Hematologic complications of critical illness: anemia, neutropenia, thrombocytopenia, and more

Hemogram parameters can predict in-hospital mortality of patients with Myasthenic crisis

BACKGROUND

Myasthenia gravis (MG) is an autoimmune disease involving the neuromuscular junction. Myasthenic crisis (MC), which is characterized by respiratory failure and the requirement of mechanical ventilation in patients with MG, is still a medical emergency despite the decrease in mortality with the advances in acute management. Hemogram is a cost-effective test for evaluating hematological complications and systemic inflammation, and hemogram data have been used to predict various clinical outcomes of several diseases. The relationship between hemogram and MG has been discussed, but the role of hemogram data in predicting the prognosis of MC patients has not been established.

METHODS

To identify whether hemogram data can predict in-hospital mortality in patients with MC, we retrospectively investigated 188 myasthenic crisis events from the Chang Gung Research Database between April 2001 and March 2019. Demographic and clinical characteristics were collected, as well as hemogram data before intubation and extubation. The endpoints were mortality during mechanical ventilation and mortality after extubation.

RESULTS

The overall in-hospital mortality rate was 22%. Multivariate logistic regression analysis for predicting mortality during mechanical ventilation showed that old age at MC onset (OR = 1.039, p = 0.022), moderate-to-severe anemia (OR = 5.851, p = 0.001), and extreme leukocytosis (OR = 5.659, p = 0.022) before intubation were strong predictors of mortality, while acute management with plasma exchange or double-filtration plasmapheresis (PE/DFPP) significantly decreased mortality (OR = 0.236, p = 0.012). For predicting mortality after extubation, moderate-to-severe anemia before extubation (OR = 8.452, p = 0.017) and non-treated with disease-modifying therapy before MC (OR = 5.459, p = 0.031) were crucial predictive factors.

CONCLUSION

This study demonstrated that both old age at MC onset and moderate-to-severe anemia are important predictors of in-hospital mortality in patients with MC, and extreme leukocytosis is another crucial predictor of mortality during mechanical ventilation. The suggested mechanism is that anemia-induced hypoxia may enhance the release of proinflammatory cytokines, exacerbate systemic inflammation, and lead to multiple organ dysfunction syndrome and, finally, mortality.

Active exercise in critically ill adults affected by thrombocytopaenia

Introduction

Thrombocytopaenia (TCP), or low platelet count, is a haematological disorder that commonly occurs in critically ill patients and is defined as a platelet count below 100 000/μL. Patients are at higher risk of muscular atrophy and other complications after prolonged bed rest. This literature review aims to clarify the appropriateness of active exercise in critically ill adult patients with TCP.

Methods

A review of the literature was conducted using the following key words that are PubMed medical subheading (MeSH) terms: ‘critical illness’, ‘exercise therapy’, ‘manual therapy’, ‘physical therapy’, ‘physiotherapy’, ‘postoperative care’, ‘rehabilitation’, ‘thrombocytopenia’, and ‘thrombopenia’. The search was limited by publication date (2000 to 2013) and language (English only) in three main databases: PubMed, SCOPUS, and CINAHL.

Results

The key word searches found a total of 78 citations. Of these, only those meeting the inclusion criteria were selected after reading the title and abstract. Two studies were included after reading the full-texts. Exercise is used to treat muscular atrophy in critically ill adult patients, and rehabilitation plays an important role in the care pathway. Results of our analysis do not support evidence for or against exercise in critically ill adult patients with TCP; therefore, health professionals must pay close attention to the presence of signs of bleeding in these patients when proposing exercise.

Discussion

Surprisingly, no study was found that directly covered this issue. Aggressive exercise may not be appropriate in patients with very low platelet counts. On the other hand, critically ill patients are at high risk of muscular atrophy due to the forced bed rest, especially after complex surgery or in prolonged hospitalisation. Physiotherapists and those providing care must share their observations with the rest of the multidisciplinary team before treatment starts.

Conclusions

Active exercise in critically ill adult patients with severe TCP must be personalised and platelet count carefully monitored before proposing physical activity. Physical recovery can be challenging in critically ill adult patients, and it can be limited by severe TCP, mostly when bleeding is present.