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Sadana D, Kummangal B, Moghekar A, Banerjee K, Kaur S, Balasubramanian S, Tolich D, Han X, Wang X, Hanane T, Mireles-Cabodevila E, Quraishy N, Duggal A, Krishnan S. Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit. Transfus Med 2021; 31:227-235. [PMID: 33749043 DOI: 10.1111/tme.12771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/17/2021] [Accepted: 03/05/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. OBJECTIVES In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. METHODS We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. RESULTS In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β1 .8.26, 95% CI 4.09-12.43; p < 0.01). CONCLUSION A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.
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Affiliation(s)
- Divyajot Sadana
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Basheer Kummangal
- Department of Hospital Medicine, Detroit Receiving Hospital, Detroit, Michigan, USA
| | - Ajit Moghekar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kinjal Banerjee
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Simrat Kaur
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shailesh Balasubramanian
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah Tolich
- Department of Surgical Operations, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xiaozhen Han
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tarik Hanane
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - NurJehan Quraishy
- Department of Clinical Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin 2020; 36:1961-1973. [PMID: 33090028 DOI: 10.1080/03007995.2020.1840970] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, Hall (Tyrol), Austria
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