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Gandhi A, Görlinger K, Nair SC, Kapoor PM, Trikha A, Mehta Y, Handoo A, Karlekar A, Kotwal J, John J, Apte S, Vohra V, Gupta G, Tiwari AK, Rani A, Singh SA. Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group. J Anaesthesiol Clin Pharmacol 2021; 37:3-13. [PMID: 34103816 PMCID: PMC8174427 DOI: 10.4103/joacp.joacp_410_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/09/2020] [Accepted: 10/04/2020] [Indexed: 01/09/2023] Open
Abstract
In a developing country like India, with limited resources and access to healthcare facilities, dealing with massive hemorrhage is a major challenge. This challenge gets compounded by pre-existing anemia, hemostatic disorders, and logistic issues of timely transfer of such patients from peripheral hospitals to centers with adequate resources and management expertise. Despite the awareness amongst healthcare providers regarding management modalities of bleeding patients, no uniform Patient Blood Management (PBM) or perioperative bleeding management protocols have been implemented in India, yet. In light of this, an interdisciplinary expert group came together, comprising of experts working in transfusion medicine, hematology, obstetrics, anesthesiology and intensive care, to review current practices in management of bleeding in Indian healthcare institutions and evaluating the feasibility of implementing uniform PBM guidelines. The specific intent was to perform a gap analysis between the ideal and the current status in terms of practices and resources. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management. Here, trauma, major surgery, postpartum hemorrhage, cardiac and liver surgery are the most common clinical settings associated with massive blood loss. Accordingly, PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.
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Affiliation(s)
- Ajay Gandhi
- Head - Clinical Affairs, Instrumentation Laboratory India Pvt Ltd, New Delhi, India
| | - Klaus Görlinger
- Medical Director, TEM Innovations/PBM Instrumentation Laboratory, Munich, Germany
| | - Sukesh C Nair
- Department of Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Poonam M Kapoor
- Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Trikha
- Department of Anaesthesiology, Pain Medicine and Critical Care, In Charge Trauma Intensive Care Unit and Trauma Anaesthesia, JPN Apex Trauma Centre, New Delhi, India
| | - Yatin Mehta
- Department of Cardiac Anaesthesia, Medanta the Medicity, Gurugram, Haryana, India
| | - Anil Handoo
- Department of Laboratory Medicine, BLK Superspeciality Hospital, New Delhi, India
| | - Anil Karlekar
- Department of Cardiac Anaesthesia, Fortis Escorts Heart Institute, New Delhi, India
| | - Jyoti Kotwal
- Department of Haematology, Sir Gangaram Hospital, New Delhi, India
| | - Joseph John
- Department of Haematology and Bone Marrow Transplant, Christian Medical College, Ludhiana, Punjab, India
| | - Shashikant Apte
- Department of Clinical Haematology, Sahayadri Hospital, Pune, Maharashtra, India
| | - Vijay Vohra
- Department of Liver Transplant Anaesthesia, Medanta the Medicity, Gurugram, Haryana, India
| | - Gajendra Gupta
- Medical Director and Head, Laboratory and Blood Bank, Santokhba Durlabhji Hospital, Jaipur, Rajasthan, India
| | - Aseem K Tiwari
- Department of Transfusion Medicine, Medanta the Medicity, Gurugram, Haryana, India
| | - Anjali Rani
- Department of Liver Transplant Anaesthesia, Max Superspeciality Hospital, New Delhi, India
| | - Shweta A Singh
- Department of Obstetrics and Gynaecology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Pollack MM, Chamberlain JM, Patel AK, Heneghan JA, Rivera EAT, Kim D, Bost JE. The Association of Laboratory Test Abnormalities With Mortality Risk in Pediatric Intensive Care. Pediatr Crit Care Med 2021; 22:147-160. [PMID: 33258574 PMCID: PMC7855885 DOI: 10.1097/pcc.0000000000002610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To determine the bivariable associations between abnormalities of 28 common laboratory tests and hospital mortality and determine how mortality risks changes when the ranges are evaluated in the context of commonly used laboratory test panels. DESIGN A 2009-2016 cohort from the Health Facts (Cerner Corporation, Kansas City, MO) database. SETTING Hospitals caring for children in ICUs. PATIENTS Children cared for in ICUs with laboratory data. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 2,987,515 laboratory measurements in 71,563 children. The distribution of laboratory test values in 10 groups defined by population percentiles demonstrated the midrange of tests was within the normal range except for those measured predominantly when significant abnormalities are suspected. Logistic regression analysis at the patient level combined the population-based groups into ranges with nonoverlapping mortality odds ratios. The most deviant test ranges associated with increased mortality risk (mortality odds ratios > 5.0) included variables associated with acidosis, coagulation abnormalities and blood loss, immune function, liver function, nutritional status, and the basic metabolic profile. The test ranges most associated with survival included normal values for chloride, pH, and bicarbonate/total Co2. When the significant test ranges from bivariable analyses were combined in commonly used test panels, they generally remained significant but were reduced as risk was distributed among the tests. CONCLUSIONS The relative importance of laboratory test ranges vary widely, with some ranges strongly associated with mortality and others strongly associated with survival. When evaluated in the context of test panels rather than isolated tests, the mortality odds ratios for the test ranges decreased but generally remained significant as risk was distributed among the components of the test panels. These data are useful to develop critical values for children in ICUs, to identify risk factors previously underappreciated, for education and training, and for future risk score development.
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Affiliation(s)
- Murray M Pollack
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Anita K Patel
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Julia A Heneghan
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eduardo A Trujillo Rivera
- Biomedical Informatics Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Dongkyu Kim
- Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E Bost
- Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
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Expert Consensus for a Principle-based Classification for Treatment of Diaphyseal Pediatric Femur Fractures. J Pediatr Orthop 2020; 40:e669-e675. [PMID: 32251113 DOI: 10.1097/bpo.0000000000001550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Recent studies demonstrate considerable deviation from the American Academy of Orthopaedic Surgeons (AAOS) evidence-based guidelines for the treatment of pediatric diaphyseal femur fractures (PDFFs). This study aimed to determine if expert-consensus can be reached on a principle-based classification to be applied broadly to a wide variety of PDFF scenarios and if outcomes correspond to adherence to the classification. METHODS A 2-stage study was performed. First, a survey of experts using a principle-based approach to PDFF. We conducted a survey of 17 thought-leaders (criteria≥20 y' experience+authors of the seminal pediatric femur fracture studies) who were asked to classify 15 cases of PDFF using the principle-based classification for agreement. Next, we conducted a retrospective review of 289 consecutive PDFF treated (2011-2015) at a level 1 pediatric trauma center. For each case, we compared the actual treatment and proposed "ideal" principle-based classification. We then compared clinical results and outcome data points including the length of stay, physician visits, and hospital charge data. RESULTS A substantial (κ=0.7) expert-agreement was noted for assigning treatment principles with near-perfect (κ=0.93) agreement on conservative versus surgical management. We obtained agreement on employing a flexible implant (κ=0.84) rigid fixation (κ=0.75) and damage control philosophy (κ=0.64). Suboptimal clinical results were noted in 43% of the undertreated patients (24/56), 18.8% of the adequately treated, and 14.3% of overtreated (P<0.01) patients. An increasing trend for the length of hospital stay and a number of clinic visits was noted as the treatment class increased (P<0.01). Charges were 4.2 times higher for an episode of operative versus nonoperative care (P<0.01). Rigid fixation (class 4) had significantly (P=0.01) higher total and material charges than flexible fixation (class 3). DISCUSSION The proposed classification has a substantial agreement among thought-leaders. Clinical results demonstrated significantly more suboptimal results in undertreated fractures, compared with ideally treated or more invasively treated fractures. More invasive treatments led to increased burden to families and the system in terms of length of stay and hospital charges. LEVEL OF EVIDENCE Level III.
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