests to frank bleeding. The aim of this study was to assess the etiology of diseases that present with bleeding, its common bleeding manifestations, incidence, MICU stay, mortality, and transfusion requirements in an Indian setup and also to assess if the Acute Physiology and Chronic Health Evaluation II (APACHE II) score can be used as a predictor for blood transfusion requirements. Materials and Methods: Between July 2013 and August 2014, 200 patients with clinically significant bleeding admitted in the MICU were prospectively evaluated. Detailed history, examination, laboratory investigations, APACHE II score, and requirement of blood products were also noted. The endpoints were discharge or death. Results: The spectrum of diseases that presented with bleeding was 47 patients with malaria (23.5%) followed by 36 acute undifferentiated febrile illness (18.0%), 33 dengue (16.5%), 30 leptospirosis (15.0%), 31 acute fulminant hepatitis (15.5%), 14 sepsis (7.0%), and the rest nine miscellaneous causes. The most common bleeding manifestation observed was hematuria in 62/200 (31%). Among the patients studied, 126 expired (63%) and 74 survived (37%). Of the 200 patients, 48/200 (24%) received packed cells, 78/200 (39%) fresh frozen plasma, and 82/200 (41%) platelets. Conclusions: Tropical diseases formed the majority of admissions with bleeding manifestations. Thrombocytopenia is an important marker to predict mortality and also has a significant association with MICU stay. APACHE II score was found to be a good predictor of blood transfusion requirements.
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Affiliation(s)
| | - Ameena Meah
- Department of Medicine, Topiwala National Medical College & B.Y.L. Nair Ch Hospital, Mumbai, Maharashtra, India
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9
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The role of four-factor prothrombin complex concentrate in coagulopathy of trauma: A propensity matched analysis. J Trauma Acute Care Surg 2018; 85:18-24. [DOI: 10.1097/ta.0000000000001938] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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10
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Chowdary P, Tang A, Watson D, Besser M, Collins P, Creagh MD, Qureshi H, Rokicka M, Nokes T, Diprose P, Gill R. Retrospective Review of a Prothrombin Complex Concentrate (Beriplex P/N) for the Management of Perioperative Bleeding Unrelated to Oral Anticoagulation. Clin Appl Thromb Hemost 2018; 24:1159-1169. [PMID: 29415562 PMCID: PMC6714747 DOI: 10.1177/1076029617753537] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A multicenter, retrospective, observational study of 4-factor prothrombin complex concentrate (PCC) and/or fresh frozen plasma (FFP) use within routine clinical care unrelated to vitamin K antagonists was conducted. The PCC was administered preprocedure for correction of coagulopathy (prophylactic cohort) and treatment of bleeding postsurgery (treatment cohort). Of the 445 patients included, 40 were in the prophylactic cohort (PCC alone [n = 16], PCC and FFP [n = 5], FFP alone [n = 19]) and 405 were in the treatment cohort (PCC alone [n = 228], PCC and FFP [n = 123], FFP alone [n = 54]). Cardiovascular surgery was the most common setting. PCC doses ranged between 500 and 5000 IU. Effectiveness (assessed retrospectively) was reported as effective in 93.0% in the PCC-only group (95% confidence interval, 89.1% to 95.9%), 78.9% (70.8% to 85.6%) with PCC and FFP, and 86.3% (76.2% to 93.2%) with FFP alone. In the treatment cohort, international normalized ratio was significantly reduced in all 3 groups. In patients who received PCC, the rate of thromboembolic events (1.9%) was below rates in the literature for similar procedures. PCCs offer a potential alternative to FFP in the management of perioperative bleeding unrelated to oral anticoagulant therapy.
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Affiliation(s)
- Pratima Chowdary
- 1 Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, United Kingdom
| | - Augustine Tang
- 2 Lancashire Cardiac Centre, Blackpool Teaching Hospital FT, Blackpool, United Kingdom.,3 Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom.,Deceased
| | - Dale Watson
- 2 Lancashire Cardiac Centre, Blackpool Teaching Hospital FT, Blackpool, United Kingdom
| | - Martin Besser
- 4 Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Collins
- 5 Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff, United Kingdom
| | | | - Hafiz Qureshi
- 7 Department of Transfusion Medicine, Glenfield Hospital, Leicester, United Kingdom
| | | | - Tim Nokes
- 9 Derriford Hospital, Plymouth, United Kingdom
| | - Paul Diprose
- 10 Department of Anaesthesia, University Hospital Southampton, Southampton, United Kingdom
| | - Ravi Gill
- 10 Department of Anaesthesia, University Hospital Southampton, Southampton, United Kingdom
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11
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Patlán M, Sánchez-Muñoz F, Amezcua-Guerra LM, Granados A, Páez A, Massó F, Mejía AM, Soster A, Bojalil R, Pavón L, Jiménez-Zamudio LA, Márquez-Velasco R. Effect of fresh frozen plasma on the in vitro activation of U937 monocytes: a potential role for the age of blood donors and their underlying cytokine profile. Biol Res 2017; 50:42. [PMID: 29268779 PMCID: PMC5740577 DOI: 10.1186/s40659-017-0146-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 12/04/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Fresh frozen plasma (FFP) administration may increase the risk of nosocomial infections in parallel with the development of immune modulation. This could be driven by soluble mediators, possibly influencing the in vitro activation of human U937 monocyte cells, in a manner dependent on the age of the donors. METHODS FFP donors were stratified into groups of 19-30 years, 31-40 years or 41-50 years, and U937 cells were cultured with FFP (alone or plus lipopolysaccharide-LPS) for 24 h. Both in FFP and supernatants, TNF, IL-1β, IL-6, and IL-10 levels were measured by ELISA. Additionally, CD11B, TLR2, and CASP3 gene expression were measured by qtPCR in U937 cells. Total phagocytic activity was also assayed. RESULTS Elevated IL-10, but low TNF and IL-1β levels were measured in FFP from individuals aged 19-40 years, whereas in individuals aged 41-50 years FFP were characterized by equalized TNF and IL-10 levels. Elevated IL-6 levels were found in all FFP samples, especially in those from the oldest individuals. FFP stimulation was associated with striking modifications in cytokine production in an age-dependent way. Exposure to FFP attenuates the response to LPS. TLR2 and CD11B expression were enhanced regardless of the age of plasma donors, although CASP3 expression was increased only when FFP from individuals aged 19-40 years were tested. Phagocytosis decreased after exposure to FFP regardless of donor age. CONCLUSION Our results suggest that soluble mediators in FFP may modulate the functioning of monocytes. Interestingly, this effect appears to be partially influenced by the age of donors.
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Affiliation(s)
- Mariana Patlán
- Doctorado en Ciencias Quimicobiológicas, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico.,Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No1, Col Sección XVI, 14080, Mexico City, Mexico
| | - Fausto Sánchez-Muñoz
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No1, Col Sección XVI, 14080, Mexico City, Mexico
| | - Luis M Amezcua-Guerra
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No1, Col Sección XVI, 14080, Mexico City, Mexico.,Department of Health Care, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | - Adriana Granados
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No1, Col Sección XVI, 14080, Mexico City, Mexico
| | - Araceli Páez
- Department of Physiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Felipe Massó
- Department of Physiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Ana M Mejía
- Blood Bank, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Angeles Soster
- Blood Bank, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Rafael Bojalil
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No1, Col Sección XVI, 14080, Mexico City, Mexico.,Department of Health Care, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | - Lenin Pavón
- Neuropsicoimmunology Laboratory, Instituto Nacional de Psiquiatría Ramón de la Fuente, Mexico City, Mexico
| | - Luis A Jiménez-Zamudio
- Department of Immunology, Escuela Nacional de Ciencias Biológicas, Instituto Politecnico Nacional, Prolongación de Carpio y Plan de Ayala s/n, Santo Tomas, 11340, Mexico City, Mexico.
| | - Ricardo Márquez-Velasco
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No1, Col Sección XVI, 14080, Mexico City, Mexico.
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12
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Warner MA, Chandran A, Jenkins G, Kor DJ. Prophylactic Plasma Transfusion Is Not Associated With Decreased Red Blood Cell Requirements in Critically Ill Patients. Anesth Analg 2017; 124:1636-1643. [PMID: 28181937 DOI: 10.1213/ane.0000000000001730] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Critically ill patients frequently receive plasma transfusion under the assumptions that abnormal coagulation test results confer increased risk of bleeding and that plasma transfusion will decrease this risk. However, the effect of prophylactic plasma transfusion remains poorly understood. The objective of this study was to determine the relationship between prophylactic plasma transfusion and bleeding complications in critically ill patients. METHODS This is a retrospective cohort study of adults admitted to the intensive care unit (ICU) at a single academic institution between January 1, 2009 and December 31, 2013. Inclusion criteria included age ≥18 years and an international normalized ratio measured during ICU admission. Multivariable propensity-matched analyses were used to evaluate associations between prophylactic plasma transfusion and outcomes of interest with a primary outcome of red blood cell transfusion in the ensuing 24 hours and secondary outcomes of hospital- and ICU-free days and mortality within 30 days of ICU discharge. RESULTS A total of 27,561 patients were included in the investigation with 2472 (9.0%) receiving plasma therapy and 1105 (44.7%) for which plasma transfusion was prophylactic in nature. In multivariable propensity-matched analyses, patients receiving plasma had higher rates of red blood cell transfusion (odds ratio: 4.3 [95% confidence interval: 3.3-5.7], P < .001) and fewer hospital-free days (estimated % increase: -11.0% [95% confidence interval: -11.4, -10.6%], P < .001). There were no significant differences in ICU-free days or mortality. These findings appeared robust, persisting in multiple predefined sensitivity analyses. CONCLUSIONS Prophylactic administration of plasma in the critically ill was not associated with improved clinical outcomes. Further investigation examining the utility of plasma transfusion in this population is warranted.
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Affiliation(s)
- Matthew A Warner
- From the *Department of Anesthesiology, Division of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; †Internal Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts; ‡Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; §Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and ‖Department of Anesthesiology, Division of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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13
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Hernández-Tejedor A, Peñuelas O, Sirgo Rodríguez G, Llompart-Pou J, Palencia Herrejón E, Estella A, Fuset Cabanes M, Alcalá-Llorente M, Ramírez Galleymore P, Obón Azuara B, Lorente Balanza J, Vaquerizo Alonso C, Ballesteros Sanz M, García García M, Caballero López J, Socias Mir A, Serrano Lázaro A, Pérez Villares J, Herrera-Gutiérrez M. Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.medine.2017.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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14
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Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. Med Intensiva 2017; 41:285-305. [PMID: 28476212 DOI: 10.1016/j.medin.2017.03.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/25/2017] [Accepted: 03/11/2017] [Indexed: 12/14/2022]
Abstract
The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.
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15
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Warner MA, Woodrum DA, Hanson AC, Schroeder DR, Wilson GA, Kor DJ. Prophylactic Plasma Transfusion Before Interventional Radiology Procedures Is Not Associated With Reduced Bleeding Complications. Mayo Clin Proc 2016; 91:1045-55. [PMID: 27492911 PMCID: PMC4982754 DOI: 10.1016/j.mayocp.2016.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/15/2016] [Accepted: 05/04/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the association between prophylactic plasma transfusion and periprocedural red blood cell (RBC) transfusion rates in patients with elevated international normalized ratio (INR) values undergoing interventional radiology procedures. PATIENTS AND METHODS In this retrospective cohort study, adult patients undergoing interventional radiology procedures with a preprocedural INR available within 30 days of the procedure during a study period of January 1, 2009, to December 31, 2013, were eligible for inclusion. Baseline characteristics, coagulation parameters, transfusion requirements, and procedural details were extracted. Univariate and multivariable propensity-matched analyses were used to assess the relationships between prophylactic plasma transfusion and the outcomes of interest, with a primary outcome assessed a priori of RBC transfusion occurring during the procedure or within the first 24 hours postprocedurally. RESULTS A total of 18,204 study participants met inclusion criteria for this study, and 1803 (9.9%) had an INR of 1.5 or greater before their procedure. Of these 1803 patients, 196 patients (10.9%) received prophylactic plasma transfusion with a median time of 1.9 hours (interquartile range [IQR], 1.1-3.2 hours) between plasma transfusion initiation and procedure initiation. In multivariable propensity-matched analysis, plasma administration was associated with increased periprocedural RBC transfusions (odds ratio, 2.20; 95% CI, 1.38-3.50; P<.001) and postprocedural intensive care unit admission rates (odds ratio, 2.11; 95% CI, 1.41-3.14; P<.001) as compared with those who were not transfused preprocedurally. Similar relationships were seen at higher INR thresholds for plasma transfusion. CONCLUSION In patients undergoing interventional radiology procedures, preprocedural plasma transfusions given in the setting of elevated INR values were associated with increased periprocedural RBC transfusions. Additional research is needed to clarify this potential association between preprocedural plasma transfusion and periprocedural RBC transfusion.
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Affiliation(s)
- Matthew A Warner
- Department of Anesthesiology, Mayo Clinic, Rochester, MN; Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, MN
| | - David A Woodrum
- Department of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Gregory A Wilson
- Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, MN; Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology, Mayo Clinic, Rochester, MN; Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, MN.
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Prophylactic plasma transfusion for surgical patients with abnormal preoperative coagulation tests: a single-institution propensity-adjusted cohort study. LANCET HAEMATOLOGY 2016; 3:e139-48. [PMID: 26947202 DOI: 10.1016/s2352-3026(15)00283-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Perioperative haemorrhage negatively affects patient outcomes and results in substantial consumption of health-care resources. Plasma transfusions are often administered to address abnormal preoperative coagulation tests, with the hope to mitigate bleeding complications. We aimed to assess the associations between preoperative plasma transfusion and bleeding complications in patients with elevated international normalised ratio (INR) undergoing non-cardiac surgery. METHODS We did an observational study in a consecutive sample of adult patients undergoing non-cardiac surgery with preoperative INR greater than or equal to 1·5. The exposure of interest was transfusion of preoperative plasma for elevated INR. The primary outcome was WHO grade 3 bleeding in the early perioperative period (from entry into the operating room until 24 h following exit from operating room). Hypotheses were tested with univariate and propensity-matched analyses. We did multiple sensitivity analyses to further evaluate the robustness of study findings. FINDINGS Between Jan 1, 2008, and Dec 31, 2011, we identified 1234 (8·4%) of 14 743 patients who had an INR of 1·5 or above and were included in this investigation. Of 1234 study participants, 139 (11%) received a preoperative plasma transfusion. WHO grade 3 bleeding occurred in 73 (53%) of 139 patients who received preoperative plasma compared with 350 (32%) of 1095 patients who did not (odds ratio [OR] 2·35, 95% CI 1·65-3·36; p<0·0001). Among the propensity-matched cohort, 65 (52%) of 125 plasma recipients had WHO grade 3 bleeding compared with 97 (40%) of 242 of those who did not receive preoperative plasma (OR 1·75, 95% CI 1·09-2·81; p=0·021). Results from multiple sensitivity analyses were qualitatively similar. INTERPRETATION Preoperative plasma transfusion for elevated international normalised ratios was associated with an increased frequency of perioperative bleeding complications. Findings were robust in the sensitivity analyses, suggestive that more conservative management of abnormal preoperative international normalised ratios is warranted. FUNDING Mayo Clinic, National Institutes of Health.
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Transfusion Patterns in All Patients Admitted to the Intensive Care Unit and in Those Who Die in Hospital: A Descriptive Analysis. PLoS One 2015; 10:e0138427. [PMID: 26378791 PMCID: PMC4575028 DOI: 10.1371/journal.pone.0138427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 08/29/2015] [Indexed: 11/19/2022] Open
Abstract
While it is known that the use of health care resources increases at the end of life in patients admitted to the Intensive Care Unit (ICU), the allocation of blood products at the end of life has not been described. The objective of this study was to describe overall transfusion patterns in the ICU, and specifically in patients who die in hospital. We conducted a retrospective cohort study of adult patients admitted to the ICU of a university-affiliated hospital, who were discharged or died between November 1, 2006 and June 30, 2012. During the study period, 10,642 patients were admitted at least once to the ICU. Of these patients, 4079 (38.3%) received red blood cells (RBCs), plasma or platelets in the ICU. The ICU mortality rate was 28.1% and in-hospital mortality rate was 32.3%. Among 39,591 blood product units transfused over the course of the study in the ICU (18,144 RBC units, 16,920 plasma units and 4527 platelet units), 46.2% were administered to patients who later died within the same hospitalization (41.2% of RBCs, 50.4% of plasma and 50.8% of platelets). Of all blood product units (RBCs, plasma and platelets) administered in the ICU over the study period, 11% were given within the last 24 hours before death. A large proportion of blood products used in the ICU are administered to patients who ultimately succumb to their illness in hospital, and many of these blood units are given in close proximity to death.
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Karam O, Demaret P, Shefler A, Leteurtre S, Spinella PC, Stanworth SJ, Tucci M. Indications and Effects of Plasma Transfusions in Critically Ill Children. Am J Respir Crit Care Med 2015; 191:1395-402. [PMID: 25859890 DOI: 10.1164/rccm.201503-0450oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE Plasma transfusions are frequently prescribed for critically ill children, although their indications lack a strong evidence base. Plasma transfusions are largely driven by physician conceptions of need, and these are poorly documented in pediatric intensive care patients. OBJECTIVES To identify patient characteristics and to characterize indications leading to plasma transfusions in critically ill children, and to assess the effect of plasma transfusions on coagulation tests. METHODS Point-prevalence study in 101 pediatric intensive care units in 21 countries, on 6 predefined weeks. All critically ill children admitted to a participating unit were included if they received at least one plasma transfusion. MEASUREMENTS AND MAIN RESULTS During the 6 study weeks, 13,192 children were eligible. Among these, 443 (3.4%) received at least one plasma transfusion and were included. The primary indications for plasma transfusion were critical bleeding in 22.3%, minor bleeding in 21.2%, planned surgery or procedure in 11.7%, and high risk of postoperative bleeding in 10.6%. No bleeding or planned procedures were reported in 34.1%. Before plasma transfusion, the median international normalized ratio (INR) and activated partial thromboplastin time (aPTT) values were 1.5 and 48, respectively. After plasma transfusion, the median INR and aPTT changes were -0.2 and -5, respectively. Plasma transfusion significantly improved INR only in patients with a baseline INR greater than 2.5. CONCLUSIONS One-third of transfused patients were not bleeding and had no planned procedure. In addition, in most patients, coagulation tests are not sensitive to increases in coagulation factors resulting from plasma transfusion. Studies assessing appropriate plasma transfusion strategies are urgently needed.
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Affiliation(s)
- Oliver Karam
- 1 Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.,2 EA 2694, Public Health: Epidemiology and Quality of Care, University of Lille-Nord-de-France, Lille, France
| | - Pierre Demaret
- 3 Pediatric Intensive Care Unit, Centre Hospitalier Chrétien Liège, Liège, Belgium
| | - Alison Shefler
- 4 Pediatric Intensive Care Unit, Oxford University Hospitals, Oxford, United Kingdom
| | - Stéphane Leteurtre
- 2 EA 2694, Public Health: Epidemiology and Quality of Care, University of Lille-Nord-de-France, Lille, France.,5 Pediatric Intensive Care Unit, Centre Hospitalier Universitaire (CHU) Lille, Lille, France
| | - Philip C Spinella
- 6 Pediatric Intensive Care Unit, St. Louis Children's Hospital, St. Louis, Missouri
| | - Simon J Stanworth
- 7 National Health Service Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom; and
| | - Marisa Tucci
- 8 Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada
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Lacroix J. Plasma Transfusion in Critically Ill Children. A Magical Mystery Tour? Am J Respir Crit Care Med 2015; 191:1347-9. [PMID: 26075418 DOI: 10.1164/rccm.201504-0810ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jacques Lacroix
- 1 Sainte-Justine Hospital Université de Montréal Montréal, Québec, Canada
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Joseph B, Aziz H, Pandit V, Hays D, Kulvatunyou N, Yousuf Z, Tang A, O'Keeffe T, Green D, Friese RS, Rhee P. Prothrombin complex concentrate versus fresh-frozen plasma for reversal of coagulopathy of trauma: is there a difference? World J Surg 2015; 38:1875-81. [PMID: 24798029 DOI: 10.1007/s00268-014-2631-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The development of coagulopathy of trauma is multifactorial associated with hypoperfusion and consumption of coagulation factors. Previous studies have compared the role of factor replacement versus FPP for reversal of trauma coagulopathy. The purpose of our study was to determine the time to correction of coagulopathy and blood product requirement in patients who received PCC+FFP compared with patients who received FFP alone. METHODS We performed a retrospective analysis of a prospectively maintained database of all coagulopathic (INR ≥ 1.5) trauma patients presenting to our level I trauma center during a 2-years period (2011-2012). Patients were stratified into two groups: patients who received PCC+FFP and patients who received FFP alone. Patients in the two groups were matched in a 1:3 (PCC+FFP:FFP) ratio using propensity score matching for demographics, injury severity, vital parameters, and initial INR. The two groups were then compared for: correction of INR, time to correction of INR, thromboembolic complications, mortality, and cost of therapy. RESULTS A total of 252 were included in the analysis [PCC+FFP:63; FFP:189]. The mean age was 44 ± 20 years; 70 % were male, with a median ISS score of 27 [16-38]. PCC use was associated with an accelerated correction of INR (394 vs. 1,050 min; p 0.001), reduction in requirement of pack red blood cell (6.6 vs. 10 units; p 0.001) and FFP (2.8 vs. 3.9 units; p 0.01), and decline in mortality (23 vs. 28%; p 0.04). PCC+FFP use was associated with a higher cost of therapy ($1,470 ± 845 vs. 1,171 ± 949; p 0.01) but lower overall cost of transfusion ($7,110 ± 1,068 vs. 9,571 ± 1,524; p 0.01) compared with FFP therapy alone. CONCLUSIONS PCC in conjunction with FFP rapidly corrects INR in a matched cohort of trauma patients not on warfarin therapy compared with FFP therapy alone. The use of PCC as an adjunct to FFP therapy is associated with reduction of blood product requirement and also lowers overall cost.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Avenue, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, US,
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21
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Beer KS, Silverstein DC. Controversies in the use of fresh frozen plasma in critically ill small animal patients. J Vet Emerg Crit Care (San Antonio) 2015; 25:101-6. [PMID: 25603692 DOI: 10.1111/vec.12280] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 09/15/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review the literature supporting or discouraging the use of fresh frozen plasma (FFP) transfusion in critically ill patients. DATA SOURCES Human and animal publications were searched using PubMed without time limits and the following keywords were used: "fresh frozen plasma," "coagulopathy," "hypocoagulable state," "hypercoagulable states," and "critical illness." HUMAN DATA SYNTHESIS The commonly used tests of coagulation (eg, prothrombin time, activated partial thromboplastin time, international normalized ratio) are poorly predictive of clinical bleeding. FFP use in critically ill patients is unlikely to result in improved outcomes and may be associated with increased risks. VETERINARY DATA SYNTHESIS There is insufficient evidence to make definitive conclusions regarding the use of FFP in critically ill animals, but clinical studies are underway that may provide further data that clarify the optimal use of FFP in animals. CONCLUSIONS The use of FFP in critically ill patients remains controversial. In the absence of clinical bleeding or a risk for clinical bleeding associated with a planned procedure, treatment use of FFP is not recommended in human patients. There are insufficient data in critically ill animals to enable formulation of recommendations. Further research is warranted in dogs and cats to establish evidence-based guidelines.
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Affiliation(s)
- Kari Santoro Beer
- Department of Clinical Studies, University of Pennsylvania, Philadelphia, PA
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22
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Shih AW, Kolesar E, Ning S, Manning N, Arnold DM, Crowther MA. Evaluation of the appropriateness of frozen plasma usage after introduction of prothrombin complex concentrates: a retrospective study. Vox Sang 2014; 108:274-80. [PMID: 25556889 DOI: 10.1111/vox.12226] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/26/2014] [Accepted: 10/30/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prothrombin complex concentrates (PCCs) can be used instead of frozen plasma (FP) transfusion to reverse the effect of warfarin. Audits have demonstrated over usage of FP transfusions even before the introduction of PCC. The objective of this study was to determine the appropriateness of current FP transfusion practice in the current era since the introduction of PCCs. METHODS A retrospective cohort study of consecutive patients receiving FP over 3 months was carried out. Each episode of FP use over a 24-h period was adjudicated independently by two reviewers as appropriate (consistent with Canadian/AABB guidelines), appropriate but inconsistent with guidelines or inappropriate. Discrepancies were resolved by a third reviewer. Use of FP to reverse warfarin was considered inappropriate. FP usage from previous years was assessed as baseline. RESULTS During the study period, 111 FP transfusions were administered. 74.8% of FP usage occurred in the ICU. The proportion of FP transfusions that were deemed appropriate, inconsistent yet appropriate or inappropriate were 33/89 (37.1%), 16/89 (18.0%) and 40/89 (44.9%), respectively, when use of FP for therapeutic plasma exchange was excluded. The most common reasons for inappropriate use were the absence of bleeding with an increased INR or warfarin reversal. CONCLUSION Our study is the first to audit FP transfusions in the post-PCC era in Canada. FP usage remains inappropriately high in INR prolongation without another indication or to reverse warfarin. Targeted interventions to reduce FP usage in the future should focus on the ICU and on education about warfarin reversal.
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Affiliation(s)
- A W Shih
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Transfusions de plasma en réanimation pédiatrique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0900-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Müller MC, Arbous MS, Spoelstra-de Man AM, Vink R, Karakus A, Straat M, Binnekade JM, de Jonge E, Vroom MB, Juffermans NP. Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: a randomized clinical trial (CME). Transfusion 2014; 55:26-35; quiz 25. [PMID: 24912653 DOI: 10.1111/trf.12750] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/03/2014] [Accepted: 05/04/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prophylactic use of fresh-frozen plasma (FFP) is common practice in patients with a coagulopathy undergoing an invasive procedure. Evidence that FFP prevents bleeding is lacking, while risks of transfusion-related morbidity after FFP have been well demonstrated. We aimed to assess whether omitting prophylactic FFP transfusion in nonbleeding critically ill patients with a coagulopathy who undergo an intervention is noninferior to a prophylactic transfusion of FFP. STUDY DESIGN AND METHODS A multicenter randomized open-label trial with blinded endpoint evaluation was performed in critically ill patients with a prolonged international normalized ratio (INR; 1.5-3.0). Patients undergoing placement of a central venous catheter, percutaneous tracheostomy, chest tube, or abscess drainage were eligible. Patients with clinically overt bleeding, thrombocytopenia, or therapeutic use of anticoagulants were excluded. Patients were randomly assigned to omitting or administering a prophylactic transfusion of FFP (12 mL/kg). Outcomes were occurrence of postprocedural bleeding complications, INR correction, and occurrence of lung injury. RESULTS Due to slow inclusion, the trial was stopped before the predefined target enrollment was reached. Eighty-one patients were randomly assigned, 40 to FFP and 41 to no FFP transfusion. Incidence of bleeding did not differ between groups, with a total of one major and 13 minor bleedings (p = 0.08 for noninferiority). FFP transfusion resulted in a reduction of INR to less than 1.5 in 54% of transfused patients. No differences in lung injury scores were observed. CONCLUSION In critically ill patients undergoing an invasive procedure, no difference in bleeding complications was found regardless whether FFP was prophylactically administered or not.
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Affiliation(s)
- Marcella C Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands
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Karam O, Tucci M, Combescure C, Lacroix J, Rimensberger PC. Plasma transfusion strategies for critically ill patients. Cochrane Database Syst Rev 2013:CD010654. [PMID: 24374651 DOI: 10.1002/14651858.cd010654.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although plasma transfusions are frequently prescribed for critically ill patients, most clinical uses of plasma are not supported by evidence. Plasma transfusions do not seem to correct mild coagulation abnormalities based on international normalised ratio (INR) testing, but they seem to be independently associated with worse clinical outcomes in non-massively bleeding patients. Current recommendations on plasma transfusion strategies advocate limiting plasma transfusions to patients who are actively bleeding or who are at risk of bleeding and concomitantly have moderately abnormal coagulation tests. OBJECTIVES To determine whether use of a restrictive versus a liberal plasma transfusion threshold affects mortality or morbidity in critically ill patients, and to assess the clinical effects of different plasma transfusion thresholds in critically ill patients. SEARCH METHODS A search for studies was run on 15 August 2013. We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE(R) Ovid, MEDLINE(R) Ovid In-Process & Other Non-Indexed Citations, MEDLINE(R) Ovid Daily and OLDMEDLINE(R) Ovid, EMBASE Classic + EMBASE (Ovid SP), reference lists, related websites and trial registries and checked lists of references. SELECTION CRITERIA Randomised clinical trials that assessed the effects of two plasma transfusion strategies, using a restrictive and a liberal threshold of at least one coagulation test, in critically ill participants. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality using the standard methods of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS Of 843 references identified by our search, none of the trials satisfied our predefined inclusion criteria. No studies are included in this review. AUTHORS' CONCLUSIONS This review highlights the lack of evidence that is available to guide plasma transfusions in critically ill patients. Randomised controlled trials are needed to determine the appropriate plasma transfusion strategy in critically ill patients.
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Affiliation(s)
- Oliver Karam
- Pediatric Critical Care Unit, Geneva University Hospital, 6 rue Willy Donzé, Geneva, Switzerland, 1211
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Doussau A, Perez P, Puntous M, Calderon J, Jeanne M, Germain C, Rozec B, Rondeau V, Chêne G, Ouattara A, Janvier G. Fresh-frozen plasma transfusion did not reduce 30-day mortality in patients undergoing cardiopulmonary bypass cardiac surgery with excessive bleeding: the PLASMACARD multicenter cohort study. Transfusion 2013; 54:1114-24. [PMID: 24117772 DOI: 10.1111/trf.12422] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND During on-pump cardiac surgery, hemorrhagic complications occur frequently. Fresh-frozen plasma (FFP) is widely transfused to provide coagulation factors. Yet, no randomized clinical trial has demonstrated its benefits on mortality. We assessed the relationship between therapeutic transfusion of FFP and 30-day mortality in cardiac surgery patients suffering from excessive bleeding in a prospective cohort study. STUDY DESIGN AND METHODS Adult patients who underwent on-pump cardiac surgery and experienced excessive bleeding during the 48-hour perioperative period were recruited from 15 French centers between February 2004 and January 2006. Patients who received a preventive FFP transfusion were excluded. The association between FFP transfusion and all cause 30-day mortality was estimated using a Cox proportional hazards model, adjusted for confounding. A propensity score (PS) sensitivity analysis was also performed. RESULTS Among 967 patients included in this study, 58.1% received FFP. The median dose was 11.3 mL/kg (interquartile range, 7.6-19.5). The cumulative 30-day mortality rate was 11.3% (95% confidence interval [CI], 9.5-13.5). FFP transfusion was associated with a higher 30-day mortality (hazard ratio [HR], 3.2; 95% CI, 1.7-6.1) in univariate analysis; however, after adjusting for prognostic factors, there was no longer any association (HR, 1.5; 95% CI, 0.8-3.0, p = 0.20). The results of the PS analysis were consistent with the adjusted analysis. CONCLUSION Among on-pump cardiac surgery patients experiencing excessive perioperative bleeding, there is no evidence of a beneficial impact of FFP transfusion on mortality.
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Affiliation(s)
- Adélaïde Doussau
- Pole de Sante Publique et CIC-EC7, Unité de Soutien Méthodologique à la Recherche Clinique et Épidémiologique, CHU de Bordeaux, Bordeaux, France; CIC-EC7 et Centre INSERM U897-Epidemiologie-Biostatistique, INSERM, Bordeaux, France; ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Université Bordeaux, Bordeaux, France
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Karam O, Tucci M, Lacroix J, Rimensberger PC. International survey on plasma transfusion practices in critically ill children. Transfusion 2013; 54:1125-32. [PMID: 24032693 DOI: 10.1111/trf.12393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/16/2013] [Accepted: 07/17/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Studies have shown heterogeneity in red blood cell transfusion practices. Although plasma transfusion is common in intensive care, there are no data on plasma transfusion practices in pediatric critical care units. STUDY DESIGN AND METHODS A scenario-based survey was sent to 718 pediatric critical care physicians working in Europe, North America, Australia, and New Zealand. Respondents were asked to report their decisions regarding plasma transfusion practice with respect to four scenarios: pneumonia, septic shock, traumatic brain injury (TBI), and postoperative care after a Tetralogy of Fallot correction. RESULTS The response rate was 187 of 718 (26%); half of the responders worked in North America. The proportion of physicians who transfused plasma to nonbleeding patients, solely based on abnormal international normalized ratio (INR), varied from 66% for pneumonia to 84% for TBI (p < 0.001). In such nonbleeding patients, the median INR threshold that would trigger plasma transfusion was 2.5 for pneumonia and septic shock patients and 2.0 for TBI and the cardiac postoperative patients (p < 0.001). Minor bleeding, minor surgery, insertion of a femoral line, hypotension, abnormal activated partial thromboplastin time, thrombocytopenia, and anemia levels were important determinants of plasma transfusion, whereas none of the respondents' demographic characteristics were important. CONCLUSION More than two-thirds of responding pediatric critical care physicians prescribe plasma transfusions for nonbleeding critically ill children. Additionally, there is a significant variation in transfusion practice patterns with respect to plasma transfusion thresholds.
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Affiliation(s)
- Oliver Karam
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland
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Labarinas S, Arni D, Karam O. Plasma in the PICU: why and when should we transfuse? Ann Intensive Care 2013; 3:16. [PMID: 23725411 PMCID: PMC3698065 DOI: 10.1186/2110-5820-3-16] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/07/2013] [Indexed: 11/10/2022] Open
Abstract
Whereas red blood cell transfusions have been used since the 19th century, plasma has only been available since 1941. It was originally mainly used as volume replacement, mostly during World War II and the Korean War. Over the years, its indication has shifted to correct coagulation factors deficiencies or to prevent bleeding. Currently, it remains a frequent treatment in the intensive care unit, both for critically ill adults and children. However, observational studies have shown that plasma transfusion fail to correct mildly abnormal coagulation tests. Furthermore, recent epidemiological studies have shown that plasma transfusions are associated with an increased morbidity and mortality in critically ill patients. Therefore, plasma, as any other treatment, has to be used when the benefits outweigh the risks. Based on observational data, most experts suggest limiting its use either to massively bleeding patients or bleeding patients who have documented abnormal coagulation tests, and refraining for transfusing plasma to nonbleeding patients whatever their coagulation tests. In this paper, we will review current evidence on plasma transfusions and discuss its indications.
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Affiliation(s)
- Sonia Labarinas
- Pediatric Critical Care Unit, Geneva University Hospital, 6 rue Willy Donzé, Geneva 1211, Switzerland.
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Tinmouth A, Thompson T, Arnold DM, Callum JL, Gagliardi K, Lauzon D, Owens W, Pinkerton P. Utilization of frozen plasma in Ontario: a provincewide audit reveals a high rate of inappropriate transfusions. Transfusion 2013; 53:2222-9. [PMID: 23672421 DOI: 10.1111/trf.12231] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Frozen plasma (FP) is frequently transfused inappropriately, an intervention that results in risk without benefit for the patient. To better understand current utilization practices in our region, we undertook a provincewide prospective audit to evaluate the clinical indications and appropriateness of FP transfusion. STUDY DESIGN AND METHODS All hospitals in the Canadian province of Ontario with transfusion medicine services were invited to participate in a 5-day audit of FP utilization. FP dose, indication, and clinical patient data were collected for each transfusion request. Indications for FP transfusions were independently adjudicated as appropriate, inappropriate, or indeterminate based on predefined criteria. RESULTS Seventy-six (49%) of 155 invited hospitals participated in the audit, which included 573 requests for 2012 units of FP. A total of 559 transfusions (1909 units) were administered. Of 573 requests, 164 (28.6%) were deemed inappropriate most often because: 1) they were administered to patients with an international normalized ratio below 1.5 or 2) they were administered in absence of bleeding or emergency surgery. The most frequent indications for FP transfusions were before surgery and warfarin reversal. Overall, patients admitted to the clinical areas of surgery, internal medicine, and the emergency department represented the largest users of FP, but this varied by hospital type (community vs. academic). The most frequently requested doses of FP were 2 and 4 units. CONCLUSION This point-prevalence hospital audit revealed that transfusion of FP is frequently inappropriate. Focusing on reducing the two most common reasons for inappropriate FP transfusions could lead to a significant improvement in FP utilization.
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Affiliation(s)
- Alan Tinmouth
- Department of Medicine, Ottawa Hospital and University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Ontario Regional Blood Coordinating Network Office, Toronto, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Laboratory Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Canadian Blood Services, Ottawa and Hamilton, Ontario, Canada
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Yazer MH, Triulzi DJ, Reddy V, Waters JH. Effectiveness of a real-time clinical decision support system for computerized physician order entry of plasma orders. Transfusion 2013; 53:3120-7. [DOI: 10.1111/trf.12228] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 02/19/2013] [Accepted: 02/20/2013] [Indexed: 01/24/2023]
Affiliation(s)
| | | | - Vivek Reddy
- Departments of Anesthesiology and Bioengineering; University of Pittsburgh
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Gross I, Shander A, Sweeney J. Patient blood management and outcome, too early or not? Best Pract Res Clin Anaesthesiol 2013; 27:161-72. [DOI: 10.1016/j.bpa.2012.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 12/17/2012] [Indexed: 01/01/2023]
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Abstract
Three transfusion complications are responsible for the majority of the morbidity and mortality in hospitalized patients. This article discusses the respiratory complications associated with these pathophysiologic processes, including definitions, diagnosis, mechanism, incidence, risk factors, clinical management, and strategies for prevention. It also explores how different patient populations and different blood components differentially affect the risk of these deadly transfusion complications. Lastly, the article discusses how health care providers can risk stratify individual patients or patient populations to determine whether a given transfusion is more likely to benefit or harm the patient based on the transfusion indication, risk, and expected result.
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Affiliation(s)
- Alexander B Benson
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, 12700 East 19th Avenue, Aurora, CO 80045, USA.
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Halperin JL, Goyette RE. Management of Atrial Fibrillation: Direct Factor IIa and Xa Inhibitors or “Warfarin Shotgun”? ACTA ACUST UNITED AC 2012; 79:705-20. [DOI: 10.1002/msj.21346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Hall D, Lone N, Watson D, Stanworth S, Walsh T. Factors associated with prophylactic plasma transfusion before vascular catheterization in non-bleeding critically ill adults with prolonged prothrombin time: a case–control study. Br J Anaesth 2012; 109:919-27. [DOI: 10.1093/bja/aes337] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Abstract
Plasma utilization has increased over the past two decades, and there is a growing concern that many plasma transfusions are inappropriate. Plasma transfusion is not without risk, and certain complications are more likely with plasma than other blood components. Clinical and laboratory investigations of the patients suffering reactions after infusion of fresh-frozen plasma (FFP) define the etiology and pathogenesis of the panoply of adverse effects. We review here the pathogenesis, diagnosis, and management of the risks associated with plasma transfusion. Risks commonly associated with FFP include: 1) transfusion-related acute lung injury, 2) transfusion-associated circulatory overload, and 3) allergic and/or anaphylactic reactions. Other less common risks include 1) transmission of infections, 2) febrile nonhemolytic transfusion reactions, 3) red blood cell alloimmunization, and 4) hemolytic transfusion reactions. The effects of pathogen inactivation or reduction methods on these risks are also discussed. Fortunately, a majority of the adverse effects are not lethal and are adequately treated in clinical practice.
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Affiliation(s)
- Suchitra Pandey
- Department of Laboratory Medicine, University of California, San Francisco, California 94143, USA
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36
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Tinmouth A. Evidence for a rationale use of frozen plasma for the treatment and prevention of bleeding. Transfus Apher Sci 2012; 46:293-8. [DOI: 10.1016/j.transci.2012.03.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Müller MCA, de Jonge E, Arbous MS, Spoelstra-de Man AME, Karakus A, Vroom MB, Juffermans NP. Transfusion of fresh frozen plasma in non-bleeding ICU patients--TOPIC trial: study protocol for a randomized controlled trial. Trials 2011; 12:266. [PMID: 22196464 PMCID: PMC3284461 DOI: 10.1186/1745-6215-12-266] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 12/23/2011] [Indexed: 12/31/2022] Open
Abstract
Background Fresh frozen plasma (FFP) is an effective therapy to correct for a deficiency of multiple coagulation factors during bleeding. In past years, use of FFP has increased, in particular in patients on the Intensive Care Unit (ICU), and has expanded to include prophylactic use in patients with a coagulopathy prior to undergoing an invasive procedure. Retrospective studies suggest that prophylactic use of FFP does not prevent bleeding, but carries the risk of transfusion-related morbidity. However, up to 50% of FFP is administered to non-bleeding ICU patients. With the aim to investigate whether prophylactic FFP transfusions to critically ill patients can be safely omitted, a multi-center randomized clinical trial is conducted in ICU patients with a coagulopathy undergoing an invasive procedure. Methods A non-inferiority, prospective, multicenter randomized open-label, blinded end point evaluation (PROBE) trial. In the intervention group, a prophylactic transfusion of FFP prior to an invasive procedure is omitted compared to transfusion of a fixed dose of 12 ml/kg in the control group. Primary outcome measure is relevant bleeding. Secondary outcome measures are minor bleeding, correction of International Normalized Ratio, onset of acute lung injury, length of ventilation days and length of Intensive Care Unit stay. Discussion The Transfusion of Fresh Frozen Plasma in non-bleeding ICU patients (TOPIC) trial is the first multi-center randomized controlled trial powered to investigate whether it is safe to withhold FFP transfusion to coagulopathic critically ill patients undergoing an invasive procedure. Trial Registration Trial registration: Dutch Trial Register NTR2262 and ClinicalTrials.gov: NCT01143909
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Application of frozen plasma to red cell consumption ratios as a possible indicator for audit of use of frozen plasma in hospital clinical transfusion practice. Transfus Apher Sci 2011; 45:203-5. [PMID: 21840763 DOI: 10.1016/j.transci.2011.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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39
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The conundrum of persistent inappropriate use of frozen plasma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:160. [PMID: 21635704 PMCID: PMC3218970 DOI: 10.1186/cc10215] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Frozen plasma (FP) is commonly used for the treatment of bleeding or the prevention of bleeding in critically ill patients, but clinical evidence to help aid the critical care clinician make decisions on whether to transfuse or not is at present limited. Despite the limited evidence, it appears FP is administered not infrequently in the absence of bleeding or with no required procedure when the international normalized ratio (INR) is essentially normal (<1.5) or only mildly deranged (<2.5). The study by Stanworth and colleagues in a recent issue of Critical Care raises awareness of FP transfusion use in the critically ill, should prompt a consideration of curbing its use when it is not clearly appropriate, and illustrates the need for future high quality evidence to guide FP use in the critically ill when the risk:benefit ratio is less clear.
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40
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Stanworth SJ, Walsh TS, Prescott RJ, Lee RJ, Watson DM, Wyncoll D. A national study of plasma use in critical care: clinical indications, dose and effect on prothrombin time. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R108. [PMID: 21466676 PMCID: PMC3219386 DOI: 10.1186/cc10129] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 03/09/2011] [Accepted: 04/05/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Fresh frozen plasma (FFP) is widely used, but few studies have described patterns of plasma use in critical care. We carried out a multicentre study of coagulopathy in intensive care units (ICUs) and here describe overall FFP utilisation in adult critical care, the indications for transfusions, factors indicating the doses used and the effects of FFP use on coagulation. METHODS We conducted a prospective, multicentre, observational study of all patients sequentially admitted to 29 adult UK general ICUs over 8 weeks. Daily data throughout ICU admission were collected concerning coagulation, relevant clinical outcomes (including bleeding), coagulopathy (defined as international normalised ratio (INR) >1.5, or equivalent prothrombin time (PT)), FFP and cryoprecipitate use and indications for transfusion. RESULTS Of 1,923 admissions, 12.7% received FFP in the ICU during 404 FFP treatment episodes (1,212 FFP units). Overall, 0.63 FFP units/ICU admission were transfused (0.11 units/ICU day). Reasons for FFP transfusion were bleeding (48%), preprocedural prophylaxis (15%) and prophylaxis without planned procedure (36%). Overall, the median FFP dose was 10.8 ml kg⁻¹, but doses varied widely (first to third quartile, 7.2 to 14.4 ml kg⁻¹). Thirty-one percent of FFP treatments were to patients without PT prolongation, and 41% were to patients without recorded bleeding and only mildly deranged INR (<2.5). Higher volumes of FFP were administered when the indication was bleeding (median doses: bleeding 11.1 ml kg⁻¹, preprocedural prophylaxis 9.8 ml kg⁻¹, prophylaxis without procedure 8.9 ml kg⁻¹; P = 0.009 across groups) and when the pretransfusion INR was higher (ranging from median dose 8.9 ml kg⁻¹ at INR ≤ 1.5 to 15.7 ml kg⁻¹ at INR >3; P < 0.001 across ranges). Regression analyses suggested bleeding was the strongest predictor of higher FFP dose. Pretransfusion INR was more frequently normal when the transfusion indication was bleeding. Overall, posttransfusion corrections of INR were consistently small unless the pretransfusion INR was >2.5, but administration during bleeding was associated with greater INR corrections. CONCLUSIONS There is wide variation in FFP use by ICU clinicians, and a high proportion of current FFP transfusions are of unproven clinical benefit. Better evidence from clinical trials could significantly alter patterns of use and modify current treatment costs.
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Affiliation(s)
- Simon J Stanworth
- Department of Haematology/Transfusion Medicine, John Radcliffe Hospital, NHS Blood & Transplant/Oxford Radcliffe Hospitals Trust, and University of Oxford, Osler Road, Headington, Oxford, OX3 9BQ, UK.
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41
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Arnold DM, Lauzier F, Whittingham H, Zhou Q, Crowther MA, McDonald E, Cook DJ. A multifaceted strategy to reduce inappropriate use of frozen plasma transfusions in the intensive care unit. J Crit Care 2011; 26:636.e7-636.e13. [PMID: 21439762 DOI: 10.1016/j.jcrc.2011.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Revised: 02/09/2011] [Accepted: 02/13/2011] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study is to determine the effect of a multifaceted behavior-change strategy on inappropriate use of frozen plasma (FP) transfusions in the intensive care unit (ICU). MATERIALS AND METHODS A prospective, time-series study was conducted in a 15-bed medical-surgical ICU in 3 phases: (1) baseline observation; (2) educational campaign, audit and feedback to prescribers, and implementation of an FP request form; and (3) FP request form only. Independently, in triplicate and blinded to study phase, appropriateness of each FP request was adjudicated based on published guidelines and clinical context. RESULTS Over the 15-month study period, 626 FP transfusions (210 FP requests) were administered to 88 patients. Inappropriate FP requests decreased slightly from phases I to III (60% vs 46%; P = .09), FP requests that were consistent with the guidelines did not change (23% vs 22%; P = .86), and FP requests that were appropriate for the ICU yet inconsistent with the guidelines increased (17% vs 32%; P = .04). Although uptake of the FP request form decreased in phase III, it was associated with fewer inappropriate transfusions. CONCLUSIONS The behavior-change strategy modestly improved appropriate use of FP transfusions in the ICU. Improving FP request form accuracy, completeness, and compliance may be required to achieve maximum effect and ensure sustainability.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8N 3Z5.
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Leal-Noval SR, Arellano-Orden V, Maestre-Romero A, Muñoz-Gómez M, Fernández-Cisneros V, Ferrándiz-Millón C, Corcia Y. Impact of national transfusion indicators on appropriate blood usage in critically ill patients. Transfusion 2011; 51:1957-65. [PMID: 21392019 DOI: 10.1111/j.1537-2995.2011.03091.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective was to investigate the impact of three national blood transfusion indicators (NBTIs) specifically designed for critical care regarding the appropriate blood transfusion indications. STUDY DESIGN AND METHODS This was a prospective, single-center study, carried out at a university hospital. A total of 1808 patients admitted to the intensive care unit (ICU) in 1 year were included. RESULTS The study consisted of four 90-day periods (P). P1 was a control period with no intervention. P2 followed the inclusion of NBTIs into the ICU database, aimed at reinforcing NBTI knowledge. After presenting and discussing the results of P1 and P2, the early (P3) and late (P4) impacts of NBTI knowledge were evaluated. All patients who were transfused with at least 1 unit of any blood component (33.3%) were included. Thirteen percent of red blood cell transfusions (RBCTs) were given outside of NBTI protocols (13% deviation of NBTIs for RBCTs) without a significant change throughout the duration of the study. Most RBCTs (95%) were prescribed for a hemoglobin threshold of less than 90 g/L. There was a steady and significant improvement in the adherence to NBTI guidelines for platelet concentrate transfusions (PCTs) from 36% (P1) to 52% (P4; p < 0.01). In contrast, the lack of adherence to NBTI guidelines for fresh-frozen plasma transfusions (FFPTs) remained high (74%) and stable throughout the study period. The most frequent reason for inappropriate use of FFPTs or PCTs was absence of severe bleeding. CONCLUSION The introduction of NBTI guidelines demonstrated a variable impact on the appropriateness of blood component transfusions in critically ill patients.
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Watson DM, Stanworth SJ, Wyncoll D, McAuley DF, Perkins GD, Young D, Biggin KJ, Walsh TS. A national clinical scenario-based survey of clinicians' attitudes towards fresh frozen plasma transfusion for critically ill patients. Transfus Med 2010; 21:124-9. [PMID: 21062383 DOI: 10.1111/j.1365-3148.2010.01049.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is known that 20-30% of fresh frozen plasma (FFP) is used in intensive care units (ICUs), but little is known about variations in decision making between clinicians in relation to coagulopathy management. Our aim was to describe ICU clinicians' beliefs and practice in relation to FFP treatment of non-bleeding coagulopathic critically ill patients. METHODS Two patient-based scenarios were developed and sent to 2700 members of two UK intensive care professional societies. Scenario 1 was a non-bleeding septic patient with coagulopathy; scenario 2 was a non-bleeding critically ill patient with hepatic cirrhosis and coagulopathy. Responses were sought in relation to FFP prophylaxis, and prior to central venous cannulation. A supplementary question asked clinicians' view of prophylaxis in relation to other ICU procedures. RESULTS Two-thousand-and-seven-hundred clinicians were surveyed from whom 601 responses were received (22·3% response rate). For scenario 1 52% of respondents stated that they would never routinely administer prophylactic FFP, but this decreased to 9% when central venous cannulation was planned (P < 0·01). There was wide variation in the 'trigger' INR (international normalised ratio) value used prior to central vein cannulation, the most common range being 2·0-2·4. For scenario 2, responses were very similar. More than 80% of clinicians stated that they would routinely treat coagulopathy prior to lumbar puncture, epidural catheterisation, intracranial pressure monitoring and tracheostomy; and 54% prior to chest drain insertion. CONCLUSION Our survey demonstrated a wide range of responses consistent with important variations in clinical practice and substantial clinical uncertainty in relation to FFP treatment for non-bleeding ICU patients.
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Affiliation(s)
- D M Watson
- Better Blood Transfusion, Scottish National Blood Transfusion Service, Glasgow, UK.
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Prolongation of prothrombin time in the critically ill: is it time for decisive action? Crit Care Med 2010; 38:2065-6. [PMID: 20855994 DOI: 10.1097/ccm.0b013e3181f178ab] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Tavares M, DiQuattro P, Nolette N, Conti G, Sweeney J. Reduction in plasma transfusion after enforcement of transfusion guidelines (CME). Transfusion 2010; 51:754-61. [DOI: 10.1111/j.1537-2995.2010.02900.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Transfusion-related acute lung injury (TRALI) remains the deadliest complication of transfusion. Consensus definitions of TRALI have been developed but remain controversial. Recent evidence supports a strong relationship between blood transfusion and the development of acute lung injury in the critically ill and trauma population. Plasma and platelet transfusions have been the most commonly implicated blood products. The 'two hit' model may best explain the immune and nonimmune pathogenesis of TRALI. Current treatment remains largely supportive; effective measures for decreasing the incidence of TRALI include the use of predominantly male plasma and apheresis platelets. Greater understanding of the blood component and patient risk factors for TRALI will hopefully lead to novel treatment and preventive strategies for reducing the risk of this life-threatening syndrome.
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Affiliation(s)
- Mladen Sokolovic
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY 10065, USA
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Stanworth SJ, Grant-Casey J, Lowe D, Laffan M, New H, Murphy MF, Allard S. The use of fresh-frozen plasma in England: high levels of inappropriate use in adults and children. Transfusion 2010; 51:62-70. [PMID: 20804532 DOI: 10.1111/j.1537-2995.2010.02798.x] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fresh-frozen plasma (FFP) is given to patients across a range of clinical settings, frequently in association with abnormalities of standard coagulation tests. STUDY DESIGN AND METHODS A UK-wide study of FFP transfusion practice was undertaken to characterize the current patterns of administration and to evaluate the contribution of pretransfusion coagulation tests. RESULTS A total of 4969 FFP transfusions given to patients in 190 hospitals were analyzed, of which 93.3% were in adults and 6.7% in children or infants. FFP transfusions to adults were given most frequently in intensive-treatment or high-dependency units (32%), in operating rooms or recovery (23%), or on medical wards (22%). In adult patients 43% of all FFP transfusions were given in the absence of documented bleeding, as prophylaxis for abnormal coagulation tests or before procedures or surgery. There was wide variation in international normalized ratio (INR) or prothrombin times before FFP administration; in 30.9% of patients where the main reason for transfusion was prophylactic in the absence of bleeding the INR was 1.5 or less. Changes in standard coagulation results after FFP administration were generally very small for adults and children. CONCLUSIONS This study raises important questions about the clinical benefit of much of current FFP usage. It highlights the pressing need for better studies to inform and evaluate quantitative data for the effect of plasma on standard coagulation tests.
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Affiliation(s)
- Simon J Stanworth
- NHS Blood & Transplant/Oxford Radcliffe Hospitals Trust and University of Oxford, Oxford, UK
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Snow SJ, Ari Jutkowitz L, Brown AJ. Retrospective Study: Trends in plasma transfusion at a veterinary teaching hospital: 308 patients (1996-1998 and 2006-2008). J Vet Emerg Crit Care (San Antonio) 2010; 20:441-5. [DOI: 10.1111/j.1476-4431.2010.00557.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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50
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The “sticky” business of “adherence” to transfusion guidelines. Intensive Care Med 2010; 36:1107-9. [DOI: 10.1007/s00134-010-1871-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 03/08/2010] [Indexed: 10/19/2022]
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