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Wang P, Zhang Y, Xu W, Zheng Y, Jia L, He J, He M, Chen L, Hao P, Xiao Y, Peng L, Chong W, Hai Y, You C, Fang F. Association between perioperative change in red cell distribution width and mortality in patients with brain tumor craniotomy. J Clin Anesth 2024; 97:111546. [PMID: 39029152 DOI: 10.1016/j.jclinane.2024.111546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 06/28/2024] [Accepted: 07/01/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE An elevated preoperative red cell distribution width (RDW) is associated with adverse prognostic outcomes in various diseases. However, the correlation between changes in RDW (ΔRDW) and the prognosis following brain tumor craniotomy remains unclear. Accordingly, this study aimed to investigate the prognostic significance of perioperative changes in RDW in patients undergoing brain tumor craniotomy. METHODS This retrospective cohort study included patients undergoing craniotomy for brain tumors at West China Hospital, Sichuan University, from January 2011 to March 2021. We defined perioperative changes in RDW: group A (non-significant RDW changes, ΔRDW ≤0.4%), group B (drop in RDW, ΔRDW < -0.4%), and group C (rise in RDW, ΔRDW >0.4%). The relationship between the changes in RDW and all-cause mortality was analyzed by categorizing the patients according to perioperative ΔRDW (RDW at postoperative one week - RDW at admission). RESULTS The present study included a total of 9589 patients who underwent craniotomy for the treatment of brain tumors. A rise in RDW was significantly associated with increased mortality, with an adjusted OR of 3.56 (95% CI: 2.56-4.95) for 30-day mortality and 1.57 (95% CI: 1.33-1.85) for one-year mortality compared to those with non-significant RDW changes (ΔRDW ≤0.4%). Conversely, a decrease in RDW showed no significant association with 30-day mortality (adjusted OR: 1.04, 95% CI: 0.53-2.04) and one-year mortality (adjusted OR: 1.18, 95% CI: 0.92-1.53). These findings were also supported by restricted cubic spline, which shows that increases in RDW were significantly associated with lower survival rates compared to stable RDW levels during the follow-up period. CONCLUSIONS Among patients undergoing craniotomy for a brain tumor, a rise in RDW was associated with 30-day mortality and higher long-term mortality risks, even if patients' admissions for RDW values were within the normal range. It was worth noting that maintaining stable RDW levels during this period was associated with better survival.
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Affiliation(s)
- Peng Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Zhang
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China.
| | - Wenhao Xu
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yuxin Zheng
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lu Jia
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Jialing He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Miao He
- Department of Anesthesia, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Pengfei Hao
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yangchun Xiao
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China.
| | - Liyuan Peng
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China.
| | - Weelic Chong
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Yang Hai
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America.
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fang Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Wang P, Zhang Y, Xu W, Zheng Y, Jia L, He J, He M, Chen L, Hao P, Xiao Y, Peng L, Chong W, Hai Y, You C, Fang F. Association between elevated preoperative red cell distribution width and mortality after brain tumor craniotomy. Neurosurg Rev 2024; 47:237. [PMID: 38802619 DOI: 10.1007/s10143-024-02462-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Red cell distribution width (RDW) has been recognized as a potential inflammatory biomarker, with elevated levels associated with adverse outcomes in various diseases. However, its role in predicting outcomes after brain tumor craniotomy remains unclear. We aimed to assess whether preoperative RDW influences mortality and postoperative complications in patients undergoing brain tumor craniotomy. METHODS This retrospective cohort study analyzed serum RDW levels in patients undergoing brain tumor craniotomy at West China Hospital. RDW was evaluated in two forms: RDW-CV and RDW-SD, and was categorized into four quartiles for analysis by using logistic regression and multivariate analysis to adjust for confounding. RESULTS The study encompassed 10,978 patients undergoing brain tumor craniotomy. our analysis revealed no significant difference in 30-day mortality across various RDW-CV levels. However, we observed a dose-response relationship with preoperative RDW-CV levels in assessing long-term mortality risks. Specifically, patients with RDW-CV levels of 12.6-13.2% (HR 1.04, 95% CI 1.01-1.18), 13.2-13.9% (HR 1.12, 95% CI 1.04-1.26), and > 13.9% (HR 1.34, 95% CI 1.18-1.51) exhibited a significantly higher hazard of long-term mortality compared to those with RDW-CV < 12.6%. When preoperative RDW-CV was analyzed as a continuous variable, for each 10% increase in RDW-CV, the adjusted OR of long-term mortality was 1.09 (95% CI 1.05-1.13). we also observed significant associations between preoperative higher RDW-CV levels and certain postoperative complications including acute kidney injury (OR 1.46, 95% CI: 1.10-1.94), pneumonia infection (OR 1.19 95% CI: 1.05-1.36), myocardial infarction (OR 1.32, 95% CI: 1.05-1.66), readmission (OR 1.15, 95% CI: 1.01-1.30), and a prolonged length of hospital stay (OR 1.11, 95% CI: 1.02-1.21). For RDW-SD levels, there was no significant correlation for short-term mortality, long-term mortality, and postoperative complications. CONCLUSIONS Our study showed elevated preoperative RDW-CV is significantly associated with increased long-term mortality and multiple postoperative complications, but no such association is observed with RDW-SD. These findings show the prognostic importance of RDW-CV, reinforcing its potential as a valuable tool for risk stratification in the preoperative evaluation of brain tumor craniotomy patients.
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Affiliation(s)
- Peng Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Yu Zhang
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Wenhao Xu
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yuxin Zheng
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lu Jia
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Jialing He
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Miao He
- Department of Anesthesia, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Pengfei Hao
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yangchun Xiao
- Center for Evidence-Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Liyuan Peng
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yang Hai
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Fang Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China.
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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Lan W, Liu E, Sun D, Li W, Zhu J, Zhou J, Jin M, Jiang W. Red cell distribution in critically ill patients with chronic obstructive pulmonary disease. Pulmonology 2024; 30:34-42. [PMID: 35501276 DOI: 10.1016/j.pulmoe.2022.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Red blood cell distribution width (RDW) is associated with increased mortality risk in patients with chronic obstructive pulmonary disease (COPD). However, limited data are available for critically ill patients with COPD. METHODS Data from the Medical Information Mart for Intensive Care III V1.4 database were analyzed in this retrospective cohort research. The International Classification of Diseases codes were used to identify critically ill patients with COPD. The first value of RDW was extracted within the first 24 h after intensive care unit admission. The endpoint was 28-day all-cause mortality. Multivariable logistic regression analysis was performed to examine the relationship between RDW and 28-day mortality. Age, sex, ethnicity, anemia status, comorbidities, clinical therapy, and disease severity score were considered for subgroup analysis. RESULTS A total of 2,344 patients were included with mean (standard deviation) age of 72.3 (11.3) years, in which 1,739 (53.6%) patients were men. The increase in RDW was correlated with an increased risk of 28-day mortality in the multivariate logistic regression model (odds ratio [OR] 1.15; 95% confidence interval [CI] 1.09-1.21). In comparison with the low-RDW group, the middle and high-RDW groups tended to have higher risks of 28-day all-cause mortality (OR [95% CI] 1.03 [0.78-1.34]; OR [95% CI] 1.70 [1.29-2.22]; P trend < 0.0001). Subgroup analyses show no evidence of effect modifications on the correlation of RDW and 28-day all-cause mortality. CONCLUSION An increase in RDW was associated with an increased risk of 28-day all-cause mortality in critically ill patients with COPD. Further studies are required to investigate this association.
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Affiliation(s)
- W Lan
- Department of Respiratory and Critical Care Medicine, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - E Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Disease, Wenzhou, Zhejiang 325000, China
| | - D Sun
- Department of Respiratory and Critical Care Medicine, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - W Li
- Department of Respiratory and Critical Care Medicine, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - J Zhu
- Department of Cardiology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, Zhejiang 323000, China
| | - J Zhou
- Department of Pathology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, Zhejiang 323000, China
| | - M Jin
- Department of Internal Medicine, Yunhe People's Hospital, Yunhe, Zhejiang 323600, China
| | - W Jiang
- Department of Gastroenterology, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China.
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Lai H, Wu G, Zhong Y, Chen G, Zhang W, Shi S, Xia Z. Red blood cell distribution width improves the prediction of 28-day mortality for patients with sepsis-induced acute kidney injury: A retrospective analysis from MIMIC-IV database using propensity score matching. JOURNAL OF INTENSIVE MEDICINE 2023; 3:275-282. [PMID: 37533812 PMCID: PMC10391576 DOI: 10.1016/j.jointm.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/02/2022] [Accepted: 02/07/2023] [Indexed: 08/04/2023]
Abstract
Background The predictive value of red blood cell distribution width (RDW) for mortality in patients with sepsis-induced acute kidney injury (SI-AKI) remains unclear. The present study aimed to investigate the potential association between RDW at admission and outcomes in patients with SI-AKI. Methods The Medical Information Mart for Intensive Care (MIMIC)-IV (version 2.0) database, released in June of 2022, provides medical data of SI-AKI patients to conduct our related research. Based on propensity score matching (PSM) method, the main risk factors associated with mortality in SI-AKI were evaluated using Cox proportional hazards regression analysis to construct a predictive nomogram. The concordance index (C-index) and decision curve analysis were used to validate the predictive ability and clinical utility of this model. Patients with SI-AKI were classified into the high- and low-RDW groups according to the best cut-off value obtained by calculating the maximum value of the Youden index. Results A total of 7574 patients with SI-AKI were identified according to the filter criteria. Compared with the low-RDW group, the high-RDW group had higher 28-day (9.49% vs. 31.40%, respectively, P <0.001) and 7-day (3.96% vs. 13.93%, respectively, P <0.001) mortality rates. Patients in the high-RDW group were more prone to AKI progression than those in the low-RDW group (20.80% vs. 13.60%, respectively, P <0.001). Based on matched patients, we developed a nomogram model that included age, white blood cells, RDW, combined hypertension and presence of a malignant tumor, treatment with vasopressor, dialysis, and invasive ventilation, sequential organ failure assessment, and AKI stages. The C-index for predicting the probability of 28-day survival was 0.799. Decision curve analysis revealed that the model with RDW offered greater net benefit than that without RDW. Conclusion The present findings demonstrated the importance of RDW, which improved the predictive ability of the nomogram model for the probability of survival in patients with SI-AKI.
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Affiliation(s)
- Honghao Lai
- Department of Burns, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, Guangdong, China
- Department of Burns, Changhai Hospital, Naval Medical University, Shanghai 200433, China
- Research Institute, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong 510060, China
| | - Guosheng Wu
- Department of Burns, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Yu Zhong
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Guangping Chen
- Department of Burns, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, Guangdong, China
| | - Wei Zhang
- Department of Burns, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Shengjun Shi
- Department of Burns, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, Guangdong, China
| | - Zhaofan Xia
- Department of Burns, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, Guangdong, China
- Department of Burns, Changhai Hospital, Naval Medical University, Shanghai 200433, China
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Al Sulaiman K, Aljuhani O, Korayem GB, Altebainawi AF, Vishwakarma R, AlFaifi M, Alsohimi S, Alrayes A, Albishi S, Alqahtani R, Alalawi M, Al Sulaihim I, Alanazi TA, Alqahtani RA, Almagthali A, Jomah S, Alshlowi A, Alshammari TR, Alzahrani SS, Abdulqader MI. The Impact of Recombinant Human Erythropoietin Administration in Critically ill COVID-19 Patients: A Multicenter Cohort Study. Clin Appl Thromb Hemost 2023; 29:10760296231218216. [PMID: 38073058 PMCID: PMC10714884 DOI: 10.1177/10760296231218216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 12/18/2023] Open
Abstract
The use of erythropoietin-stimulating agents (ESAs) as adjunctive therapy in critically ill patients with COVID-19 may have a potential benefit. This study aims to evaluate the effect of ESAs on the clinical outcomes of critically ill COVID-19 patients. A multicenter, retrospective cohort study was conducted from 01-03-2020 to 31-07-2021. We included adult patients who were ≥ 18 years old with a confirmed diagnosis of COVID-19 infection and admitted to intensive care units (ICUs). Patients were categorized depending on ESAs administration during their ICU stay. The primary endpoint was the length of stay; other endpoints were considered secondary. After propensity score matching (1:3), the overall included patients were 120. Among those, 30 patients received ESAs. A longer duration of ICU and hospital stay was observed in the ESA group (beta coefficient: 0.64; 95% CI: 0.31-0.97; P = < .01, beta coefficient: 0.41; 95% CI: 0.12-0.69; P = < .01, respectively). In addition, the ESA group's ventilator-free days (VFDs) were significantly shorter than the control group. Moreover, patients who received ESAs have higher odds of liver injury and infections during ICU stay than the control group. The use of ESAs in COVID-19 critically ill patients was associated with longer hospital and ICU stays, with no survival benefits but linked with lower VFDs.
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Affiliation(s)
- Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ali F. Altebainawi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Ministry of Health, Hail, Saudi Arabia
- Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail, Saudi Arabia
| | | | - Mashael AlFaifi
- Pharmaceutical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Samiah Alsohimi
- Pharmaceutical Care Services, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Aljoharah Alrayes
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sara Albishi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Reem Alqahtani
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Mai Alalawi
- Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ibrahim Al Sulaihim
- Pharmaceutical Care Department, Presidency of State Security, Central Security Hospital, Riyadh, Saudi Arabia
| | - Thamer A. Alanazi
- Respiratory Therapy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Rahaf A. Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Alaa Almagthali
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Shahamah Jomah
- Pharmaceutical Care Department, Dr Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia
| | - Areej Alshlowi
- Department of Pharmacy Practice, College of Pharmacy, Almaarefa University, Riyadh, Saudi Arabia
| | - Tahani R. Alshammari
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Ministry of Health, Hail, Saudi Arabia
| | - Shahad S. Alzahrani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Marwa I. Abdulqader
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Günter CI, Ilg FP, Hapfelmeier A, Egert-Schwender S, Jelkmann W, Giri S, Bader A, Machens HG. Relation Between Gender and Concomitant Medications With Erythropoietin-Treatment on Wound Healing in Burn Patients. Post Hoc Subgroup-Analysis of the Randomized, Placebo-Controlled Clinical Trial “EPO in Burns”. Front Pharmacol 2022; 13:812888. [PMID: 35847006 PMCID: PMC9284535 DOI: 10.3389/fphar.2022.812888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/25/2022] [Indexed: 11/21/2022] Open
Abstract
Burns are leading causes of mortality and morbidity, including prolonged hospitalization, disfigurement, and disability. Erythropoietin (EPO) is a well-known hormone causing erythropoiesis. However, EPO may play a role in healing acute and chronic wounds due to its anti-inflammatory and pro-regenerative effects. Therefore, the large, prospective, placebo-controlled, randomized, double-blind, multi-center clinical trial “EPO in Burns” was initiated to investigate the effects of EPO versus placebo treatment in severely burned patients. The primary endpoint of “EPO in Burns” was defined as the time elapsed until complete re-epithelialization of a defined split skin graft donor site. Additional analyses of post hoc defined subgroups were performed in view of the primary endpoint. The verum (n 45) and control (n 39) groups were compared with regard to the time it took for study wounds (a predefined split skin graft donor site) to reach the three stages of wound healing (re-epithelialization levels). In addition, the effects of gender (females n 18) and concomitant medications insulin (n 36), non-steroidal anti-inflammatory drugs (NSAIDs) (n 41), and vasopressor agents (n 43) were tested. Life tables were used to compare study groups (EPO vs. placebo) within subgroups. The Cox regression model was applied to evaluate interactions between the study drug (EPO) and concomitant medications for each re-epithelialization level. Using our post hoc defined subgroups, we observed a lower chance of wound healing for women compared to men (in terms of hazard ratio: hr100%: 5.984 [95%-CI: (0.805–44.490), p = 0.080]) in our study population, regardless of the study medication. In addition, results indicated an earlier onset of re-epithelialization in the first days of EPO treatment (EPO: 10% vs. Placebo: 3%). Moreover, the interpretation of the hazard ratio suggested EPO might have a positive, synergistic effect on early stages of re-epithelialization when combined with insulin [hr50%: 1.307 (p = 0.568); hr75%: 1,199 (p = 0.715)], as well as a stabilizing effect on critically ill patients [reduced need for vasopressors in the EPO group (EPO: 44% vs. Placebo 59%)]. However, additional high-quality data from clinical trials designed to address these endpoints are required to gain further insight into these effects.
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Affiliation(s)
- Christina Irene Günter
- Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- *Correspondence: Christina Irene Günter,
| | - Felicitas Paula Ilg
- Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Silvia Egert-Schwender
- Müncher Studienzentrum, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Shibashish Giri
- Institute for Cell Techniques and Applied Stem Cell Biology, University of Leipzig, Leipzig, Germany
| | - Augustinus Bader
- Institute for Cell Techniques and Applied Stem Cell Biology, University of Leipzig, Leipzig, Germany
| | - Hans-Günter Machens
- Clinic for Plastic and Hand Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Avoidable Blood Loss in Critical Care and Patient Blood Management: Scoping Review of Diagnostic Blood Loss. J Clin Med 2022; 11:jcm11020320. [PMID: 35054014 PMCID: PMC8777821 DOI: 10.3390/jcm11020320] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/27/2021] [Accepted: 01/04/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Anemia remains one of the most common comorbidities in intensive care patients worldwide. The cause of anemia is often multifactorial and triggered by underlying disease, comorbidities, and iatrogenic factors, such as diagnostic phlebotomies. As anemia is associated with a worse outcome, especially in intensive care patients, unnecessary iatrogenic blood loss must be avoided. Therefore, this scoping review addresses the amount of blood loss during routine phlebotomies in adult (>17 years) intensive care patients and whether there are factors that need to be improved in terms of patient blood management (PBM). Methods: A systematic search of the Medline Database via PubMed was conducted according to PRISMA guidelines. The reported daily blood volume for diagnostics and other relevant information from eligible studies were charted. Results: A total of 2167 studies were identified in our search, of which 38 studies met the inclusion criteria (9 interventional studies and 29 observational studies). The majority of the studies were conducted in the US (37%) and Canada (13%). An increasing interest to reduce iatrogenic blood loss has been observed since 2015. Phlebotomized blood volume per patient per day was up to 377 mL. All interventional trials showed that the use of pediatric-sized blood collection tubes can significantly reduce the daily amount of blood drawn. Conclusion: Iatrogenic blood loss for diagnostic purposes contributes significantly to the development and exacerbation of hospital-acquired anemia. Therefore, a comprehensive PBM in intensive care is urgently needed to reduce avoidable blood loss, including blood-sparing techniques, regular advanced training, and small-volume blood collection tubes.
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Khalife M, Ben Aziz M, Balestra C, Valsamis J, Sosnowski M. Physiological and Clinical Impact of Repeated Inhaled Oxygen Variation on Erythropoietin Levels in Patients After Surgery. Front Physiol 2021; 12:744074. [PMID: 34646161 PMCID: PMC8502887 DOI: 10.3389/fphys.2021.744074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 12/02/2022] Open
Abstract
The “Normobaric Oxygen Paradox” (NOP) is a physiologic mechanism that induces an increase of endogenous erythropoietin (EPO) production by creating a state of relative hypoxia in subjects previously exposed to hyperoxia, followed by a rapid return to normoxia. Oxygen exposure duration and inspired oxygen fraction required to observe a significant increase in EPO or hemoglobin are not clearly defined. Consequently, we here study the effect of one model of relative hypoxia on EPO, reticulocytes and hemoglobin stimulation in patients after surgery. Patients were prospectively randomized in two groups. The O2 group (n = 10) received 100% oxygen for 1 h per day for eight consecutive days, via a non-rebreathing mask. The control group (n = 12) received no oxygen variation. Serum EPO, hemoglobin and reticulocyte count were measured on admission and postoperatively on days seven and nine. Percentage EPO at day nine with respect to the baseline value was significantly elevated within the groups [O2 group: 323.7 (SD ± 139.0); control group: 365.6 (SD± 162.0)] but not between them. No significant difference was found between the groups in terms of reticulocytes count and hemoglobin. Our NOP model showed no difference on EPO increase between the two groups. However, both groups expressed separately significant EPO elevation.
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Affiliation(s)
- Maher Khalife
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mohammed Ben Aziz
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Costantino Balestra
- Environmental and Occupational Physiology Laboratory, Haute Ecole Bruxelles-Brabant, Brussels, Belgium
| | - Joseph Valsamis
- Universitair Verplegingscentrum (UVC) Brugmann Site Victor Horta, Clinical Biology, Brussels, Belgium
| | - Maurice Sosnowski
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Wijnberge M, Rellum SR, Bruin S, Cecconi M, Oczkowski S, Vlaar AP. Erythropoiesis‐stimulating agents as replacement therapy for blood transfusions in critically ill patients with anaemia: A systematic review with meta‐analysis. Transfus Med 2020; 30:433-441. [DOI: 10.1111/tme.12715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 08/26/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Marije Wijnberge
- Department of Anesthesiology Amsterdam UMC, Location AMC Amsterdam The Netherlands
- Department of Intensive Care Amsterdam UMC, Location AMC Amsterdam The Netherlands
| | - Santino R. Rellum
- Department of Anesthesiology Amsterdam UMC, Location AMC Amsterdam The Netherlands
| | - Sanne Bruin
- Department of Intensive Care Amsterdam UMC, Location AMC Amsterdam The Netherlands
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Humanitas Clinical and Research Center‐IRCCS Milan Italy
- Humanitas University Milan Italy
| | - Simon Oczkowski
- Department of Medicine and Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Canada
- Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group Hamilton Canada
| | - Alexander P. Vlaar
- Department of Intensive Care Amsterdam UMC, Location AMC Amsterdam The Netherlands
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Kaufner L, von Heymann C, Henkelmann A, Pace NL, Weibel S, Kranke P, Meerpohl JJ, Gill R. Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2020; 8:CD012451. [PMID: 32790892 PMCID: PMC8095002 DOI: 10.1002/14651858.cd012451.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Approximately 30% of adults undergoing non-cardiac surgery suffer from preoperative anaemia. Preoperative anaemia is a risk factor for mortality and adverse outcomes in different surgical specialties and is frequently the reason for blood transfusion. The most common causes are renal, chronic diseases, and iron deficiency. International guidelines recommend that the cause of anaemia guide preoperative anaemia treatment. Recombinant human erythropoietin (rHuEPO) with iron supplementation has frequently been used to increase preoperative haemoglobin concentrations in patients in order to avoid the need for perioperative allogeneic red blood cell (RBC) transfusion. OBJECTIVES To evaluate the efficacy of preoperative rHuEPO therapy (subcutaneous or parenteral) with iron (enteral or parenteral) in reducing the need for allogeneic RBC transfusions in preoperatively anaemic adults undergoing non-cardiac surgery. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE(R), Ovid Embase, ISI Web of Science: SCI-EXPANDED and CPCI-S, and clinical trial registries WHO ICTRP and ClinicalTrials.gov on 29 August 2019. SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared preoperative rHuEPO + iron therapy to control treatment (placebo, no treatment, or standard of care with or without iron) for preoperatively anaemic adults undergoing non-cardiac surgery. We used the World Health Organization (WHO) definition of anaemia: haemoglobin concentration (g/dL) less than 13 g/dL for males, and 12 g/dL for non-pregnant females (decision of inclusion based on mean haemoglobin concentration). We defined two subgroups of rHuEPO dosage: 'low' for 150 to 300 international units (IU)/kg body weight, and 'high' for 500 to 600 IU/kg body weight. DATA COLLECTION AND ANALYSIS Two review authors collected data from the included studies. Our primary outcome was the need for RBC transfusion (no autologous transfusion, fresh frozen plasma or platelets), measured in transfused participants during surgery (intraoperative) and up to five days after surgery. Secondary outcomes of interest were: haemoglobin concentration (directly before surgery), number of RBC units (where one unit contains 250 to 450 mL) transfused per participant (intraoperative and up to five days after surgery), mortality (within 30 days after surgery), length of hospital stay, and adverse events (e.g. renal dysfunction, thromboembolism, hypertension, allergic reaction, headache, fever, constipation). MAIN RESULTS Most of the included trials were in orthopaedic, gastrointestinal, and gynaecological surgery and included participants with mild and moderate preoperative anaemia (haemoglobin from 10 to 12 g/dL). The duration of preoperative rHuEPO treatment varied across the trials, ranging from once a week to daily or a 5-to-10-day period, and in one trial preoperative rHuEPO was given on the morning of surgery and for five days postoperatively. We included 12 trials (participants = 1880) in the quantitative analysis of the need for RBC transfusion following preoperative treatment with rHuEPO + iron to correct preoperative anaemia in non-cardiac surgery; two studies were multiarmed trials with two different dose regimens. Preoperative rHuEPO + iron given to anaemic adults reduced the need RBC transfusion (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.38 to 0.80; participants = 1880; studies = 12; I2 = 84%; moderate-quality evidence due to inconsistency). This analysis suggests that on average, the combined administration of rHuEPO + iron will mean 231 fewer individuals will need transfusion for every 1000 individuals compared to the control group. Preoperative high-dose rHuEPO + iron given to anaemic adults increased the haemoglobin concentration (mean difference (MD) 1.87 g/dL, 95% CI 1.26 to 2.49; participants = 852; studies = 3; I2 = 89%; low-quality evidence due to inconsistency and risk of bias) but not low-dose rHuEPO + iron (MD 0.11 g/dL, 95% CI -0.46 to 0.69; participants = 334; studies = 4; I2 = 69%; low-quality evidence due to inconsistency and risk of bias). There was probably little or no difference in the number of RBC units when rHuEPO + iron was given preoperatively (MD -0.09, 95% CI -0.23 to 0.05; participants = 1420; studies = 6; I2 = 2%; moderate-quality evidence due to imprecision). There was probably little or no difference in the risk of mortality within 30 days of surgery (RR 1.19, 95% CI 0.39 to 3.63; participants = 230; studies = 2; I2 = 0%; moderate-quality evidence due to imprecision) or of adverse events including local rash, fever, constipation, or transient hypertension (RR 0.93, 95% CI 0.68 to 1.28; participants = 1722; studies = 10; I2 = 0%; moderate-quality evidence due to imprecision). The administration of rHuEPO + iron before non-cardiac surgery did not clearly reduce the length of hospital stay of preoperative anaemic adults (MD -1.07, 95% CI -4.12 to 1.98; participants = 293; studies = 3; I2 = 87%; low-quality evidence due to inconsistency and imprecision). AUTHORS' CONCLUSIONS Moderate-quality evidence suggests that preoperative rHuEPO + iron therapy for anaemic adults prior to non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient. There were no important differences in the risk of adverse events or mortality within 30 days, nor in length of hospital stay. Further, well-designed, adequately powered RCTs are required to estimate the impact of this combined treatment more precisely.
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Affiliation(s)
- Lutz Kaufner
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Christian von Heymann
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Anne Henkelmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Stephanie Weibel
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Peter Kranke
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Ravi Gill
- Department of Anaesthetics, Southampton University Hospital NHS Trust, Southampton, UK
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Olafsson HB, Sigurdarson GA, Christopher KB, Karason S, Sigurdsson GH, Sigurdsson MI. A retrospective cohort study on the association between elevated preoperative red cell distribution width and all-cause mortality after noncardiac surgery. Br J Anaesth 2020; 124:718-725. [PMID: 32216958 DOI: 10.1016/j.bja.2020.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/06/2020] [Accepted: 02/07/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Elevated red cell distribution width (RDW) has been associated with worse outcomes in several medical patient populations. The aim of this study was to investigate the association of increased preoperative RDW and short- and long-term mortality after noncardiac surgery. METHODS This investigation was a retrospective cohort study including all patients undergoing noncardiac surgery between 2005 and 2015 at Landspitali-the National University Hospital in Iceland. Patients were separated into five predefined groups based on preoperative RDW (≤13.3%, 13.4-14.0%, 14.1-14.7%, 14.8-15.8%, and >15.8%). The primary outcome was all-cause long-term mortality and secondary outcomes included 30-day mortality, length of stay, and readmissions within 30 days, compared with propensity score matched (PSM) cohort from patients with RDW ≤13.3%. RESULTS There was a higher hazard of long-term mortality for patients with RDW between 14.8% and 15.8% (hazard ratio=1.33; 95% confidence interval, 1.15-1.59; P<0.001) and above 15.8% (hazard ratio=1.66; 95% confidence interval, 1.41-1.95; P<0.001), compared with matched controls with RDW ≤13.3%. This association held in multiple patient subgroups. For secondary outcomes, there was no difference in 30-day mortality, length of stay, or risk of readmission within 30 days. CONCLUSIONS Increased preoperative RDW is associated with increased long-term mortality after noncardiac surgery. RDW could be a composite biomarker of pre-existing chronic inflammation and poor nutritional status. Future studies should clarify if this is a modifiable risk factor for improved surgical outcomes.
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Affiliation(s)
| | | | - Kenneth B Christopher
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Sigurbergur Karason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Division of Anaesthesia and Intensive Care Medicine, Landspitali, National University Hospital of Iceland, Reykjavik, Iceland
| | - Gisli H Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Division of Anaesthesia and Intensive Care Medicine, Landspitali, National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Division of Anaesthesia and Intensive Care Medicine, Landspitali, National University Hospital of Iceland, Reykjavik, Iceland.
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Hegde A. Approach to an Anemic Critically Ill Patient. Indian J Crit Care Med 2019; 23:S178-S180. [PMID: 31656373 PMCID: PMC6785810 DOI: 10.5005/jp-journals-10071-23247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
How to cite this article: Hegde A. Approach to an Anemic Critically Ill Patient. Indian J Crit Care Med 2019;23(Suppl 3):S178–S180.
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Affiliation(s)
- Ashit Hegde
- Department of Critical Care and Medicine, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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14
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McConachie SM, Almadrahi Z, Wahby KA, Wilhelm SM. Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review. Ann Pharmacother 2018; 52:910-919. [DOI: 10.1177/1060028018766656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective: To determine the pharmacological treatment methods available to anemic Jehovah’s Witnesses (JW). Data Sources: MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah’s Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia. Study Selection and Data Extraction: All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion. Data Synthesis: Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia. Conclusions: There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.
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Affiliation(s)
- Sean M. McConachie
- Wayne State University, Detroit, MI, USA
- Harper University Hospital, Detroit, MI, USA
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15
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Docherty AB, Turgeon AF, Walsh TS. Best practice in critical care: anaemia in acute and critical illness. Transfus Med 2018; 28:181-189. [DOI: 10.1111/tme.12505] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/09/2017] [Accepted: 12/11/2017] [Indexed: 01/28/2023]
Affiliation(s)
- A. B. Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine; University of Edinburgh; Edinburgh UK
| | | | - T. S. Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine; University of Edinburgh; Edinburgh UK
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16
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Hasan S, Mosier MJ, Szilagyi A, Gamelli RL, Muthumalaiappan K. Discrete β-adrenergic mechanisms regulate early and late erythropoiesis in erythropoietin-resistant anemia. Surgery 2017; 162:901-916. [PMID: 28716301 PMCID: PMC5675564 DOI: 10.1016/j.surg.2017.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/07/2017] [Accepted: 06/03/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Anemia of critical illness is resistant to exogenous erythropoietin. Packed red blood cells transfusions is the only treatment option, and despite related cost and morbidity, there is a need for alternate strategies. Erythrocyte development can be divided into erythropoietin-dependent and erythropoietin-independent stages. We have shown previously that erythropoietin-dependent development is intact in burn patients and the erythropoietin-independent early commitment stage, which is regulated by β1/β2-adrenergic mechanisms, is compromised. Utilizing the scald burn injury model, we studied erythropoietin-independent late maturation stages and the effect of β1/β2, β-2, or β-3 blockade in burn mediated erythropoietin-resistant anemia. METHODS Burn mice were randomized to receive daily injections of propranolol (nonselective β1/β2 antagonist), nadolol (long-acting β1/β2 antagonist), butoxamine (selective β2 antagonist), or SR59230A (selective β3 antagonist) for 6 days after burn. Total bone marrow cells were characterized as nonerythroid cells, early and late erythroblasts, nucleated orthochromatic erythroblasts and enucleated reticulocyte subsets using CD71, Ter119, and Syto-16 by flow cytometry. Multipotential progenitors were probed for MafB expressing cells. RESULTS Although propranolol improved early and late erythroblasts, only butoxamine and selective β3-antagonist administrations were positively reflected in the peripheral blood hemoglobin and red blood cells count. While burn impeded early commitment and late maturation stages, β1/β2 antagonism increased the early erythroblasts through commitment stages via β2 specific MafB regulation. β3 antagonism was more effective in improving overall red blood cells through late maturation stages. CONCLUSION The study unfolds novel β2 and β3 adrenergic mechanisms orchestrating erythropoietin resistant anemia after burn, which impedes both the early commitment stage and the late maturation stages, respectively.
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Affiliation(s)
- Shirin Hasan
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL
| | - Michael J Mosier
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL
| | - Andrea Szilagyi
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL
| | - Richard L Gamelli
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL
| | - Kuzhali Muthumalaiappan
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL.
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Characterization of erythropoietin and hepcidin in the regulation of persistent injury-associated anemia. J Trauma Acute Care Surg 2017; 81:705-12. [PMID: 27398985 DOI: 10.1097/ta.0000000000001163] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The cause of persistent injury-associated anemia is multifactorial and includes acute blood loss, an altered erythropoietin (EPO) response, dysregulation of iron homeostasis, and impaired erythropoiesis in the setting of chronic inflammation/stress. Hepcidin plays a key role in iron homeostasis and is regulated by anemia and inflammation. Erythropoietin is a main regulator of erythropoiesis induced by hypoxia. A unique rodent model of combined lung injury (LC)/hemorrhagic shock (HS) (LCHS)/chronic restraint stress (CS) was used to produce persistent injury-associated anemia to further investigate the roles of EPO, hepcidin, iron, ferritin, and the expression of EPO receptors (EPOr). METHODS Male Sprague-Dawley rats were randomly assigned into one of the four groups of rodent models: naive, CS alone, combined LCHS, or LCHS/CS. Plasma was used to evaluate levels of EPO, hepcidin, iron, and ferritin. RNA was isolated from bone marrow and lung tissue to evaluate expression of EPOr. Comparisons between models were performed by t tests followed by one-way analysis of variance. RESULTS After 7 days, only LCHS/CS was associated with persistent anemia despite significant elevation of plasma EPO. Combined LCHS and LCHS/CS led to a persistent decrease in EPOr expression in bone marrow on Day 7. The LCHS/CS significantly decreased plasma hepcidin levels by 75% on Day 1 and 84% on Day 7 compared to LCHS alone. Hepcidin plasma levels are inversely proportional to EPO plasma levels (Pearson R = -0.362, p < 0.05). CONCLUSION Tissue injury, hemorrhagic shock, and stress stimulate and maintain high levels of plasma EPO while hepcidin levels are decreased. In addition, bone marrow EPOr and plasma iron availability are significantly reduced following LCHS/CS. The combined deficit of reduced iron availability and reduced bone marrow EPOr expression may play a key role in the ineffective EPO response associated with persistent injury-associated anemia.
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Abstract
With increasing knowledge of the risks associated with receiving blood transfusions, a new paradigm of bloodless medicine is needed. Principles of bloodless medicine include careful monitoring for obvious and hidden anemias, rapid intervention, minimizing blood losses from laboratory testing and procedures, and careful management of bleeding diatheses. As evidence is revealed and refined, standard treatment of anemia in the intensive care unit will include erythropoietin-stimulating agents, iron, folate, and vitamin B12, which will reduce risks associated with blood transfusions.
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Kaufner L, von Heymann C, Henkelmann A, Pace NL, Weibel S, Kranke P, Meerpohl JJ, Gill R. Erythropoietin with iron supplementation for preoperative anaemia in non‐cardiac surgery. Cochrane Database Syst Rev 2016; 2016:CD012451. [PMCID: PMC6463842 DOI: 10.1002/14651858.cd012451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: We aim to evaluate the efficacy and safety of preoperative erythropoietin (rHuEPO) with supplemental iron (parenteral or oral) in reducing perioperative allogeneic red blood cell transfusions in preoperatively anaemic people undergoing non‐cardiac surgery.
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Affiliation(s)
- Lutz Kaufner
- Charité ‐ University Medicine BerlinDepartment of Anaesthesiology and Intensive Care MedicineAugustenburger Platz 1BerlinGermany13353
| | - Christian von Heymann
- Vivantes Klinikum im FriedrichshainDepartment of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain TherapyLandsberger Allee 49BerlinGermany10249
| | - Anne Henkelmann
- Charité ‐ University Medicine BerlinDepartment of Anaesthesiology and Intensive Care MedicineAugustenburger Platz 1BerlinGermany13353
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUSA84132‐2304
| | - Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBreisacher Straße 153FreiburgGermany79110
| | - Ravi Gill
- Southampton University Hospital NHS TrustDepartment of AnaestheticsTremona RoadSouthamptonUKSO16 6YD
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Low-dose erythropoietin treatment is not associated with clinical benefits in severely anaemic Jehovah's Witnesses: a plea for a change. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 16:53-62. [PMID: 27893353 DOI: 10.2450/2016.0085-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 09/19/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Jehovah's Witnesses who refuse blood transfusion have high mortality. Erythropoietin (EPO) has been used as an alternative to blood transfusion. The optimal dosing of EPO in anaemic Jehovah's Witnesses is unknown. The aim of our study was to evaluate the clinical benefits of treatment with a low dose (<600 IU/kg/week) of epoietin beta (EPO-β). MATERIALS AND METHODS This was an observational study, retrospectively considering a 10-year period during which 3,529 adult Jehovah's Witnesses with a total of 10,786 hospital admissions were identified from databases of four major public hospitals in New Zealand. Patients with severe symptomatic anaemia (haemoglobin <80 g/L) who were unable to tolerate physical activity were included in the study. Patients treated without EPO were assigned to the conventional therapy group and those treated with EPO to the EPO treatment group. RESULTS Ninety-one Jehovah's Witnesses met the eligibility criteria. Propensity score matching yielded a total of 57 patients. Patients treated with conventional therapy and those treated with EPO had similar durations of severe anaemia (average difference 6.25 days, 95% confidence interval [CI]: -3.77-16.27 days; p=0.221). The mortality rate among Jehovah's Witnesses treated with conventional therapy was 4.68 per year (95% CI: 2.23-9.82), while that in those treated with EPO was 2.77 per year (95% CI: 0.89-8.60). Treatment with EPO was associated with a mortality ratio of 0.59 (95% CI: 0.1-2.6; p=0.236). Both groups of patients had similar in-hospital survival (p=0.703). DISCUSSION Treatment with low-dose EPO-β was not associated with either shorter duration of severe anaemia or a reduction in mortality.
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Rawal G, Kumar R, Yadav S, Singh A. Anemia in Intensive Care: A Review of Current Concepts. ACTA ACUST UNITED AC 2016; 2:109-114. [PMID: 29967848 DOI: 10.1515/jccm-2016-0017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 06/29/2016] [Indexed: 12/13/2022]
Abstract
Anemia in patients admitted to an intensive care unit is common and affects almost all critically ill patients. The intensivist is faced with the challenge of treating multifactorial etiologies, mainly bleeding and blood loss due to phlebotomy and decreased erythropoiesis. Red cell transfusion, the most common treatment for anemia, comes with associated risks, which may further reduce the chance of survival of these patients. The best evidence suggests the practice of restrictive RBC transfusion (transfusion at Hb<7 g/dl). In this article, the etiopathogenesis of the anemia in critically ill is reviewed, and current opinion on the pros and cons of various management strategies are discussed with emphasize on restrictive transfusion policy.
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Affiliation(s)
- Gautam Rawal
- Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Raj Kumar
- Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Sankalp Yadav
- Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India
| | - Amrita Singh
- Gen-X Diagnostics, Madhu Vihar, New Delhi, India
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Anemia and iron-restricted erythropoiesis in traumatic critical illness. J Trauma Acute Care Surg 2016; 80:538-45. [PMID: 26670117 DOI: 10.1097/ta.0000000000000939] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kumar M, Bhoi S. Cytokines, granulocyte-monocyte colony stimulating factor, interleukin-3 and erythropoietin: Can be a therapeutic option for the stimulation of hematopoietic progenitor cells in trauma-hemorrhagic shock? Indian J Crit Care Med 2016; 20:207-9. [PMID: 27303135 PMCID: PMC4906343 DOI: 10.4103/0972-5229.180040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Manoj Kumar
- Department of Emergency Medicine, JPN Apex Trauma Center, AIIMS, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPN Apex Trauma Center, AIIMS, New Delhi, India
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Uscinska E, Idzkowska E, Sobkowicz B, Musial WJ, Tycinska AM. Anemia in Intensive Cardiac Care Unit patients - An underestimated problem. Adv Med Sci 2015; 60:307-14. [PMID: 26149915 DOI: 10.1016/j.advms.2015.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/24/2015] [Accepted: 06/01/2015] [Indexed: 12/15/2022]
Abstract
The heterogeneous group of patients admitted to Intensive Cardiac Care Unit (ICCU) as well as nonspecific complaints associated with anemia might be the reason for underdiagnosing or minimization of this problem. Because of this heterogeneity, there are no clear guidelines to follow. It is known that anemia is impairing the outcome. Thus, it is crucial to keep alert in the diagnosis and treatment of anemia, especially in critically ill cardiac patients. The greatest groups of patients admitted to ICCU are those with acute coronary syndromes (ACS), acute decompensated heart failure (ADHF), severe arrhythmias as well as individuals after cardiac operations. However, patients suffering other critical cardiac illnesses quite often become anemic during hospitalization in ICCU. It is because anemia is typed in the clinical features of heavy diseases or may be the consequence of treatment. The current review focuses on the incidence, complex etiology and predictive role of anemia in a diverse group of ICCU patients. It discusses clinical aspects of anemia treatment in particular groups of critically ill cardiac patients because proper treatment increases chances for recovery and improves the outcome in this severe group of patients.
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Affiliation(s)
- Ewa Uscinska
- Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Ewelina Idzkowska
- Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Bozena Sobkowicz
- Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
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Huang KC, Tsai YH, Huang KC, Lee MS. Model for end-stage liver disease (MELD) score as a predictor and monitor of mortality in patients with Vibrio vulnificus necrotizing skin and soft tissue infections. PLoS Negl Trop Dis 2015; 9:e0003720. [PMID: 25923115 PMCID: PMC4414517 DOI: 10.1371/journal.pntd.0003720] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/25/2015] [Indexed: 12/14/2022] Open
Abstract
Background Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs) usually predispose patients with or without preexisting liver disease to septic shock, and then evolve to multiple organ dysfunction syndrome (MODS), thus resulting in high mortality in humans. However, clinicians do not have a valid prediction model to provide a reliable estimate of case-fatality rate when caring for these acutely and/or critically ill patients. Methods/Principal Findings We retrospectively analyzed 39 consecutive patients with VNSSTIs (mean age: 65.7 ± 11.3 years) at our institution between 2007 and 2010. All patients were treated with the same protocol. Demographic and clinical characteristics, disease severity on admission, treatment details, and outcomes were collected for each patient and extracted for analyses. We studied the predictive value of the model for end-stage liver disease (MELD), modified MELD including sodium (MELD-Na), and laboratory risk indicator for necrotizing fasciitis (LRINEC) scores for case-fatality. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed. The mean MELD, MELD-Na and LRINEC scores on admission were 15.1 ± 1.1, 17.7 ± 1.1, and 3.4 ± 0.4 points, respectively. After admission, these patients had temporary or progressive deterioration of nearly all their scores and lab values. The area under the ROC curve for the MELD and ΔMELD scoring models were 0.929 (p = 0.002) and 0.897 (p = 0.005), respectively. An optimal MELD/ΔMELD cutoff value ≥ 20/2 had a good sensitivity and specificity (all > 80%), with a 64/13-fold increased odds for case-fatality. Additionally, the development of severe forms of anemia (p = 0.014) and hypoalbuminemia (p = 0.019) were associated with an increased case-fatality rate. Discussion The MELD/ΔMELD scoring model is an effective risk stratification indicator at the time of admission and also an excellent condition monitor during hospitalization for medical care of acutely and/or critically ill patients with VNSSTIs. VNSSTIs have increased significantly over the last two decades, with cases now regularly reported globally. Despite advancing antibiotic and infection control practices, these infections are still highly lethal and disabling diseases. They usually predispose patients to septic shock and then evolve to liver dysfunction and MODS, thus resulting in high mortality in humans. However, clinicians do not have a valid prediction model to provide a reliable estimate of case-fatality rate when caring for these acutely and critically ill patients. MELD scoring system was originally developed to assess the short-term prognosis of cirrhotic patients undergoing the transjugular intrahepatic portosystemic shunt procedure. By using the MEGX test, the strong negative association between the scores and the residual liver function has been confirmed. Therefore, it has been validated and applied to a wide spectrum of clinical scenarios in recent years. In this work, we studied the predictive value of the MELD scoring system for case-fatality in patients suffering VNSSTIs. We have found that the MELD scoring system is an effective risk stratification indicator at the time of admission, and also an excellent condition monitor during hospitalization for medical care of acutely and critically ill patients with VNSSTIs.
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Affiliation(s)
- Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail:
| | - Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Chung Huang
- Department of Business Administration (Statistics), Nanhua University, Chiayi, Taiwan
| | - Mel S. Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Abstract
Abstract
Substantial progress has been made in our understanding of the risks and benefits of RBC transfusion through the performance of large clinical trials. More than 7000 patients have been enrolled in trials randomly allocating patients to higher transfusion thresholds (∼9-10 g/dL), referred to as liberal transfusion, or lower transfusion thresholds (∼7-8 g/dL), referred to as restrictive transfusion. The results of most of the trials suggest that a restrictive transfusion strategy is safe and, in some cases, superior to a liberal transfusion strategy. However, in patients with myocardial infarction, brain injury, stroke, or hematological disorders, more large trials are needed because preliminary evidence suggests that liberal transfusion might be beneficial or trials have not been performed at all.
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Schlenke P, Humpe A. Hematopoietic Growth Factors in Transfusion Medicine and Cellular Therapy - Part II. Transfus Med Hemother 2013; 40:300-1. [DOI: 10.1159/000354964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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