Effect of Transfusion on Mortality and Other Adverse Events Among Critically Ill Septic Patients: An Observational Study Using a Marginal Structural Cox Model

Continuation of chronic antiplatelet therapy is not associated with increased need for transfusions: a cohort study in critically ill septic patients

BACKGROUND

The decision to maintain or halt antiplatelet medication in septic patients admitted to intensive care units presents a clinical dilemma. This is due to the necessity to balance the benefits of preventing thromboembolic incidents and leveraging anti-inflammatory properties against the increased risk of bleeding.

METHODS

This study involves a secondary analysis of data from a prospective cohort study focusing on patients diagnosed with severe sepsis or septic shock. We evaluated the outcomes of 203 patients, examining mortality rates and the requirement for transfusion. The cohort was divided into two groups: those whose antiplatelet therapy was sustained (n = 114) and those in whom it was discontinued (n = 89). To account for potential biases such as indication for antiplatelet therapy, propensity score matching was employed.

RESULTS

Therapy continuation did not significantly alter transfusion requirements (discontinued vs. continued in matched samples: red blood cell concentrates 51.7% vs. 68.3%, p = 0.09; platelet concentrates 21.7% vs. 18.3%, p = 0.82; fresh frozen plasma concentrates 38.3% vs. 33.3%, p = 0.7). 90-day survival was higher within the continued group (30.0% vs. 70.0%; p < 0.001) and the Log-rank test (7-day survivors; p = 0.001) as well as Cox regression (both matched samples) suggested an association between continuation of antiplatelet therapy < 7 days and survival (HR: 0.24, 95%-CI 0.10 to 0.63, p = 0.004). Sepsis severity expressed by the SOFA score did not differ significantly in matched and unmatched patients (both p > 0.05).

CONCLUSIONS

The findings suggest that continuing antiplatelet therapy in septic patients admitted to intensive care units could be associated with a significant survival benefit without substantially increasing the need for transfusion. These results highlight the importance of a nuanced approach to managing antiplatelet medication in the context of severe sepsis and septic shock.

Effect of sodium bicarbonate infusion on hospital mortality in acute kidney injury patients with metabolic acidosis

Background

Physicians usually consider that sodium bicarbonate (SB) infusion can be used for metabolic acidosis; however, there is little evidence available to assess its effect on hospital mortality in large AKI cohorts. Here, we investigated the effect of SB infusion in patients with AKI complicated by metabolic acidosis.

Method

Patients with AKI complicated by metabolic acidosis were screened from the MIMIC-IV database. A propensity score analysis (PSA) was used to decrease baseline differences in the probability of receiving SB. The marginal structural Cox model (MSCM) was employed to adjust for both baseline and time-varying confounding factors.

Results

A total of 1853 patients with AKI complicated with metabolic acidosis were included in our study. A total of 390 pairs of patients were divided into an SB infusion group and a non-SB infusion group. The SB infusion group had more serious and worse laboratory indicators, including lower pH [7.19 (0.11) vs. 7.26 (0.07)] and bicarbonate concentration (BC) [12.36 (4.26) vs. 15.96 (3.25) mmol/l]. While there was no significant effect on overall hospital mortality in AKI patients complicated with metabolic acidosis (p = 0.056), SB infusion was observed to have beneficial correlation on hospital mortality in patients with high AG acidosis (AG > 18 mmol/L) (p = 0.012). Similar results were replicated with the MSCM.

Conclusion

We found that SB infusion in AKI patients with metabolic acidosis is not beneficial for hospital mortality. However, SB infusion for AKI patients and high AG metabolic acidosis significantly improved hospital mortality. Further larger randomized controlled trials are needed to confirm these results.

Effectiveness of early heparin therapy on outcomes in critically ill patients with sepsis-induced coagulopathy

Background: This study aimed to investigate whether early unfractionated heparin (UFH) administration provides a survival advantage for patients with sepsis-induced coagulopathy (SIC). Methods: Patients hospitalized with sepsis-induced coagulopathy from the Medical Information Mart for Intensive Care (MIMIC)-IV database were identified. Patients were divided into two groups, who received unfractionated heparin (UFH) subcutaneously within 24 h after intensive care unit (ICU) admission, and the control group, who received not. The primary endpoint was intensive care unit mortality, the secondary outcomes were 7, 14, and 28-day and hospital mortality. Propensity score matching (PSM) the marginal structural Cox model (MSCM) and E-value analysis were used to account for baseline differences, time-varying and unmeasured confounding factors. Results: A total of 3,377 patients with sepsis-induced coagulopathy were enrolled in the study, of which 815 in unfractionated heparin group and 2,562 in control group. There was significant effect on primary and secondary outcomes with unfractionated heparin after propensity score matching (intensive care unit mortality, hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.52-0.92; 7-day, HR 0.70, 95% CI 0.49-0.99; 14-day, HR 0.68.95% CI 0.50-0.92; 28-day, HR 0.72, 95% CI 0.54-0.96; hospital mortality, HR 0.74, 95% CI 0.57-0.96), marginal structural Cox model manifested unfractionated heparin associated with decreased intensive care unit mortality in all populations (HR 0.64, 95% CI 0.49-0.84), and stratification with the marginal structural Cox model indicated analysis further indicated the survival advantage only among patients with an sepsis-induced coagulopathy score of 4 (HR 0.56, 95% CI 0.38-0.81). Further analysis showed that treatment with 6,250-13750 IU/day of unfractionated heparin associated with a decreased risk of intensive care unit mortality. Similar results were replicated in subgroup analysis with propensity score matching only for patients with an sepsis-induced coagulopathy score of 4 (intensive care unit mortality, HR 0.51, 95% CI 0.34-0.76). Conclusion: This study found early unfractionated heparin therapy to patients with sepsis-induced coagulopathy appears to be associated with improved outcomes. Subgroup analysis further demonstrates heparin therapy decreased intensive care unit mortality primarily in patients only with SIC score of 4.

Clinical characteristics and risk factors associated with ICU-acquired infections in sepsis: A retrospective cohort study

Intensive care unit (ICU)-acquired infection is a common cause of poor prognosis of sepsis in the ICU. However, sepsis-associated ICU-acquired infections have not been fully characterized. The study aims to assess the risk factors and develop a model that predicts the risk of ICU-acquired infections in patients with sepsis.

Epidemiology and Associated Factors in Transfusion Management in Intensive Care Unit

Severe traumatic injury is one of the main global health issues which annually causes more than 5.8 million worldwide deaths. Uncontrolled haemorrhage is the main avoidable cause of death among severely injured individuals. Management of trauma patients is the greatest challenge in trauma emergency care, and its proper diagnosis and early management of bleeding trauma patients, including blood transfusion, are critical for patient outcomes. Aim: We aimed to describe the epidemiology of transfusion practices in severe trauma patients admitted into Spanish Intensive Care Units. Material and Methods: We performed a multicenter cross-sectional study in 111 Intensive Care Units across Spain. Adult patients with moderate or severe trauma were eligible. Distribution of frequencies was used for qualitative variables and the mean, with its 95% CI, for quantitative variables. Transfusion programmes, the number of transfusions performed, and the blood component transfused were recorded. Demographic variables, mortality rate, hospital stay, SOFA-score and haemoglobin levels were also gathered. Results: We obtained results from 109 patients. The most transfused blood component was packet red blood cells with 93.8% of total transfusions versus 43.8% of platelets and 37.5% of fresh plasma. The main criteria for transfusion were analytical criteria (43.75%), and acute anaemia with shock (18.75%) and without haemodynamic impact (18.75%). Conclusion: Clinical practice shows a ratio of red blood cells, platelets, and Fresh Frozen Plasma (FFP) of 2:1:1. It is necessary to implement Massive Transfusion Protocols as they appear to improve outcomes. Our study suggests that transfusion of RBC, platelets and FFP in a 2:1:1 ratio could be beneficial for trauma patients.

Association of red blood cell and platelet transfusions with persistent inflammation, immunosuppression, and catabolism syndrome in critically ill patients

The objective of this single-center retrospective cohort study was to investigate the relationship between blood transfusion and persistent inflammation, immunosuppression, and catabolism syndrome (PIICS). The study was conducted at the Critical Care Center at Toho University Omori Medical Center, Japan. We included 391 patients in the PIICS group (hospitalization for > 15 days, C-reactive protein > 3.0 mg/dL or albumin < 3.0 mg/dL or lymph < 800/μL on day 14) and 762 patients in the non-PIICS group (hospitalization for > 15 days and not meeting the PIICS criteria). We performed univariate and multivariate logistic regression analyses using PIICS as the objective variable and red blood cell (RBC) or fresh frozen plasma or platelet (PLT) transfusion and other confounding factors as explanatory variables. In addition, we conducted a sensitivity analysis using propensity score matching analysis. The multivariate and propensity score analyses showed that RBC and PLT transfusions were significantly associated with PIICS. This is the first study to report an association between RBC and PLT transfusions and PIICS. Our findings have contributed to better understanding the risk factors of PIICS and suggest that physicians should consider the risk of PIICS occurrence when administering blood transfusions in intensive care unit (ICU) patients.

Antithrombotic Therapy Improves ICU Mortality of Septic Patients with Peripheral Vascular Disease

OBJECTIVE

The effectiveness of antithrombotic drugs for treating sepsis is controversial. Here, we explore the association between antithrombotic therapy and intensive care unit (ICU) mortality for septic patients with peripheral vascular disease.

METHODS

This retrospective cohort study uses data from the Medical Information Mart for Intensive Care (MIMIC)-III database. Kaplan-Meier survival analyses were used to examine mortality among different groups. Cox regression and marginal structural Cox models (MSCMs) were used to adjust for confounding factors. Main Results. The final cohort from the MIMIC-III database included 776 patients, of which 701 survived and 75 perished. The anticoagulant (AC) group and the antiplatelet-anticoagulation (AC-AP) group survived better than the group without antithrombotic treatment (non-AT). The AC and AC-AP groups showed a 0.363-fold and 0.373-fold risk of ICU mortality, respectively, compared with the non-AT group when controlling for age, gender, CRRT, alcohol, heart failure, hypertension, diabetes, obesity, renal failure, liver disease, INR, PT, PPT, and SpO2. Antiplatelet therapy did not reduce ICU mortality. The same trends were apparent from the MSCM. In addition, the AC-AP group exhibited a lower risk of bleeding complications.

CONCLUSION

Although the antithrombotic group (AC and AC-AP groups) demonstrated a higher sequential organ failure assessment (SOFA) score than the group without antithrombotic treatment (non-AT group), the risk of ICU mortality was lower without increasing the risk of bleeding complications. Our study further suggested that anticoagulation therapy may benefit the prognosis of septic patients with peripheral vascular disease.

Attributable mortality of acute respiratory distress syndrome: a systematic review, meta-analysis and survival analysis using targeted minimum loss-based estimation

BACKGROUND

Although acute respiratory distress syndrome (ARDS) is associated with high mortality, its direct causal link with death is unclear. Clarifying this link is important to justify costly research on prevention of ARDS.

OBJECTIVE

To estimate the attributable mortality, if any, of ARDS.

DESIGN

First, we performed a systematic review and meta-analysis of observational studies reporting mortality of critically ill patients with and without ARDS matched for underlying risk factor. Next, we conducted a survival analysis of prospectively collected patient-level data from subjects enrolled in three intensive care unit (ICU) cohorts to estimate the attributable mortality of critically ill septic patients with and without ARDS using a novel causal inference method.

RESULTS

In the meta-analysis, 44 studies (47 cohorts) involving 56 081 critically ill patients were included. Mortality was higher in patients with versus without ARDS (risk ratio 2.48, 95% CI 1.86 to 3.30; p<0.001) with a numerically stronger association between ARDS and mortality in trauma than sepsis. In the survival analysis of three ICU cohorts enrolling 1203 critically ill patients, 658 septic patients were included. After controlling for confounders, ARDS was found to increase the mortality rate by 15% (95% CI 3% to 26%; p=0.015). Significant increases in mortality were seen for severe (23%, 95% CI 3% to 44%; p=0.028) and moderate (16%, 95% CI 2% to 31%; p=0.031), but not for mild ARDS.

CONCLUSIONS

ARDS has a direct causal link with mortality. Our findings provide information about the extent to which continued funding of ARDS prevention trials has potential to impart survival benefit.

PROSPERO REGISTRATION NUMBER

CRD42017078313.

Impact of Blood Product Transfusions on the Risk of ICU-Acquired Infections in Septic Shock

OBJECTIVES

Transfusions of blood products are common in critically ill patients and have a potential for immunomodulation. The aim of this study is to address the impact of transfusion of blood products on the susceptibility to ICU-acquired infections in the high-risk patients with septic shock.

DESIGN

A single-center retrospective study over a 10-year period (2008-2017).

SETTING

A medical ICU of a tertiary-care center.

PATIENTS

All consecutive patients diagnosed for septic shock within the first 48 hours of ICU admission were included. Patients who were discharged or died within the first 48 hours were excluded.

INTERVENTIONS

RBC, platelet, and fresh frozen plasma transfusions collected up to 24 hours prior to the onset of ICU-acquired infection.

MEASUREMENTS AND MAIN RESULTS

During the study period, 1,152 patients were admitted for septic shock, with 893 patients remaining alive in the ICU after 48 hours of management. A first episode of ICU-acquired infection occurred in 28.3% of the 48-hour survivors, with a predominance of pulmonary infections (57%). Patients with ICU-acquired infections were more likely to have received RBC, platelet, and fresh frozen plasma transfusions. In a multivariate Cox cause-specific analysis, transfusions of platelets (cause-specific hazard ratio = 1.55 [1.09-2.20]; p = 0.01) and fresh frozen plasma (cause-specific hazard ratio = 1.38 [0.98-1.92]; p = 0.05) were independently associated with the further occurrence of ICU-acquired infections.

CONCLUSIONS

Transfusions of platelets and fresh frozen plasma account for risk factors of ICU-acquired infections in patients recovering from septic shock. The occurrence of ICU-acquired infections should be considered as a relevant endpoint in future studies addressing the indications of transfusions in critically ill patients.

Linkage of alterations in systemic iron homeostasis to patients' outcome in sepsis: a prospective study

Background

Sepsis, a dysregulated host response following infection, is associated with massive immune activation and high mortality rates. There is still a need to define further risk factors and laboratory parameters predicting the clinical course. Iron metabolism is regulated by both, the body’s iron status and the immune response. Iron itself is required for erythropoiesis but also for many cellular and metabolic functions. Moreover, iron availability is a critical determinant in infections because it is an essential nutrient for most microbes but also impacts on immune function and intravascular oxidative stress. Herein, we used a prospective study design to investigate the putative impact of serum iron parameters on the outcome of sepsis.

Methods

Serum markers of iron metabolism were measured in a prospective cohort of 61 patients (37 males, 24 females) with sepsis defined by Sepsis-3 criteria in a medical intensive care unit (ICU) and compared between survivors and non-survivors. Regulation of iron parameters in patients stratified by focus of infection and co-medication as well as association of the markers with sepsis severity scores and survival were investigated with linear and logistic regression corrected for sex and age effects.

Results

Positive correlations of increased serum iron and ferritin concentrations upon ICU admission with the severity of organ failure (SOFA score) and with mortality were observed. Moreover, high TF-Sat, elevated ferritin and serum iron levels and low transferrin concentrations were associated with reduced survival. A logistic regression model consisting of SOFA and transferrin saturation (SOFA–TF-Sat) had the best predictive power for survival in septic ICU patients. Of note, administration of blood transfusions prior to ICU admission resulted in increased TF-Sat and reduced survival of septic patients.

Conclusions

Our study could show an important impact of serum iron parameters on the outcome of sepsis. Furthermore, we identified transferrin saturation as a stand-alone predictor of sepsis survival and as a parameter of iron metabolism which may in a combined model improve the prediction power of the SOFA score.

Trial registration

The study was carried out in accordance with the recommendations of the Declaration of Helsinki on biomedical research. The study was approved by the institutional ethics review board of the Medical University Innsbruck (study AN2013-0006).

The impact of high frequency oscillatory ventilation on mortality in paediatric acute respiratory distress syndrome

BACKGROUND

High-frequency oscillatory ventilation (HFOV) use was associated with greater mortality in adult acute respiratory distress syndrome (ARDS). Nevertheless, HFOV is still frequently used as rescue therapy in paediatric acute respiratory distress syndrome (PARDS). In view of the limited evidence for HFOV in PARDS and evidence demonstrating harm in adult patients with ARDS, we hypothesized that HFOV use compared to other modes of mechanical ventilation is associated with increased mortality in PARDS.

METHODS

Patients with PARDS from 10 paediatric intensive care units across Asia from 2009 to 2015 were identified. Data on epidemiology and clinical outcomes were collected. Patients on HFOV were compared to patients on other modes of ventilation. The primary outcome was 28-day mortality and secondary outcomes were 28-day ventilator- (VFD) and intensive care unit- (IFD) free days. Genetic matching (GM) method was used to analyse the association between HFOV treatment with the primary outcome. Additionally, we performed a sensitivity analysis, including propensity score (PS) matching, inverse probability of treatment weighting (IPTW) and marginal structural modelling (MSM) to estimate the treatment effect.

RESULTS

A total of 328 patients were included. In the first 7 days of PARDS, 122/328 (37.2%) patients were supported with HFOV. There were significant differences in baseline oxygenation index (OI) between the HFOV and non-HFOV groups (18.8 [12.0, 30.2] vs. 7.7 [5.1, 13.1] respectively; p < 0.001). A total of 118 pairs were matched in the GM method which found a significant association between HFOV with 28-day mortality in PARDS [odds ratio 2.3, 95% confidence interval (CI) 1.3, 4.4, p value 0.01]. VFD was indifferent between the HFOV and non-HFOV group [mean difference - 1.3 (95%CI - 3.4, 0.9); p = 0.29] but IFD was significantly lower in the HFOV group [- 2.5 (95%CI - 4.9, - 0.5); p = 0.03]. From the sensitivity analysis, PS matching, IPTW and MSM all showed consistent direction of HFOV treatment effect in PARDS.

CONCLUSION

The use of HFOV was associated with increased 28-day mortality in PARDS. This study suggests caution but does not eliminate equivocality and a randomized controlled trial is justified to examine the true association.

Anemia and red blood cell transfusion practice in prolonged mechanically ventilated patients admitted to a specialized weaning center: an observational study

Background

The impact of anemia and red blood cell (RBC) transfusion on weaning from mechanical ventilation is not known. In theory, transfusions could facilitate liberation from the ventilator by improving oxygen transport capacity. In contrast, retrospective studies of critically ill patients showed a positive correlation of transfusions with prolonged mechanical ventilation, increased mortality rates, and increased risk of nosocomial infections, which in turn could adversely affect weaning outcome.

Methods

Retrospective, observational study on prolonged mechanically ventilated, tracheotomized patients (n = 378), admitted to a national weaning center over a 5 year period. Medical records were reviewed to obtain data on patients’ demographics, comorbidities, blood counts, transfusions, weaning outcome, and nosocomial infections, defined according to the criteria of the U.S. Centers for Disease Control and Prevention. The impact of RBC transfusion on outcome measures was assessed using regression models.

Results

Ninety-eight percent of all patients showed anemia on admission to the weaning center. Transfused and non-transfused patients differed significantly regarding disease severity and comorbidities. In multivariate analyses, RBC transfusion, but not mean hemoglobin concentration in the course of weaning, was independently correlated with weaning duration (adjusted β 12.386, 95% CI 9.335–15.436; p <  0.001) and hospital length of stay (adjusted β 16.116, 95% CI 8.925–23.306; p <  0.001); there was also a trend toward increased hospital mortality (adjusted odds ratio [OR] 2.050, 95% CI 0.995–4.224; p = 0.052), but there was no independent correlation with weaning outcome or nosocomial infections. In contrast, hemoglobin level on the day of admission to the weaning center was independently associated with hospital mortality (adjusted OR 0.956, 95% CI 0.924–0.989; p = 0.010), appearing significantly elevated at values below 8.5 g/dl (AUC 0.670, 95% CI 0.593–0.747; p <  0.001).

Conclusions

A high percentage of prolonged mechanically ventilated patients showed anemia on admission to the weaning center. RBC transfusion was independently correlated with worse outcomes. Since transfused patients differed significantly regarding their clinical characteristics and comorbidities, RBC transfusion might be an indicator of disease severity rather than directly impacting patient prognosis.

Association Between the Use of Sodium Bicarbonate and Mortality in Acute Kidney Injury Using Marginal Structural Cox Model

OBJECTIVE

Acute kidney injury with metabolic acidosis is common in critically ill patients. This study assessed the associations between the use of IV sodium bicarbonate and mortality of patients with acute kidney injury and acidosis.

DESIGN

The study was conducted by using data from Beth Israel Deaconess Medical Center, which included several ICUs such as coronary care unit, cardiac surgery recovery unit, medical ICU, surgical ICU, and trauma-neuro ICU. Marginal structural Cox model was used to assess the relationship between receipt of sodium bicarbonate and hospital mortality, allowing pH, PaCO2, creatinine, and bicarbonate concentration as time-varying predictors of sodium bicarbonate exposure while adjusting for baseline characteristics of age, gender, Sequential Organ Failure Assessment score, acute kidney injury stage, Elixhauser score, quick Sequential Organ Failure Assessment, and Simplified Acute Physiology Score II.

SETTING

A large U.S.-based critical care database named Medical Information Mart for Intensive Care.

PATIENTS

Patients with Kidney Disease: Improving Global Outcomes acute kidney injury stage greater than or equal to 1 (> 1.5 (Equation is included in full-text article.)baseline creatinine) and one measurement of acidosis (pH ≤ 7.2). Baseline creatinine was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 3,406 eligible patients, 836 (24.5%) had received sodium bicarbonate treatment. Patients who received sodium bicarbonate treatment had a higher Sequential Organ Failure Assessment (9 vs 7; p < 0.001), lower pH (7.16 vs 7.18; p < 0.001), and bicarbonate concentration (16.51 ± 7.04 vs 20.57 ± 6.29 mmol/L; p < 0.001) compared with those who did not receive sodium bicarbonate. In the marginal structural Cox model by weighing observations with inverse probability of receiving sodium bicarbonate, sodium bicarbonate treatment was not associated with mortality in the overall population (hazard ratio, 1.16; 95% CI, 0.98-1.42; p = 0.132), but it appeared to be beneficial in subgroups of pancreatitis (hazard ratio, 0.53; 95% CI, 0.28-0.98; p = 0.044) and severe acidosis (pH < 7.15; hazard ratio, 0.75; 95% CI, 0.58-0.96; p = 0.024). Furthermore, sodium bicarbonate appeared to be beneficial in patients with severe bicarbonate deficit (< -50 kg·mmol/L).

CONCLUSIONS

In the analysis by adjusting for potential confounders, there is no evidence that IV sodium bicarbonate is beneficial for patients with acute kidney injury and acidosis. Although the study suggested potential beneficial effects in some highly selected subgroups, the results need to be validated in experimental trials.

Methodological considerations for linked blood donor-component-recipient analyses in transfusion medicine research

In recent years, there has been a concerted effort to improve our understanding of the quality and effectiveness of transfused blood components. The expanding use of large datasets built from electronic health records allows the investigation of potential benefits or adverse outcomes associated with transfusion therapy. Together with data collected on blood donors and components, these datasets permit an evaluation of associations between donor or blood component factors and transfusion recipient outcomes. Large linked donor-component recipient datasets provide the power to study exposures relevant to transfusion efficacy and safety, many of which would not otherwise be amenable to study for practical or sample size reasons. Analyses of these large blood banking-transfusion medicine datasets allow for characterization of the populations under study and provide an evidence base for future clinical studies. Knowledge generated from linked analyses have the potential to change the way donors are selected and how components are processed, stored and allocated. However, unrecognized confounding and biased statistical methods continue to be limitations in the study of transfusion exposures and patient outcomes. Results of observational studies of blood donor demographics, storage age, and transfusion practice have been conflicting. This review will summarize statistical and methodological challenges in the analysis of linked blood donor, component, and transfusion recipient outcomes.

Review: The Perioperative Use of Thromboelastography for Liver Transplant Patients

Thromboelastography (TEG) is a viscoelastic test that allows rapid evaluation of clot formation and fibrinolysis from a sample of whole blood. TEG is increasingly utilized to guide blood product resuscitation in surgical patients and transfusions for liver transplant patients. Patients with severe liver failure have significant derangement of their clotting function due to impaired production of procoagulant and anticoagulant factors. Traditional coagulation studies are limited by the short time needed for the result and provide little information about the dynamics and strength of clot formation. In addition, traditional coagulation studies do not correlate well with bleeding episodes and may lead to over-transfusion of various blood products. Evidence is less robust regarding the use of TEG for transfusion management decisions in severe liver failure patients awaiting, undergoing, or immediately after liver transplant surgery. However, the available evidence suggests that systematic implementation of TEG rather than traditional coagulation studies results in the administration of fewer blood products without increased mortality or complications. The purpose of this study is to review the literature regarding the use of TEG in liver failure patients prior to liver transplant, intraoperatively, and postoperatively. Additional high-quality randomized controlled studies should be performed to evaluate the use of TEG to guide transfusion decisions, particularly in the postoperative period following liver transplantation.

Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis

OBJECTIVE

Although sodium bicarbonate (SB) solution has been widely used in clinical practice, its effect on mortality when administered to a large population of patients with acidosis is not known. The study aimed to investigate the effectiveness of SB infusion in septic patients with metabolic acidosis.

METHODS

Septic patients with metabolic acidosis were identified from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score (PS) was used to account for the baseline differences in the probability to receive SB or not. The marginal structural Cox model (MSCM) was employed to adjust for both baseline and time-varying confounding factors.

MAIN RESULTS

A total of 1718 septic patients with metabolic acidosis were enrolled in the study, including 500 in the SB group and 1218 in the non-SB group. Both pH [7.16 (standard deviation (SD): 0.10) vs. 7.22 (SD: 0.07); p < 0.001] and bicarbonate concentration (BC) [11.84 (SD: 3.63) vs. 14.88 (SD: 3.36) mmol/l; p < 0.001] were significantly lower in the SB than that in the non-SB group. While there was no significant mortality effect in the overall population [hazard ratio (HR): 1.04; 95% CI 0.86-1.26; p = 0.67], SB was observed to be beneficial in patients with acute kidney injury (AKI) stage 2 or 3 and pH < 7.2 (HR 0.74; 95% CI 0.51-0.86; p = 0.021). Similar results were replicated with the MSCM.

CONCLUSION

Our study observed that SB infusion was not associated with improved outcome in septic patients with metabolic acidosis, but it was associated with improved survival in septic patients with AKI stage 2 or 3 and severe acidosis. The results need to be verified in randomized controlled trials.