Transfusion vs. alternative treatment modalities in acute bleeding: a systematic review

Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives: Chapter 5 Human Albumin - Revised

Chapter 5 'Human Albumin' that was suspended on January 10, 2011 has been completed and updated in the present version.

Retrospective Study of 122 Dogs That Were Treated with the Antifibrinolytic Drug Aminocaproic Acid: 2010-2012

Antifibrinolytic drugs are used to promote hemostasis and decrease the need for red blood cell transfusion. Medical records of 122 dogs that were prescribed either oral or intravenous aminocaproic acid between 2010 and 2012 were evaluated retrospectively. Of the 122 dogs, three experienced possible drug-related adverse effects. No significant differences were identified between dogs that experienced adverse effects and those that did not and the possible adverse effects noted were all minor. All dogs that received packed red blood cell transfusions were evaluated for correlations between baseline packed cell volume or dose of red blood cells and aminocaproic acid dose and no correlation was identified. Dogs that received aminocaproic acid as a treatment for active bleeding were divided by cause of hemorrhage into the following groups: neoplastic, non-neoplastic, and unknown. No significant differences in aminocaproic acid dose or the percentage of patients requiring a blood transfusion were identified between groups.

The effects of safety checklists in medicine: a systematic review

BACKGROUND

Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was used. All studies in which safety checklists were used as an additional tool designed to assure that an operation or task was performed as planned were included.

RESULTS

The initial search extracted 7408 hits. Twenty-nine articles met the inclusion criteria. Five additional studies were identified by a cross-referencing search. Four groups were made according to outcome measures. One group (n = 7) had 'hard' outcome measures, such as mortality and morbidity. The remaining studies, reporting 'softer' process-related measures, were divided into three categories: adherence to guidelines (n = 6), human factors (n = 16), and reduction of adverse events (n = 5). The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists.

CONCLUSION

Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients

PURPOSE

Colloids are administered to more patients than crystalloids, although recent evidence suggests that colloids may possibly be harmful in some patients. The European Society of Intensive Care Medicine therefore assembled a task force to compile consensus recommendations based on the current best evidence for the safety and efficacy of the currently most frequently used colloids--hydroxyethyl starches (HES), gelatins and human albumin.

METHODS

Meta-analyses, systematic reviews and clinical studies of colloid use were evaluated for the treatment of volume depletion in mixed intensive care unit (ICU), cardiac surgery, head injury, sepsis and organ donor patients. Clinical endpoints included mortality, kidney function and bleeding. The relevance of concentration and dosage was also assessed. Publications from 1960 until May 2011 were included. The quality of available evidence and strength of recommendations were based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RECOMMENDATIONS AND CONCLUSIONS

We recommend not to use HES with molecular weight ≥ 200 kDa and/or degree of substitution >0.4 in patients with severe sepsis or risk of acute kidney injury and suggest not to use 6% HES 130/0.4 or gelatin in these populations. We recommend not to use colloids in patients with head injury and not to administer gelatins and HES in organ donors. We suggest not to use hyperoncotic solutions for fluid resuscitation. We conclude and recommend that any new colloid should be introduced into clinical practice only after its patient-important safety parameters are established.

Human serum albumin: from bench to bedside

Human serum albumin (HSA), the most abundant protein in plasma, is a monomeric multi-domain macromolecule, representing the main determinant of plasma oncotic pressure and the main modulator of fluid distribution between body compartments. HSA displays an extraordinary ligand binding capacity, providing a depot and carrier for many endogenous and exogenous compounds. Indeed, HSA represents the main carrier for fatty acids, affects pharmacokinetics of many drugs, provides the metabolic modification of some ligands, renders potential toxins harmless, accounts for most of the anti-oxidant capacity of human plasma, and displays (pseudo-)enzymatic properties. HSA is a valuable biomarker of many diseases, including cancer, rheumatoid arthritis, ischemia, post-menopausal obesity, severe acute graft-versus-host disease, and diseases that need monitoring of the glycemic control. Moreover, HSA is widely used clinically to treat several diseases, including hypovolemia, shock, burns, surgical blood loss, trauma, hemorrhage, cardiopulmonary bypass, acute respiratory distress syndrome, hemodialysis, acute liver failure, chronic liver disease, nutrition support, resuscitation, and hypoalbuminemia. Recently, biotechnological applications of HSA, including implantable biomaterials, surgical adhesives and sealants, biochromatography, ligand trapping, and fusion proteins, have been reported. Here, genetic, biochemical, biomedical, and biotechnological aspects of HSA are reviewed.

Trends in transfusion of trauma victims--evaluation of changes in clinical practice

Background

The present study was performed to compare blood product consumption and clinical results in consecutive, unselected trauma patients during the first 6 months of year 2002, 2004 and 2007.

Methods

Clinical data, blood product consumption, lowest haemoglobin values on day 1-10 after admission, and 30-day mortality were extracted from in-hospital trauma registry and the blood bank data base. The subpopulation of massively transfused patients was identified and analysed separately.

Results

The total number of admitted trauma patients increased by 48% from 2002 to 2007, but the clinical data remained essentially unchanged. The mean number of erythrocyte units given day 1-10 decreased insignificantly from 9.4 in 2002 to 6.8 in 2007. New Injury Severity Score (NISS) increased in transfused and massively transfused patients, but not significantly. The number of patients transfused with plasma increased and the mean ratio of erythrocyte to plasma units transfused decreased by about 50%. The mean haemoglobin value in transfused patients on day 2 after admittance was significantly lower in 2007 than in 2002, while that on day 10 was significantly higher in 2007 than in 2002 and 2004. There was no change of 30-day survival from 2002 to 2007.

Conclusions

Significant changes of transfusion practice occurred during the past decade, probably as a result of increased focus on haemostasis and more precise criteria for transfusion. Despite a lower consumption of erythrocytes in 2007 than in 2002 and 2004, the mean haemoglobin level of transfused patients was higher on day 10 in 2007. The low number of transfused patients in this material makes evaluation of effect on survival difficult. Larger studies with strict control of all influencing factors are needed.

Trauma-induced coagulopathy--a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice?

Systematic reviews are accepted as a robust and less biased means of appraising and synthesizing results from high-quality studies. This report collated and summarized all the systematic review evidence relating to the diagnosis and management of trauma-related coagulopathy and transfusion, thereby covering the widest possible body of literature. We defined 4 key clinical questions: (1) What are the best methods of predicting and diagnosing trauma-related coagulopathy? (2) Which methods of clinical management correct coagulopathy? (3) Which methods of clinical management correct bleeding? and (4) What are the outcomes of transfusion in trauma? Thirty-seven systematic reviews were identified through searches of MEDLINE (1950-July 2010), EMBASE (1980-July 2010), The Cochrane Library (Issue 7, 2010), National Guidelines Clearing House, National Library for Health Guidelines Finder, and UKBTS SRI Transfusion Evidence Library (www.transfusionevidencelibrary.com). The evidence from the systematic review literature was scanty with many gaps, and we were not able to conclusively answer any of our 4 questions. Much more needs to be understood about how coagulopathy and bleeding in trauma are altered by transfusion practices and, most importantly, whether this translates into improved survival. There is a need for randomized controlled trials to answer these questions. The approach described in this report provides a framework for incorporating new evidence.

A systematic review of oxymorphone in the management of chronic pain

Opioids are recommended for control of moderate-to-severe, chronic, malignant, and nonmalignant pain. A controlled-release formulation of the opioid oxymorphone has recently been launched. The aim of this review was to assess the effectiveness of oxymorphone as an analgesic in chronic pain. A systematic search for published studies of oral oxymorphone in the management of chronic pain was conducted. The studies were evaluated for their internal validity according to standard criteria. They were also evaluated for their external validity and research ethic aspects. A meta-analysis was performed to examine the effect of oxymorphone compared with placebo. Nine studies were evaluated; three were excluded because of low quality. Six controlled studies (duration 2-12 weeks) included a total of 1489 subjects suffering from chronic low back pain, chronic pain from osteoarthritis, and chronic cancer pain. Three of the studies were of high quality and three of medium quality. External validity was assessed to be high, medium, and low (in one, three, and two studies, respectively). The meta-analysis suggests that daily doses of 40-100mg are superior to placebo; however, the estimate (reduction of pain intensity compared with placebo) of the treatment effect is imprecise (95% confidence interval -17.08, -8.69). Limited evidence suggests that oxymorphone is effective for pain control in patients with cancer. No significant differences between oxymorphone and oxycodone at equipotent doses were found. In conclusion, oxymorphone is superior to placebo. There is no evidence that the efficacy of oxymorphone differs from other opioids.

Update on Transfusion Medicine

Clinical pharmacists often participate on critical care teams that manage patients with bleeding emergencies. Although blood products are usually dispensed from the blood bank and not the pharmacy, pharmacists should be conversant in the language and trends of transfusion medicine, much like they are with other therapeutic agents. Toward that goal, this review provides a concise transfusion medicine tutorial, covering all commonly used blood products, including red blood cells, platelets, fresh frozen plasma, and plasma derivatives such as cryoprecipitate, prothrombin complex concentrates, and albumin. Usage patterns, the rationale for administering the various blood products, and studies that have attempted to determine appropriate criteria for ordering transfusions (transfusion triggers) are discussed. The benefits, risks, and several ongoing controversies that relate to the appropriateness and safety of blood product use are also summarized.

Identification and Resuscitation of the Trauma Patient in Shock

This article focuses on rapid diagnosis and treatment of the patient suffering from trauma-related shock, including early identification of patients at risk for occult hypoperfusion. Resuscitation strategies (delayed resuscitation, damage control resuscitation), end points of resuscitation, and the role of blood products and pro-coagulants for resuscitation are discussed.

Crystalloid infusion rate during fluid resuscitation from acute haemorrhage

BACKGROUND

Information is lacking concerning optimal infusion rates of crystalloid during resuscitation from acute haemorrhage. In this study, a mathematical model was used to predict infusion volume of crystalloid needed to restore and maintain blood volume after acute haemorrhage.

METHODS

The scenario was a haemorrhage of 15 ml kg(-1) over 30 min in a 70 kg man. A bolus of crystalloid was administered at a rate of 40, 60, 80, 100, or 120 ml kg(-1) h(-1) until blood volume was restored. Fluid infusion rate needed to maintain blood volume for a further 1 h was computed.

RESULTS

Blood volume was restored earlier at high bolus infusion rates compared with low bolus infusion rates (6 min at 120 ml kg(-1) h(-1) vs 63 min at 40 ml kg(-1) h(-1)). Fluid infusion rates for blood volume maintenance approached 33 ml kg(-1) h(-1) irrespective of bolus infusion rates. The restoration fluid volume at 40 ml kg(-1) h(-1) was 2.9 litre, three times that at 80-120 ml kg(-1) h(-1). The maintenance fluid volume at 80-120 ml kg(-1) h(-1) was 2.9 litre, 0.6 litre more than that at 40 ml kg(-1) h(-1). During the blood volume maintenance, the interstitial volume increased to 3.8 litre above normal at 40 ml kg(-1) h(-1) and to 2.5 litre at 80-120 ml kg(-1) h(-1).

CONCLUSIONS

Bolus crystalloid infusion exceeding 80 ml kg(-1) h(-1) may not increase effectiveness of fluid resuscitation. Crystalloid resuscitation for more than 2 h may be detrimental in view of an excessive net fluid retention.