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Naderi-Boldaji V, Zand F, Asmarian N, Banifatemi M, Masjedi M, Sabetian G, Ouhadian M, Bayati N, Saeedizadeh H, Naderi N, Kasraian L. Does red blood cell transfusion affect clinical outcomes in critically ill patients? A report from a large teaching hospital in south Iran. Ann Saudi Med 2024; 44:84-92. [PMID: 38615186 PMCID: PMC11016154 DOI: 10.5144/0256-4947.2024.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/09/2023] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Despite the beneficial effects, RBC transfusion can be associated with infectious and non-infectious complications in critically ill patients. OBJECTIVES Investigate current RBC transfusion practices and their effect on the clinical outcomes of patients in intensive care units (ICUs). DESIGN Retrospective observational study. SETTING Three mixed medical-surgical adult ICUs of a large academic tertiary hospital. PATIENTS AND METHODS From March 2018 to February 2020, all adult patients admitted to medical or surgical ICU. Patients who received one or more RBC transfusions during the first month of ICU admission were included in the "transfusion" group, while the remaining patients were assigned to the "non-transfusion" group. MAIN OUTCOME MEASURES Mortality and length of ICU and hospital stay. SAMPLE SIZE 2159 patients. RESULTS Of 594 patients who recieved transfusions, 27% of patients received red blood cell (RBC) products. The mean pre-transfusion hemoglobin (Hb) level was 8.05 (1.46) g/dL. There was a significant relationship between higher APACHE II scores and ICU mortality in patients with Hb levels of 7-9 g/dL (OR adjusted=1.05). Also, ICU mortality was associated with age (OR adjusted=1.03), APACHE II score (OR adjusted=1.08), and RBC transfusion (OR adjusted=2.01) in those whose Hb levels were >9 (g/dl). CONCLUSION RBC transfusion was associated with an approximately doubled risk of ICU mortality in patients with Hb>9 g/dL. High APACHE II score and age increase the chance of death in the ICU by 8% and 3%, respectively. Hence, ICU physicians should consider a lower Hb threshold for RBC transfusion, and efforts must be made to optimize RBC transfusion practices. LIMITATIONS Single-center and retrospective study.
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Affiliation(s)
- Vida Naderi-Boldaji
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farid Zand
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naeimehossadat Asmarian
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Banifatemi
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mansoor Masjedi
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Golnar Sabetian
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Ouhadian
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Najmeh Bayati
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamideh Saeedizadeh
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nima Naderi
- From the Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Kasraian
- From the Iranian Blood Transfusion Research Center, High Institute for Education and Research in Transfusion Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Watanabe Y, Tara S, Nishino T, Kato K, Kubota Y, Hayashi D, Mozawa K, Matsuda J, Miyachi H, Tokita Y, Iwasaki YK, Yasutake M, Asai K. Impact of Red Blood Cell Transfusion on Subsequent Cardiovascular Events in Patients with Acute Heart Failure and Anemia. Int Heart J 2024; 65:190-198. [PMID: 38556330 DOI: 10.1536/ihj.23-596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Red blood cell (RBC) transfusion therapy is often performed in patients with acute heart failure (AHF) and anemia; however, its impact on subsequent cardiovascular events is unclear. We examined whether RBC transfusion influences major adverse cardiovascular events (MACE) after discharge in patients with AHF and anemia.We classified patients with AHF and anemia (nadir hemoglobin level < 10 g/dL) according to whether they received RBC transfusion during hospitalization. The endpoint was MACE (composite of all-cause death, non-fatal acute coronary syndrome/stroke, or heart failure readmission) 180 days after discharge. For survival analysis, we used propensity score matching analysis with the log-rank test. As sensitivity analysis, we performed inverse probability weighting analysis and multivariable Cox regression analysis.Among 448 patients with AHF and anemia (median age, 81 years; male, 55%), 155 received RBC transfusion and 293 did not. The transfused patients had worse clinical features than the non-transfused patients, with lower levels of nadir hemoglobin and serum albumin and a lower estimated glomerular filtration rate. In the propensity-matched cohort of 87 pairs, there was no significant difference in the MACE-free survival rate between the 2 groups (transfused, 73.8% vs. non-transfused, 65.3%; P = 0.317). This result was consistent in the inverse probability weighting analysis (transfused, 76.0% vs. non-transfused, 68.7%; P = 0.512), and RBC transfusion was not significantly associated with post-discharge MACE in the multivariable Cox regression analysis (adjusted hazard ratio: 1.468, 95% confidence interval: 0.976-2.207; P = 0.065).In conclusion, this study suggests that RBC transfusions for anemia may not improve clinical outcomes in patients with AHF.
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Affiliation(s)
| | - Shuhei Tara
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Takuya Nishino
- Department of Health Care Administration, Nippon Medical School
| | - Katsuhito Kato
- Department of Hygiene and Public Health, Nippon Medical School
| | - Yoshiaki Kubota
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Daisuke Hayashi
- Department of Pharmaceutical Service, Nippon Medical School Hospital
| | - Kosuke Mozawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Junya Matsuda
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Hideki Miyachi
- Department of Cardiovascular Medicine, Nippon Medical School
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Yukichi Tokita
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masahiro Yasutake
- Department of General Medicine and Health Science, Nippon Medical School
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School
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Braaten JA, Dillon BS, Wothe JK, Olson CP, Lusczek ER, Sather KJ, Beilman GJ, Brunsvold ME. Extracorporeal Membrane Oxygenation Patient Outcomes Following Restrictive Blood Transfusion Protocol. Crit Care Explor 2023; 5:e1020. [PMID: 38107536 PMCID: PMC10723844 DOI: 10.1097/cce.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES To investigate the effect of a restrictive blood product utilization protocol on blood product utilization and clinical outcomes. DESIGN We retrospectively reviewed all adult extracorporeal membrane oxygenation (ECMO) patients from January 2019 to December 2021. The restrictive protocol, implemented in March 2020, was defined as transfusion of blood products for a hemoglobin level less than 7, platelet levels less than 50, and/or fibrinogen levels less than 100. Subgroup analysis was performed based on the mode of ECMO received: venoarterial ECMO, venovenous ECMO, and ECMO support following extracorporeal cardiopulmonary resuscitation (ECPR). SETTING M Health Fairview University of Minnesota Medical Center. PATIENTS The study included 507 patients. INTERVENTIONS One hundred fifty-one patients (29.9%) were placed on venoarterial ECMO, 70 (13.8%) on venovenous ECMO, and 286 (56.4%) on ECPR. MEASUREMENTS AND MAIN RESULTS For patients on venoarterial ECMO (48 [71.6%] vs. 52 [63.4%]; p = 0.374), venovenous ECMO (23 [63.9%] vs. 15 [45.5%]; p = 0.195), and ECPR (54 [50.0%] vs. 69 [39.2%]; p = 0.097), there were no significant differences in survival on ECMO. The last recorded mean hemoglobin value was also significantly decreased for venoarterial ECMO (8.10 [7.80-8.50] vs. 7.50 [7.15-8.25]; p = 0.001) and ECPR (8.20 [7.90-8.60] vs. 7.55 [7.10-8.88]; p < 0.001) following implementation of the restrictive transfusion protocol. CONCLUSIONS These data suggest that a restrictive transfusion protocol is noninferior to ECMO patient survival. Additional, prospective randomized trials are required for further investigation of the safety of a restrictive transfusion protocol.
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Taccone FS, Badenes R, Rynkowski CB, Bouzat P, Caricato A, Kurtz P, Moller K, Diaz MQ, Van Der Jagt M, Videtta W, Vincent JL. TRansfusion strategies in Acute brain INjured patients (TRAIN): a prospective multicenter randomized interventional trial protocol. Trials 2023; 24:20. [PMID: 36611210 PMCID: PMC9825124 DOI: 10.1186/s13063-022-07061-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Although blood transfusions can be lifesaving in severe hemorrhage, they can also have potential complications. As anemia has also been associated with poor outcomes in critically ill patients, determining an optimal transfusion trigger is a real challenge for clinicians. This is even more important in patients with acute brain injury who were not specifically evaluated in previous large randomized clinical trials. Neurological patients may be particularly sensitive to anemic brain hypoxia because of the exhausted cerebrovascular reserve, which adjusts cerebral blood flow to tissue oxygen demand. METHODS We described herein the methodology of a prospective, multicenter, randomized, pragmatic trial comparing two different strategies for red blood cell transfusion in patients with acute brain injury: a "liberal" strategy in which the aim is to maintain hemoglobin (Hb) concentrations greater than 9 g/dL and a "restrictive" approach in which the aim is to maintain Hb concentrations greater than 7 g/dL. The target population is patients suffering from traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). The primary outcome is the unfavorable neurological outcome, evaluated using the extended Glasgow Outcome Scale (eGOS) of 1-5 at 180 days after the initial injury. Secondary outcomes include, among others, 28-day survival, intensive care unit (ICU) and hospital lengths of stay, the occurrence of extra-cerebral organ dysfunction/failure, and the development of any infection or thromboembolic events. The estimated sample size is 794 patients to demonstrate a reduction in the primary outcome from 50 to 39% between groups (397 patients in each arm). The study was initiated in 2016 in several ICUs and will be completed in December 2022. DISCUSSION This trial will assess the impact of a liberal versus conservative strategy of blood transfusion in a large cohort of critically ill patients with a primary acute brain injury. The results of this trial will help to improve blood product and transfusion use in this specific patient population and will provide additional data in some subgroups of patients at high risk of brain ischemia, such as those with intracranial hypertension or cerebral vasospasm. TRIAL REGISTRATION ClinicalTrials.gov NCT02968654.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 808, 1070, Brussels, Belgium.
- Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina.
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma ICU, Hospital Clínic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Carla Bittencourt Rynkowski
- Intensive Care Unit of Cristo Redentor Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Hospital Ernesto Dornelles, Porto Alegre, Brazil
| | - Pierre Bouzat
- Université Grenoble AlpesInserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Grenoble, France
| | - Anselmo Caricato
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Pedro Kurtz
- Department of Intensive Care Medicine, DOr Institute of Research and Education, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Instituto Estadual Do Cerebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Kirsten Moller
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University, Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Manuel Quintana Diaz
- Department of Intensive Care Medicine, Hospital Universitario de La Paz, Madrid, Spain
| | - Mathieu Van Der Jagt
- Department of Intensive Care Adults, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Walter Videtta
- Department of Intensive Care Adults, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jean-Louis Vincent
- Department of Intensive Care, Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 808, 1070, Brussels, Belgium
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Lim HS. Phenotyping and Hemodynamic Assessment in Cardiogenic Shock: From Physiology to Clinical Application. Cardiol Ther 2022; 11:509-522. [PMID: 36335176 PMCID: PMC9652191 DOI: 10.1007/s40119-022-00286-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 11/08/2022] Open
Abstract
There is growing interest in invasive hemodynamic assessment in cardiogenic shock, primarily due to the widespread adoption of mechanical circulatory support (MCS). Invasive hemodynamic assessment is central to two aspects of cardiogenic shock management: (1) the phenotyping of cardiogenic shock, and (2) the assessment of response to therapy. Phenotyping of cardiogenic shock serves to guide timely therapeutic intervention, and the assessment of hemodynamic response to therapy directs the escalation or de-escalation of therapy, including MCS. This review aims to discuss these two aspects of hemodynamic assessment in cardiogenic shock. Firstly, the physiologic underpinnings of a phenotyping schema, and the implication of the cardiogenic shock phenotype on the MCS strategy in cardiogenic shock will be discussed. Secondly, the concept of cardiac power output and 'effective' oxygen delivery will be discussed in relation to hemodynamic response to therapy in cardiogenic shock.
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Affiliation(s)
- Hoong Sern Lim
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2TH, UK.
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Iqbal J, Khan AA, Aziz T, Ali W, Ahmad S, Rahman SU, Iqbal Z, Dablool AS, Alruways MW, Almalki AA, Alamri AS, Alhomrani M. Phytochemical Investigation, Antioxidant Properties and In Vivo Evaluation of the Toxic Effects of Parthenium hysterophorus. Molecules 2022; 27:molecules27134189. [PMID: 35807432 PMCID: PMC9268705 DOI: 10.3390/molecules27134189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Parthenium hysterophorus L. is a poisonous Asteraceae weed. The phytochemical profile, antioxidant activity, total phenolic contents (TPC), total flavonoid contents (TFC), and cytotoxicity of Parthenium hysterophorus L. flower extract were evaluated in this study, and the toxic effects were assessed in rabbits. The HPLC-DAD system was used for phytochemical analysis. The hemolytic and DPPH assays were performed. The effects of orally administering the flower crude extract to rabbits (n = 5) at four different doses (10, 20, 40, and 80 mg/kg) for ten days on hematological and biochemical parameters were investigated. The crude extract of the flower contained phenolic compounds such as Gallic acid, Chlorogenic acid, Ellagic acid, and P Coumaric acid, which were detected at different retention times, according to the HPLC results. With a sample peak of 4667.475 %, chlorogenic acid was abundant. At concentrations of 80 µg, the methanolic extract of flowers had total phenolic contents (89.364 ± 4.715 g GAE/g) and total flavonoid contents (65.022 ± 2.694 g QE/g). In the DPPH free radical scavenging assay, 80 µg of extract had the highest cell inhibition of 76.90% with an IC50 value of 54.278 µg/µL, while in the hemolytic assay 200 µg of extract had the highest cell inhibition of 76.90% with an IC50 > 500. The biochemical and hematological parameters were altered in the flower extract-fed groups as compared to the control (p < 0.05). The toxic effects on the blood, liver, and kidneys were confirmed. The findings also confirmed the presence of phenolic and flavonoid content in the flower extract, both of which contribute to the plant’s antioxidant potential.
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Affiliation(s)
- Javed Iqbal
- Department of Biotechnology, Faculty of Biological Sciences, University of Malakand, Chakdara 18800, Pakistan; (J.I.); (W.A.)
| | - Ayaz Ali Khan
- Department of Biotechnology, Faculty of Biological Sciences, University of Malakand, Chakdara 18800, Pakistan; (J.I.); (W.A.)
- Correspondence: (A.A.K.); (T.A.)
| | - Tariq Aziz
- Pak-Austria Fachhochschule, Institute of Applied Sciences and Technology, Haripur 22621, Pakistan
- Correspondence: (A.A.K.); (T.A.)
| | - Waqar Ali
- Department of Biotechnology, Faculty of Biological Sciences, University of Malakand, Chakdara 18800, Pakistan; (J.I.); (W.A.)
| | - Saeed Ahmad
- Department of Zoology, Faculty of Biological Sciences, University of Malakand, Chakdara 18800, Pakistan;
| | - Shafiq Ur Rahman
- Department of Environmental Sciences, Shaheed Benazir Bhutto University, Sheringal 18050, Pakistan;
| | - Zafar Iqbal
- Institute of Nursing Sciences, Khyber Medical University, Peshawar 25120, Pakistan;
| | - Anas S. Dablool
- Department of Public Health, Health Sciences College Al-Leith, Umm Al-Qura University, Makkah al-Mukarramah 24382, Saudi Arabia;
| | - Mashael W. Alruways
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Shaqra University, Shaqra 15273, Saudi Arabia;
| | - Abdulraheem Ali Almalki
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia; (A.A.A.); (A.S.A.); (M.A.)
| | - Abdulhakeem S. Alamri
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia; (A.A.A.); (A.S.A.); (M.A.)
| | - Majid Alhomrani
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia; (A.A.A.); (A.S.A.); (M.A.)
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Park M, Hur M, Kim H, Oh K, Kim H, Song YH, Ko DH, Chung Y. Questionnaire Survey on Current Red Blood Cell Transport and Storage in Korea for Reducing Wastage. Ann Lab Med 2022; 42:342-351. [PMID: 34907104 PMCID: PMC8677485 DOI: 10.3343/alm.2022.42.3.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/13/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background To ensure safe red blood cell (RBC) transfusion practice, it is important to comply with storage and transport requirements of RBC units. We conducted a comprehensive survey on the practice of RBC transport and storage to explore the awareness of and compliance with the 30-minute rule, the current status of RBC unit transport, and possible utility of temperature indicators (TIs) to reduce RBC wastage. Methods From June to August of 2019, 64 blood bank physicians (14 questions) in 64 secondary- and tertiary-care hospitals and 673 nurses (13 questions) in 42 tertiary-care hospitals replied to a questionnaire survey. The results of the survey were analyzed with descriptive statistics. Results Among the physicians surveyed, 97.0% (N=62) of hospitals had transfusion guidelines in place. The RBC wastage in 2018 ranged from less than five units to more than 200 units. Among the nurses surveyed, 99.4% (N=669) were aware of and complied with the 30-minute rule; 13.5% (N=91) of the nurses had experience of RBC wastage due to violation of the 30-minute rule. Both physicians (67%, N=43) and nurses (83.1%, N=559) responded that TIs would help reduce RBC wastage. Conclusions This is the first survey on the practices related to RBC transport and storage in Korea. This study provides fundamental data on current practice for the blood cold chain, insights into RBC wastage, and highlights the utility of TIs.
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Affiliation(s)
- Mikyoung Park
- Department of Laboratory Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hahah Kim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kyungmi Oh
- Department of Nursing, Kyungbok University, Namyangju, Korea
| | - Hyunmi Kim
- Department of Nursing, Konkuk University Medical Center, Seoul, Korea
| | - Young Hye Song
- Department of Nursing, Konkuk University Medical Center, Seoul, Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Yousun Chung
- Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Korea
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8
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Buchtele N, Schörgenhofer C, Schwameis M, Jilma B, Schellongowski P, Herkner H, Riss K, Schmid M, Hermann A, Robak O, Nagler B, Traby L, Bojic A, Staudinger T. Add-on Prostaglandin E1 in Venovenous Extracorporeal Membrane Oxygenation: A Randomized, Double-blind, Placebo-controlled Pilot Trial. Am J Respir Crit Care Med 2022; 206:170-177. [DOI: 10.1164/rccm.202110-2359oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nina Buchtele
- Medical University of Vienna, Department of Medicine I, Vienna, Austria
| | | | - Michael Schwameis
- Medical University of Vienna, Department of Emergency Medicine, Vienna, Austria
| | - Bernd Jilma
- Clinical Pharmacology, AKH Wien, vienna, Austria
| | | | | | | | - Monika Schmid
- Medical University of Vienna, 27271, Department of Medicine III, Wien, Austria
| | | | - Oliver Robak
- Medical University of Vienna, 1Department of Internal Medicine I, Vienna, Austria
| | - Bernhard Nagler
- Medical University of Vienna, Department of Medicine I, Vienna, Austria
| | - Ludwig Traby
- Medical University of Vienna, Department of Medicine I, Vienna, Austria
| | - Andja Bojic
- Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Medical University of Vienna, Dept. of Internal Medicine I, Vienna, Austria
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9
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RBC Transfusion in Venovenous Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study. Crit Care Med 2022; 50:224-234. [PMID: 35100195 DOI: 10.1097/ccm.0000000000005398] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES In the general critical care patient population, restrictive transfusion regimen of RBCs has been shown to be safe and is yet implemented worldwide. However, in patients on venovenous extracorporeal membrane oxygenation, guidelines suggest liberal thresholds, and a clear overview of RBC transfusion practice is lacking. This study aims to create an overview of RBC transfusion in venovenous extracorporeal membrane oxygenation. DESIGN Mixed method approach combining multicenter retrospective study and survey. SETTING Sixteen ICUs worldwide. PATIENTS Patients receiving venovenous extracorporeal membrane oxygenation between January 2018 and July 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was the proportion receiving RBC, the amount of RBC units given daily and in total. Furthermore, the course of hemoglobin over time during extracorporeal membrane oxygenation was assessed. Demographics, extracorporeal membrane oxygenation characteristics, and patient outcome were collected. Two-hundred eight patients received venovenous extracorporeal membrane oxygenation, 63% male, with an age of 55 years (45-62 yr), mainly for acute respiratory distress syndrome. Extracorporeal membrane oxygenation duration was 9 days (5-14 d). Prior to extracorporeal membrane oxygenation, hemoglobin was 10.8 g/dL (8.9-13.0 g/dL), decreasing to 8.7 g/dL (7.7-9.8 g/dL) during extracorporeal membrane oxygenation. Nadir hemoglobin was lower on days when a transfusion was administered (8.1 g/dL [7.4-9.3 g/dL]). A vast majority of 88% patients received greater than or equal to 1 RBC transfusion, consisting of 1.6 U (1.3-2.3 U) on transfusion days. This high transfusion occurrence rate was also found in nonbleeding patients (81%). Patients with a liberal transfusion threshold (hemoglobin > 9 g/dL) received more RBC in total per transfusion day and extracorporeal membrane oxygenation day. No differences in survival, hemorrhagic and thrombotic complication rates were found between different transfusion thresholds. Also, 28-day mortality was equal in transfused and nontransfused patients. CONCLUSIONS Transfusion of RBC has a high occurrence rate in patients on venovenous extracorporeal membrane oxygenation, even in nonbleeding patients. There is a need for future studies to find optimal transfusion thresholds and triggers in patients on extracorporeal membrane oxygenation.
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Cortesi V, Raffaeli G, Amelio GS, Amodeo I, Gulden S, Manzoni F, Cervellini G, Tomaselli A, Colombo M, Araimo G, Artoni A, Ghirardello S, Mosca F, Cavallaro G. Hemostasis in neonatal ECMO. Front Pediatr 2022; 10:988681. [PMID: 36090551 PMCID: PMC9458915 DOI: 10.3389/fped.2022.988681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.
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Affiliation(s)
- Valeria Cortesi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo S Amelio
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Gulden
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Manzoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gaia Cervellini
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Andrea Tomaselli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Marta Colombo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella Araimo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Chiang YT, Lin TH, Hu RH, Lee PC, Shih HC. Predicting factors for major trauma patient mortality analyzed from trauma registry system. Asian J Surg 2020; 44:262-268. [PMID: 32859471 DOI: 10.1016/j.asjsur.2020.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/18/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE We investigated the predictors of mortality in major trauma patients using a trauma registry system database. METHODS Data were obtained from the trauma registry of a level I trauma center for all patients aged ≥18 years admitted to an intensive care unit (ICU) between January 1, 2006 and December 31, 2013. Models were adjusted for patient demographics, injury mechanism, preexisting comorbidity, Glasgow coma scale (GCS), injury severity score (ISS), emergency department (ED) and ICU procedures, surgical procedures, and complications. Multivariate logistic regression analysis was used to determine predictors of mortality and odds ratios of its associated factors. RESULTS In total, 1561 patients met the inclusion criteria. The overall mortality rate was 13.4%. After controlling for all variables in a logistic regression model, the factors associated with increased mortality risk (P < 0.05) were age ≥ 45 years; ISS > 24; GCS score < 8 and 8-12; fall accident; preexisting comorbidity of renal insufficiency; ED cardiopulmonary resuscitation (CPR) procedures; ICU blood transfusion; and cardiovascular, respiratory, digestive system and infection complications. CONCLUSION Our data showed some predictors of patient mortality after major trauma, most of which were determined during the trauma event. Only those treatment complications may be improved when performing the treatment procedures.
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Affiliation(s)
- Yueh-Tzu Chiang
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taiwan, ROC; Department of Orthopedics, KuangTien General Hospital, Taiwan, ROC.
| | - Tzu-Hsin Lin
- Department of Traumatology, National Taiwan University Hospital, And College of Medicine, National Taiwan University, Taiwan, ROC.
| | - Rey-Heng Hu
- Department of Traumatology, National Taiwan University Hospital, And College of Medicine, National Taiwan University, Taiwan, ROC
| | - Po-Chu Lee
- Department of Traumatology, National Taiwan University Hospital, And College of Medicine, National Taiwan University, Taiwan, ROC
| | - Hsin-Chin Shih
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taiwan, ROC
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12
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Gameiro J, Fonseca JA, Marques F, Lopes JA. Management of Acute Kidney Injury Following Major Abdominal Surgery: A Contemporary Review. J Clin Med 2020; 9:E2679. [PMID: 32824854 PMCID: PMC7463962 DOI: 10.3390/jcm9082679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/05/2020] [Accepted: 08/14/2020] [Indexed: 12/12/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent occurrence following major abdominal surgery and is independently associated with both in-hospital and long-term mortality, as well as with a higher risk of progressing to chronic kidney disease (CKD) and cardiovascular events. Postoperative AKI can account for up to 40% of in-hospital AKI cases. Given the differences in patient characteristics and the pathophysiology of postoperative AKI, it is inappropriate to assume that the management after noncardiac and nonvascular surgery are the same as those after cardiac and vascular surgery. This article provides a comprehensive review on the available evidence on the management of postoperative AKI in the setting of major abdominal surgery.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE. Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal; (J.A.F.); (F.M.); (J.A.L.)
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13
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Abstract
Massive transfusion protocol (MTP) with fresh-frozen plasma and packed red blood cells (PRBCs) in a 1:1 ratio is one of the most common resuscitative strategies used in patients with severe hemorrhage. There are no studies to date that examine the best postoperative hematocrit range as a marker for survival after MTP. We hypothesize a postoperative hematocrit dose-dependent survival benefit in patients receiving MTP. This was a 53-month retrospective analysis of patients with intra-abdominal injuries requiring surgery and transfusion of 10 units PRBCs or more at a single Level I trauma center. Groups were defined by postoperative hematocrit (less than 21, 21 to 29, 29.1 to 39, and 39 or more). Kaplan-Meier (KM) survival probability was calculated. One hundred fifty patients requiring operative abdominal explorations and 10 units PRBCs or more were identified. There were no significant differences in demographics between groups. When comparing postoperative hematocrit groups, relative to a hematocrit of less than 21 per cent in KM survival analysis, an overall survival advantage was only evident in patients transfused to hematocrits 29.1 to 39 per cent ( P < 0.03; odds ratio [OR], 0.284; 95% confidence interval [CI], 0.089 to 0.914). This survival advantage was not seen in the other groups (21 to 29: OR, 0.352; 95% CI, 0.103 to 1.195 or 39% or greater: OR, 0.107; 95% CI, 0.010 to 1.121). This is the first study to examine the impact of postoperative hematocrit as an indicator of survival after MTP in the trauma patient. Transfusion to hematocrits between 29.1 and 39 per cent conveyed a survival benefit, whereas resuscitation to supraphysiologic hematocrits 39 per cent or greater conveyed no additional survival benefit. This study highlights the need for judicious PRBC administration during MTP and its potential impact on survival in patients with postoperative supraphysiologic hematocrits.
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14
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Zhang V, Ganz T, Nemeth E, Kim A. Iron overload causes a mild and transient increase in acute lung injury. Physiol Rep 2020; 8:e14470. [PMID: 32596989 PMCID: PMC7322498 DOI: 10.14814/phy2.14470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/27/2022] Open
Abstract
Recent studies have demonstrated a strong link between acute respiratory distress syndrome (ARDS) and the levels of iron and iron-related proteins in the lungs. However, the role of iron overload in ARDS development has yet to be characterized. In this study, we compared the highly iron-overloaded hepcidin knockout mice (HKO) to their iron-sufficient wild-type (WT) littermates in a model of sterile acute lung injury (ALI) induced by treatment with oropharyngeal (OP) LPS. There were no major differences in systemic inflammatory response or airway neutrophil infiltration between the two groups at the time of maximal injury (days 2 and 3) or during the recovery phase (day 7). Hepcidin knockout mice had transiently increased bronchoalveolar lavage fluid (BALF) protein and MPO activity in the lung and BALF on day 3, indicating worse vascular leakage and increased neutrophil activity, respectively. The increased ALI severity in iron-overloaded mice may be a result of increased apoptosis of lung tissue, as evidenced by an increase in cleaved capsase-3 protein in lung homogenates from HKO mice versus WT mice on day 3. Altogether, our data suggest that even severe iron overload has a relatively minor and transient effect in LPS-induced ALI.
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Affiliation(s)
- Vida Zhang
- Department of MedicineDavid Geffen School of MedicineUCLALos AngelesCAUSA
- Department of Molecular and Medical PharmacologyUCLALos AngelesCAUSA
| | - Tomas Ganz
- Department of MedicineDavid Geffen School of MedicineUCLALos AngelesCAUSA
| | - Elizabeta Nemeth
- Department of MedicineDavid Geffen School of MedicineUCLALos AngelesCAUSA
| | - Airie Kim
- Department of MedicineDavid Geffen School of MedicineUCLALos AngelesCAUSA
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15
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Sniderman J, Monagle P, Annich GM, MacLaren G. Hematologic concerns in extracorporeal membrane oxygenation. Res Pract Thromb Haemost 2020; 4:455-468. [PMID: 32548547 PMCID: PMC7292669 DOI: 10.1002/rth2.12346] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.
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Affiliation(s)
| | - Paul Monagle
- Department of PaediatricsDepartment of HaematologyUniversity of MelbourneThe Royal Children's HospitalHaematology Research Murdoch Children’s Research InstituteMelbourneVic.Australia
| | - Gail M. Annich
- Department of Critical Care MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Graeme MacLaren
- Paediatric ICURoyal Children’s HospitalMelbourneVic.Australia
- Department of PaediatricsUniversity of MelbourneParkvilleVic.Australia
- Cardiothoracic ICUNational University Health SystemSingapore CitySingapore
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16
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Gameiro J, Branco T, Lopes JA. Artificial Intelligence in Acute Kidney Injury Risk Prediction. J Clin Med 2020; 9:jcm9030678. [PMID: 32138284 PMCID: PMC7141311 DOI: 10.3390/jcm9030678] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent complication in hospitalized patients, which is associated with worse short and long-term outcomes. It is crucial to develop methods to identify patients at risk for AKI and to diagnose subclinical AKI in order to improve patient outcomes. The advances in clinical informatics and the increasing availability of electronic medical records have allowed for the development of artificial intelligence predictive models of risk estimation in AKI. In this review, we discussed the progress of AKI risk prediction from risk scores to electronic alerts to machine learning methods.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal;
- Correspondence:
| | - Tiago Branco
- Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal;
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal;
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Burchard R, Daginnus A, Soost C, Schmitt J, Graw JA. Gender differences in blood transfusion strategy for patients with hip fractures - a retrospective analysis. Int J Med Sci 2020; 17:620-625. [PMID: 32210711 PMCID: PMC7085213 DOI: 10.7150/ijms.33954] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 10/16/2019] [Indexed: 01/28/2023] Open
Abstract
Background: In the last decades, transfusion therapy with allogenic blood has progressively shifted to a more restrictive approach. The current study analyzed the transfusion practice and transfusion-associated factors in a regional trauma center over the course of five years. Methods: Retrospective analysis of all patients undergoing surgery for hip fractures in a level 1 trauma center of an academic teaching hospital from 2010 to 2014 (n=650). The number of transfused packed red blood cells (PRBCs), preoperative Hb concentrations, and intensive care unit (ICU) and hospital length of stay (LOS) were analyzed. A logistic regression analysis was performed to evaluate transfusion and ICU LOS-associated risk factors. (Ethical Review Board approval: 2015-497-f-S). Results: From 2010 to 2014 the average number of PRBCs transfused per patient decreased continuously despite similar preoperative Hb levels. During the same period, ICU LOS increased while hospital LOS decreased. Advanced patient age, preoperative Hb concentrations, surgical complications, and ICU LOS were associated with increased transfusion requirements. Although preoperative Hb levels were lower, females received fewer PRBCs compared to males. Conclusion: Over the course of five years, a restrictive transfusion strategy was implemented within clinical practice in patients undergoing surgery for hip fractures. In parallel, a significant reduction in the hospital LOS and an increased ICU LOS was noted. Whether there is an association between increased ICU LOS and decreasing hospital LOS and whether there is a gender effect on transfusion requirements in patients with surgery for hip fractures should be subject to further research.
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Affiliation(s)
- Rene Burchard
- Department of Statistics an Econometrics, University of Siegen, Siegen, Germany.,Department of Health, University of Witten/Herdecke, Witten, Germany.,Department of Trauma- and Orthopaedic Surgery, Kreisklinikum Siegen, Siegen, Germany
| | - Alina Daginnus
- Department of Trauma- and Orthopaedic Surgery, Kreisklinikum Siegen, Siegen, Germany.,Department of Orthopaedics and Trauma Surgery, University of Marburg, Marburg, Germany
| | - Christian Soost
- Department of Statistics an Econometrics, University of Siegen, Siegen, Germany.,FOM University of Applied Sciences, Essen, Germany
| | - Jan Schmitt
- Department of Orthopaedics and Trauma Surgery, Lahn-Dill-Kliniken, Wetzlar, Germany
| | - Jan Adriaan Graw
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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18
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A Study of the Change in Sodium and Potassium Ion Concentrations in Stored Donor Blood and Their Effect on Electrolyte Balance of Recipients. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8162975. [PMID: 31662997 PMCID: PMC6791281 DOI: 10.1155/2019/8162975] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/22/2019] [Accepted: 09/07/2019] [Indexed: 01/24/2023]
Abstract
Background Preserved blood cells undergo progressive structural and functional changes that may affect their function, integrity, and viability after transfusion. The impact of transfusion of stored blood on potassium, sodium, or acid-base balance in the recipient may be complex, but information on it is inconsistent. This study therefore sought to determine the changes in the potassium and sodium levels in whole blood stored at 4°C for 28 days and clinical outcomes when such blood are transfused. Methods Whole blood were taken into double CPDA-1 bags and 50 ml transferred into the satellite bags for the study. Electrolyte concentration determinations were made on each of the blood sample on days 0, 7, 14, 21, and 28 using the Vitalab Selectra Junior chemistry analyser. The remaining blood in the main bags was transfused after the 28-day period, and biochemical analysis carried out on the patients before and after the transfusion. One-way ANOVA was used for the analysis of variance between the weekly ion concentrations and independent sample Mann-Whitney U test for the data obtained from the patients. Results The mean potassium level of all the samples started with a normal value of 3.45 mmol/L on the first day followed by a sharp rise to 9.40 mmol/L on day 7, 13.40 mmol/L on day 14, 14.60 mmol/L on day 21, and 15.40 mmol/L on day 28. Sodium on the other hand started with a high value of 148.4 mmol/L on day 0 and then reduced to 146.4 mmol/L on day 7, 140.8 mmol/L on day 14, 135.6 mmol/L on day 21, and a low value of 130.8 mmol/L on day 28. No adverse clinical outcomes were seen in patients after they were transfused with the blood. Conclusion It can be deduced that potassium concentration in refrigerated blood increases, whilst sodium concentration reduces with time and when such blood is transfused, it may not result in any adverse clinical outcome.
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19
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To transfuse or not transfuse: an intensive appraisal of red blood cell transfusions in the ICU. Curr Opin Hematol 2019; 25:468-472. [PMID: 30281035 DOI: 10.1097/moh.0000000000000460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW This review is a critical appraisal of the current data comparing restrictive vs. liberal transfusion strategies for patients who are critically ill in ICUs. We focus on four subsets of critically ill patients: pediatric patients, patients with gastrointestinal bleeds, septic patients and patients undergoing cardiac surgery. RECENT FINDINGS Almost a decade after the TRICC trial, a randomized trial showing the safety of a restrictive transfusion threshold in critically ill patients, four large randomized controlled trials have shown that a restrictive transfusion strategy is safe in pediatric critically ill patients, patients with acute upper gastrointestinal bleeds, patients with septic shock and patients undergoing cardiac surgery. A large multicenter randomized trial is underway to determine the safety of a restrictive strategy in myocardial infarction. SUMMARY A restrictive transfusion threshold is recommended in nearly all critically ill patients. This is at least noninferior to more liberal transfusion practice; in addition, a restrictive threshold has shown improved outcomes in some patients and decreased chances of adverse events in patients. Judicious use of red cells improves patient outcome and protects the blood supply, a limited resource. More data are needed to determine appropriate transfusion threshold recommendations for patients with traumatic brain injury and acute coronary syndrome.
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20
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Wood MD, Jacobson JA, Maslove DM, Muscedere JG, Boyd JG. The physiological determinants of near-infrared spectroscopy-derived regional cerebral oxygenation in critically ill adults. Intensive Care Med Exp 2019; 7:23. [PMID: 31049754 PMCID: PMC6497723 DOI: 10.1186/s40635-019-0247-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/07/2019] [Indexed: 02/08/2023] Open
Abstract
Background To maintain adequate oxygen delivery to tissue, resuscitation of critically ill patients is guided by assessing surrogate markers of perfusion. As there is no direct indicator of cerebral perfusion used in routine critical care, identifying an accurate strategy to monitor brain perfusion is paramount. Near-infrared spectroscopy (NIRS) is a non-invasive technique to quantify regional cerebral oxygenation (rSO2) that has been used for decades during cardiac surgery which has led to targeted algorithms to optimize rSO2 being developed. However, these targeted algorithms do not exist during critical care, as the physiological determinants of rSO2 during critical illness remain poorly understood. Materials and methods This prospective observational study was an exploratory analysis of a nested cohort of patients within the CONFOCAL study (NCT02344043) who received high-fidelity vital sign monitoring. Adult patients (≥ 18 years) admitted < 24 h to a medical/surgical intensive care unit were eligible if they had shock and/or required mechanical ventilation. Patients underwent rSO2 monitoring with the FORESIGHT oximeter for 24 h, vital signs were concurrently recorded, and clinically ordered arterial blood gas samples and hemoglobin concentration were also documented. Simultaneous multiple linear regression was performed using all available predictors, followed by model selection using the corrected Akaike information criterion (AICc). Results Our simultaneous multivariate model included age, heart rate, arterial oxygen saturation, mean arterial pressure, pH, partial pressure of oxygen, partial pressure of carbon dioxide (PaCO2), and hemoglobin concentration. This model accounted for a significant proportion of variance in rSO2 (R2 = 0.58, p < 0.01) and was significantly associated with PaCO2 (p < 0.05) and hemoglobin concentration (p < 0.01). Our selected regression model using AICc accounted for a significant proportion of variance in rSO2 (R2 = 0.54, p < 0.01) and was significantly related to age (p < 0.05), PaCO2 (p < 0.01), hemoglobin (p < 0.01), and heart rate (p < 0.05). Conclusions Known and established physiological determinants of oxygen delivery accounted for a significant proportion of the rSO2 signal, which provides evidence that NIRS is a viable modality to assess cerebral oxygenation in critically ill adults. Further elucidation of the determinants of rSO2 has the potential to develop a NIRS-guided resuscitation algorithm during critical illness. Trial registration This trial is registered on clinicaltrials.gov (Identifier: NCT02344043), retrospectively registered January 8, 2015. Electronic supplementary material The online version of this article (10.1186/s40635-019-0247-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael D Wood
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada
| | - Jill A Jacobson
- Department of Psychology, Queen's University, 62 Arch Street, 318 Craine Hall, Kingston, ON, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada.,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada. .,Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada. .,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada.
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21
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Nguyen VL, Fitzpatrick M. Should phosphatidylethanol be currently analysed using whole blood, dried blood spots or both? ACTA ACUST UNITED AC 2019; 57:617-622. [DOI: 10.1515/cclm-2018-0667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 09/09/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Phosphatidylethanol (PEth) are phospholipids produced through non-oxidative ethanol metabolism. They accumulate in red blood cells and have been traditionally analysed in whole blood as potential biomarkers for moderate to long-term alcohol consumption. More recently, their analysis in dried blood spots has been gaining favour, namely, due to the ease in sampling, transport and storage conditions required. This paper aims at providing a short comparative review between analysing PEth in whole blood and dried blood spots and the potential pitfalls that researchers may face when setting up PEth testing for clinical use.
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22
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Zhang W, Yu K, Chen N, Chen M. Age of Red Cells for Transfusion and Outcomes in Critically Ill Patients: A Meta-Analysis. Transfus Med Hemother 2019; 46:248-255. [PMID: 31700507 DOI: 10.1159/000498863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/11/2019] [Indexed: 11/19/2022] Open
Abstract
Objective Whether the age of red blood cells (RBCs) affects mortality after transfusion in critically ill patients is controversial. Methods We searched MEDLINE, EMBASE, PubMed, Web of Science, and the Cochrane Library Central Register of Controlled Trials databases from inception to January 10, 2018 to identify systematic reviews or meta-analyses and published randomized controlled trials of the effects of fresh versus older blood transfusion on mortality of adults in the intensive care unit (ICU). There were no date restrictions, but the language was restricted to English. The primary outcome was mortality. Risk ratios (RR) and 95% confidence intervals (CI) were calculated. Results We included six trials that enrolled 8,467 critically ill patients and compared fresh RBC transfusion with current standard practice. There were no significant differences in 90-day mortality (RR 1.04, 95% CI 0.97, 1.12), 28/30-day mortality (RR 1.04, 95% CI 0.96, 1.13), in-hospital mortality (RR 1.06, 95% CI 0.94, 1.19), and in-ICU mortality (RR 1.11, 95% CI 0.97, 1.27) with fresh RBC transfusion compared with older blood transfusion. Conclusions The study concluded that age of red cells for transfusion did not affect the outcomes in critically ill patients.
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Affiliation(s)
- Wei Zhang
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Kun Yu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ni Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Miao Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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23
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König C, Röhr AC, Frey OR, Brinkmann A, Roberts JA, Wichmann D, Braune S, Kluge S, Nierhaus A. In vitro removal of anti-infective agents by a novel cytokine adsorbent system. Int J Artif Organs 2018; 42:57-64. [DOI: 10.1177/0391398818812601] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: The aim of this study is to describe the in vitro adsorption of anti-infective drugs onto an extracorporeal cytokine adsorber. Methods: Various anti-infective drugs (β-lactams, quinolones, aminoglycosides, glycopeptides, azole antimycotics) were prepared in normal saline 0.9% and human albumin 5%, and pumped through a cytokine cartridge (CytoSorb®; CytoSorbents Corporation, Monmouth Junction, NJ, USA) at a flow rate of 1.2 L/h for 1.5 h. In addition, meropenem and ciprofloxacin were dissolved in reconstituted blood and run through a CytoSorb cartridge, which was integrated into a continuous renal replacement therapy circuit with a flow rate of 2 L/h for 18 h. Samples from the solution, pre- and post-filter, were quantified by high-performance liquid chromatography with ultraviolet detection and fluorescence polarisation immunoassay. Results: Observed mean clearance of the drugs in normal saline was 1.22 ± 0.07 L/h. In human albumin, clearance was 1.29 ± 0.08 L/h. In reconstituted blood, clearance of meropenem decreased from 5.4 to 1.4 L/h and for ciprofloxacin from 6.3 to 4.3 L/h within the first 1.5 h because of early drug adsorption. Continuous renal replacement therapy clearance measured without CytoSorb was stable at 2 and 1.7 L/h, respectively. Approximately 400 mg of meropenem and 300 mg of ciprofloxacin had been adsorbed by CytoSorb, suggesting that these amounts are the maximum adsorptive capacity for these drugs. Conclusion: In these settings, all tested drugs were adsorbed by the cartridge in relevant amounts. The identified maximum adsorptive capacity and the rapid decline in concentration during the first 1.5 h of CytoSorb use suggest that the administration of an additional dose within the first hours of CytoSorb treatment may be reasonable. In addition, early therapeutic drug monitoring should be considered.
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Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anka C Röhr
- Hospital Pharmacy, Heidenheim General Hospital, Heidenheim, Germany
| | - Otto R Frey
- Hospital Pharmacy, Heidenheim General Hospital, Heidenheim, Germany
| | - Alexander Brinkmann
- Department of Anaesthesia and Critical Care Medicine, Heidenheim General Hospital, Heidenheim, Germany
| | - Jason A Roberts
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stephan Braune
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Kashefi P, Rahmani A, Khalifesoltani M. Changes in the hemoglobin level after one unit of packed red blood cell transfusion in Intensive Care Unit patients. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2018; 23:85. [PMID: 30294353 PMCID: PMC6161483 DOI: 10.4103/jrms.jrms_64_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/09/2017] [Accepted: 07/04/2017] [Indexed: 11/30/2022]
Abstract
Background: Blood transfusion is essential in severely ill patients whose hemoglobin (Hb) levels are low, but there are some factors that inhibit optimal increase in Hb. The aim of this study was to evaluate the amount of increase in Hb levels after packed red blood cell (PRBC) transfusions in the Intensive Care Unit (ICU) patients and its related factors. Materials and Methods: This cross-sectional study included 124 patients admitted to the ICU, and needed PRBC transfusion. Demographic information, Hb on the 1st day of admission, blood volume transfusions during the 7 days, and the 7th day of admission Hb level were extracted from patients’ records. Results: The average initial Hb level of patients was reported as 6.17 ± 1.43 g/dl, and after administrating PRBC (4.23 ± 1.87 units during 7 days), the Hb level was 8.09 ± 1.66 g/dl after 7 days (mean difference was 1.91 ± 1.93, t = 11.06, P < 0.001). No significant differences were found between change in Hb level in the terms of age, gender, underlying illness, body mass index, hospitalization history, fever, and duration of hospitalization (P > 0.05). However, the mean increased Hb level in hospitalized patients with internal disorders was the lowest (0.25 g/dl, P = 0.002). Conclusion: The results of our study showed that the increased Hb level based on one unit of received PRBC was low, especially in patients with internal. Therefore, based on high frequency of anemia in ICU patients and relative complications, physicians should pay attention to factors affecting Hb levels after PRBC transfusion such as medical history.
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Affiliation(s)
- Parvis Kashefi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amin Rahmani
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Litton E, Baker S, Erber W, Farmer S, Ferrier J, French C, Gummer J, Hawkins D, Higgins A, Hofmann A, De Keulenaer B, McMorrow J, Olynyk JK, Richards T, Towler S, Trengove R, Webb S. Hepcidin predicts response to IV iron therapy in patients admitted to the intensive care unit: a nested cohort study. J Intensive Care 2018; 6:60. [PMID: 30214812 PMCID: PMC6131742 DOI: 10.1186/s40560-018-0328-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/23/2018] [Indexed: 01/26/2023] Open
Abstract
Background Both anaemia and red blood cell (RBC) transfusion are common and associated with adverse outcomes in patients admitted to the intensive care unit (ICU). The aim of this study was to determine whether serum hepcidin concentration, measured early after ICU admission in patients with anaemia, could identify a group in whom intravenous (IV) iron therapy decreased the subsequent RBC transfusion requirement. Methods We conducted a prospective observational study nested within a multicenter randomized controlled trial (RCT) of IV iron versus placebo. The study was conducted in the ICUs of four tertiary hospitals in Perth, Western Australia. Critically ill patients with haemoglobin (Hb) of < 100 g/L and within 48 h of admission to the ICU were eligible for participation after enrolment in the IRONMAN RCT. The response to IV iron therapy compared with placebo was assessed according to tertile of hepcidin concentration. Results Hepcidin concentration was measured within 48 h of ICU admission in 133 patients. For patients in the lower two tertiles of hepcidin concentration (< 53.0 μg), IV iron therapy compared with placebo was associated with a significant decrease in RBC transfusion requirement [risk ratio 0.48 (95% CI 0.26–0.85), p = 0.013]. Conclusions In critically ill patients with anaemia admitted to an ICU, baseline hepcidin concentration predicts RBC transfusion requirement and is able to identify a group of patients in whom IV iron compared with placebo is associated with a significant decrease in RBC transfusion requirement. Trial registration Australian New Zealand Clinical Trials Registry: ANZCTRN12612001249 Registered 26/11/2012 Electronic supplementary material The online version of this article (10.1186/s40560-018-0328-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edward Litton
- 1Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia 6065 Australia.,2School of Medicine, University of Western Australia, Perth, Western Australia 6009 Australia.,14Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia 6150 Australia
| | - Stuart Baker
- Intensive Care Unit, Sir Charles Gardner Hospital, Perth, Western Australia 6009 Australia
| | - Wendy Erber
- School of Patholody, University of Australia, Perth, Western Australia 6009 Australia
| | - Shannon Farmer
- 5Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia 6009 Australia
| | - Janet Ferrier
- 1Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia 6065 Australia
| | - Craig French
- 6Western Health, Melbourne, Victoria Australia.,7University of Melbourne, Melbourne, Victoria Australia
| | - Joel Gummer
- 8Separation Science and Metabolomics Laboratory Metabolomics Australia (Western Australia node), Murdoch University, Perth, Western Australia Australia
| | - David Hawkins
- Intensive Care Unit, Joondalup Health Campus, Joondalup, Western Australia Australia
| | - Alisa Higgins
- 10Centre of Research Excellence for Patient Blood Management in Critical Illness and Trauma, Monash University, Melbourne, Victoria Australia
| | - Axel Hofmann
- 5Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia 6009 Australia
| | - Bart De Keulenaer
- 1Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia 6065 Australia
| | - Julie McMorrow
- 11Intensive Care Unit, Royal Perth Hospital, Perth, Western Australia 6000 Australia
| | - John K Olynyk
- 12School of Medicine, University of Western Australia, Perth, Western Australia 6009 Australia
| | | | - Simon Towler
- 1Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia 6065 Australia
| | - Robert Trengove
- 8Separation Science and Metabolomics Laboratory Metabolomics Australia (Western Australia node), Murdoch University, Perth, Western Australia Australia
| | - Steve Webb
- 2School of Medicine, University of Western Australia, Perth, Western Australia 6009 Australia.,11Intensive Care Unit, Royal Perth Hospital, Perth, Western Australia 6000 Australia
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Nguyen VL, Seth D. Letter to the Editor Regarding Afshar et al. (2017): Cut-Point Levels of Phosphatidylethanol to Identify Alcohol Misuse in a Mixed Cohort Including Critically Ill Patients. Alcohol Clin Exp Res 2018; 42:2061-2063. [PMID: 30059168 DOI: 10.1111/acer.13851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/22/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Van Long Nguyen
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Devanshi Seth
- Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia.,Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Centenary Institute of Cancer Medicine and Cell Biology (DS), The University of Sydney, NSW, Australia
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27
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Abstract
OBJECTIVES To determine the prevailing hemoglobin levels in PICU patients, and any potential correlates. DESIGN Post hoc analysis of prospective multicenter observational data. SETTINGS Fifty-nine PICUs in seven countries. PATIENTS PICU patients on four specific days in 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients' hemoglobin and other clinical and institutional data. Two thousand three hundred eighty-nine patients with median age of 1.9 years (interquartile range, 0.3-9.8 yr), weight 11.5 kg (interquartile range, 5.4-29.6 kg), and preceding PICU stay of 4.0 days (interquartile range, 1.0-13.0 d). Their median hemoglobin was 11.0 g/dL (interquartile range, 9.6-12.5 g/dL). The prevalence of transfusion in the 24 hours preceding data collection was 14.2%. Neonates had the highest hemoglobin at 13.1 g/dL (interquartile range, 11.2-15.0 g/dL) compared with other age groups (p < 0.001). The percentage of 31.3 of the patients had hemoglobin of greater than or equal to 12 g/dL, and 1.1% had hemoglobin of less than 7 g/dL. Blacks had lower median hemoglobin (10.5; interquartile range, 9.3-12.1 g/dL) compared with whites (median, 11.1; interquartile range, 9.0-12.6; p < 0.001). Patients in Spain and Portugal had the highest median hemoglobin (11.4; interquartile range, 10.0-12.6) compared with other regions outside of the United States (p < 0.001), and the highest proportion (31.3%) of transfused patients compared with all regions (p < 0.001). Patients in cardiac PICUs had higher median hemoglobin than those in mixed PICUs or noncardiac PICUs (12.3, 11.0, and 10.6 g/dL, respectively; p < 0.001). Cyanotic heart disease patients had the highest median hemoglobin (12.6 g/dL; interquartile range, 11.1-14.5). Multivariable regression analysis within diagnosis groups revealed that hemoglobin levels were significantly associated with the geographic location and history of complex cardiac disease in most of the models. In children with cancer, none of the variables tested correlated with patients' hemoglobin levels. CONCLUSIONS Patients' hemoglobin levels correlated with demographics like age, race, geographic location, and cardiac disease, but none found in cancer patients. Future investigations should account for the effects of these variables.
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Kratzert WB, Boyd EK, Schwarzenberger JC. Management of the Critically Ill Adult With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2017; 32:1682-1700. [PMID: 29500124 DOI: 10.1053/j.jvca.2017.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Indexed: 02/01/2023]
Abstract
Survival of adults with congenital heart disease (CHD) has improved significantly over the last 2 decades, leading to an increase in hospital and intensive care unit (ICU) admissions of these patients. Whereas most of the ICU admissions in the past were related to perioperative management, the incidence of medical emergencies from long-term sequelae of palliative or corrective surgical treatment of these patients is rising. Intensivists now are confronted with patients who not only have complex anatomy after congenital cardiac surgery, but also complex pathophysiology due to decades of living with abnormal cardiac anatomy and diseases of advanced age. Comorbidities affect all organ systems, including cognitive function, pulmonary and cardiovascular systems, liver, and kidneys. Critical care management requires an in-depth understanding of underlying anatomy and pathophysiology in order to apply contemporary concepts of adult ICU care to this population and optimize patient outcomes. In this review, the main CHD lesions and their common surgical management approaches are described, and the sequelae of CHD physiology are discussed. In addition, the effects of chronic comorbidities on the management of critically ill adults are explored, and the adjustments of current ICU management modalities and pharmacology to optimize care are discussed.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA
| | - Johanna C Schwarzenberger
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA
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29
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Nielsen ND, Martin-Loeches I, Wentowski C. The Effects of red Blood Cell Transfusion on Tissue Oxygenation and the Microcirculation in the Intensive Care Unit: A Systematic Review. Transfus Med Rev 2017; 31:205-222. [PMID: 28800876 DOI: 10.1016/j.tmrv.2017.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/12/2017] [Accepted: 07/11/2017] [Indexed: 01/15/2023]
Abstract
The transfusion of red blood cells (RBCs) is a common intervention in intensive care unit (ICU) patients, yet the benefits are far from clear in patients with moderate anemia (eg, hemoglobin (Hb) levels of 7-10 g/dL). Determining which of these patients benefit, and how to even define benefit, from transfusion is challenging. As the intended physiological benefit underpinning RBC transfusion is to improve tissue oxygenation, several studies utilizing a wide range of assessment techniques have attempted to study the effects of transfusion on tissue oxygenation and microcirculatory function. The objective of this systematic review was to determine whether RBC transfusion improves tissue oxygenation/microcirculatory indices in the ICU population, and to provide an introduction to the techniques used in these studies. Eligible studies published between January 1996 and February 2017 were identified from searches of PubMed, Embase, Cinahl, ScienceDirect, Web of Science, and The Cochrane Library. Seventeen studies met inclusion criteria, though there was significant heterogeneity in study design, patient population, assessment techniques and outcomes reported. Overall, the majority of studies (11 of 17) concluded that transfusion did not generally improve tissue oxygenation or microcirculation. Inter-individual effects were highly variable, however, and closer review of sub-groups available in 9 studies revealed that patients with abnormal tissue oxygenation or microcirculatory indices prior to transfusion had improvement in these indices with transfusion, irrespective of assessment method. This finding suggests a new strategy for future trials in the ICU: utilizing tissue oxygenation/microcirculatory parameters to determine the need for transfusion rather than largely arbitrary hemoglobin concentrations.
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Affiliation(s)
- Nathan D Nielsen
- Section of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Department of Clinical Medicine, Trinity College, Dublin, Ireland
| | - Catherine Wentowski
- Division of Pulmonary and Critical Care Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
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30
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Jalal UM, Kim SC, Shim JS. Histogram analysis for smartphone-based rapid hematocrit determination. BIOMEDICAL OPTICS EXPRESS 2017; 8:3317-3328. [PMID: 28717569 PMCID: PMC5508830 DOI: 10.1364/boe.8.003317] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/20/2017] [Accepted: 06/07/2017] [Indexed: 06/07/2023]
Abstract
A novel and rapid analysis technique using histogram has been proposed for the colorimetric quantification of blood hematocrits. A smartphone-based "Histogram" app for the detection of hematocrits has been developed integrating the smartphone embedded camera with a microfluidic chip via a custom-made optical platform. The developed histogram analysis shows its effectiveness in the automatic detection of sample channel including auto-calibration and can analyze the single-channel as well as multi-channel images. Furthermore, the analyzing method is advantageous to the quantification of blood-hematocrit both in the equal and varying optical conditions. The rapid determination of blood hematocrits carries enormous information regarding physiological disorders, and the use of such reproducible, cost-effective, and standard techniques may effectively help with the diagnosis and prevention of a number of human diseases.
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31
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Frazier SK, Higgins J, Bugajski A, Jones AR, Brown MR. Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention. Crit Care Nurs Clin North Am 2017; 29:271-290. [PMID: 28778288 DOI: 10.1016/j.cnc.2017.04.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.
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Affiliation(s)
- Susan K Frazier
- PhD Program, RICH Heart Program, College of Nursing, University of Kentucky, CON Building, Office 523, 751 Rose Street, Lexington, KY 40536-0232, USA.
| | - Jacob Higgins
- College of Nursing, University of Kentucky, CON Building, 751 Rose Street, Lexington, KY 40536-0232, USA
| | - Andrew Bugajski
- College of Nursing, University of Kentucky, CON Building, 751 Rose Street, Lexington, KY 40536-0232, USA
| | - Allison R Jones
- Department of Acute, Chronic & Continuing Care, School of Nursing, University of Alabama at Birmingham, NB 543, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Michelle R Brown
- Clinical Laboratory Science, University of Alabama at Birmingham, SHPB 474, 1705 University Boulevard, Birmingham, AL 35294, USA
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32
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Raiten JM, Wong ZZ, Spelde A, Littlejohn JE, Augoustides JG, Gutsche JT. Anticoagulation and Transfusion Therapy in Patients Requiring Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2017; 31:1051-1059. [DOI: 10.1053/j.jvca.2016.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Indexed: 11/11/2022]
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Simonetti A, Ezzeldin H, Menis M, McKean S, Izurieta H, Anderson SA, Forshee RA. Modeling the potential impact on the US blood supply of transfusing critically ill patients with fresher stored red blood cells. PLoS One 2017; 12:e0174033. [PMID: 28319164 PMCID: PMC5358863 DOI: 10.1371/journal.pone.0174033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/02/2017] [Indexed: 01/09/2023] Open
Abstract
Background Although some studies have suggested that transfusion recipients may have better medical outcomes if transfused with red blood cell units stored for a short time, the overall body of evidence shows mixed results. It is important to understand how using fresher stored red blood cell units for certain patient groups may affect blood availability. Methods Based on the Stock-and-Flow simulation model of the US blood supply developed by Simonetti et al. 2014, we evaluated a newly implemented allocation method of preferentially transfusing fresher stored red blood cell units to a subset of high-risk group of critically ill patients and its potential impact on supply. Results Simulation results showed that, depending on the scenario, the US blood total supply might be reduced between 2-42%, when compared to the standard of care in transfusion medicine practice. Among our simulated scenarios, we observed that the number of expired red blood cell units modulated the supply levels. The age threshold of the required red blood cell units was inversely correlated with both the supply levels and the number of transfused units that failed to meet that age threshold. Conclusion To our knowledge, this study represents the first attempt to develop a comprehensive framework to evaluate the impact of preferentially transfusing fresher stored red blood cells to the higher-risk critically ill patients on supply. Model results show the difficulties to identify an optimal scenario.
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Affiliation(s)
- Arianna Simonetti
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
- * E-mail:
| | - Hussein Ezzeldin
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Mikhail Menis
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
| | | | - Hector Izurieta
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Steven A. Anderson
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Richard A. Forshee
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
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34
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Kim HS, Park S. Blood Transfusion Strategies in Patients Undergoing Extracorporeal Membrane Oxygenation. Korean J Crit Care Med 2017; 32:22-28. [PMID: 31723612 PMCID: PMC6786745 DOI: 10.4266/kjccm.2016.00983] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/30/2017] [Accepted: 02/06/2017] [Indexed: 12/19/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is frequently associated with bleeding and coagulopathy complications, which may lead to the need for transfusion of multiple blood products. However, blood transfusions are known to increase morbidity and mortality, as well as hospital cost, in critically ill patients. In current practice, patients on ECMO receive a transfusion, on average, of 1-5 packed red blood cells (RBCs)/day, with platelet transfusion accounting for the largest portion of transfusion volume. Generally, adult patients require more transfusions than neonates or children, and patients receiving venovenous ECMO for respiratory failure tend to need smaller transfusion volumes compared to those receiving venoarterial ECMO for cardiac failure. Observation studies have reported that a higher transfusion volume was associated with increased mortality. To date, the evidence for transfusion in patients undergoing ECMO is limited; most knowledge on transfusion strategies was extrapolated from studies in critically ill patients. However, current data support a restrictive blood transfusion strategy for ECMO patients, and a low transfusion trigger seems to be safe and reasonable.
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Affiliation(s)
- Hyoung Soo Kim
- Department of Cardiothoracic Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Beyer A, Rees R, Palmer C, Wessman BT, Fuller BM. Blood product transfusion in emergency department patients: a case-control study of practice patterns and impact on outcome. Int J Emerg Med 2017; 10:5. [PMID: 28155184 PMCID: PMC5289930 DOI: 10.1186/s12245-017-0133-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/31/2017] [Indexed: 01/28/2023] Open
Abstract
Background Blood product transfusion occurs in a significant percentage of intensive care unit (ICU) patients. Pulmonary complications, such as acute respiratory distress syndrome (ARDS), occurring in the setting of transfusion, are associated with increased morbidity and mortality. Contrary to the ICU setting, there is little evidence describing the epidemiology of transfusion in the emergency department (ED) or its potential impact on outcome. The objectives of this study were to: (1) characterize transfusion practices in the ED with respect to patient characteristics and pre-transfusion laboratory values; and (2) investigate the effect of ED blood product transfusion on the incidence of pulmonary complications after admission. We hypothesized that blood product transfusion would increase the event rate for pulmonary complications, and have a negative impact on other clinically significant outcomes. Methods This was a retrospective case-control study with one-one matching of 204 transfused ED patients to 204 non-transfused controls. The primary outcome was a composite pulmonary outcome that included: acute respiratory failure, new need for ICU admission, and ARDS. Multivariable logistic regression was used to evaluate the primary outcome as a function of transfusion. Results One-hundred twenty four (60.8%) patients were transfused packed red blood cells (PRBC) in the ED. The mean pre-transfusion hemoglobin level was 8.5 g/dl. There were 73 patients with a hemoglobin value ≥10 g/dl; 19 (26.0%) received a PRBC transfusion. A total of 54 (26.5%) patients were transfused platelets. The main indications were thrombocytopenia (27.8%) and neurologic injury (24.1%). Ten patients had a platelet level <10,000 (guideline recommended threshold for transfusion to prevent spontaneous hemorrhage). The mean platelet count for neurologic injury patients was 197,000 prior to transfusion. The primary outcome occurred in 26 control patients (12.7%), as compared with 28 cases (13.7%). In multivariable logistic regression analysis, ED transfusion was not associated with an increased odds of primary outcome [adjusted OR 0.91 (0.48–1.72), P = 0.77]. The mortality rate was 10.8% in the cases and 8.8% in the controls, P = 0.51. Conclusions A significant percentage of ED blood product transfusions are discordant with guideline recommendations. However, there was no association with ED transfusion and worse clinical outcome. Electronic supplementary material The online version of this article (doi:10.1186/s12245-017-0133-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexander Beyer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Ryan Rees
- Washington University School of Medicine in St. Louis, St. Louis, MO, 63110, USA
| | - Christopher Palmer
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, 63110, USA
| | - Brian T Wessman
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, 63110, USA
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, 63110, USA.
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Comportamiento de la hemoglobina en los pacientes críticos: Un análisis de la práctica transfusional en una unidad de cuidados intensivos. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.acci.2016.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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37
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Graw JA, Spies CD, Wernecke KD, Braun JP. End-of-life decisions in surgical intensive care medicine - the relevance of blood transfusions. Transfus Apher Sci 2016; 54:416-20. [PMID: 27068352 DOI: 10.1016/j.transci.2016.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/21/2016] [Accepted: 03/22/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND End-of-life decisions (EOLDs) are common in the intensive care unit (ICU). EOLDs underlie a dynamic process and limitation of ICU-therapies is often done sequentially. Questionnaire-based and observational studies on medical ICUs and in palliative care reveal blood transfusions as the first therapy physicians withhold as an EOLD. METHODS To test whether this practice also applies to surgical ICU-patients, in an observational study, all deceased patients (n = 303) admitted to an academic surgical ICU in a three-year period were analyzed for the process of limiting ICU-therapies. RESULTS Restriction of further surgery (85.4%) and limiting doses of vasopressors (75.8%) were the most frequent forms of limitations in surgical ICU therapies. Surgical patients, who had blood transfusions withheld (44.6%), had more ICU-therapies withheld or withdrawn simultaneously than patients who had transfusions maintained (5 ± 2 vs. 2 ± 1, p < 0.001). Secondary EOLDs and subsequent limitations occurred less frequently in patients who had transfusions withheld with their first EOLD (17.1% vs. 35.6%, p < 0.05). CONCLUSION Limitation orders for blood transfusions are not a prioritized decision in EOLDs of surgical ICU patients. Withholding blood transfusions correlates with discontinuation of further significant life-support therapies. This suggests that EOLDs to withhold blood transfusions are part of the most advanced limitations of therapy on the surgical ICU.
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Affiliation(s)
- Jan A Graw
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany.
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany
| | - Klaus-D Wernecke
- Charité - Universitätsmedizin Berlin and SOSTANA GmbH, Berlin, Germany
| | - Jan-P Braun
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Klinikum Hildesheim, Germany
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Multipronged strategy to reduce routine-priority blood testing in intensive care unit patients. J Crit Care 2016; 31:212-6. [DOI: 10.1016/j.jcrc.2015.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/11/2015] [Accepted: 09/13/2015] [Indexed: 11/22/2022]
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Kawase H, Egi M, Kanazawa T, Shimizu K, Toda Y, Iwasaki T, Morita K. Storage duration of transfused red blood cells is not significantly associated with postoperative adverse events in pediatric cardiac surgery patients. Transfus Apher Sci 2016; 54:111-6. [PMID: 26856639 DOI: 10.1016/j.transci.2016.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 11/29/2015] [Accepted: 01/20/2016] [Indexed: 01/08/2023]
Abstract
The aim of this study was to evaluate the association of storage duration of transfused red blood cells with the risk of postoperative serious adverse events in pediatric cardiac surgery patients. We studied 517 patients and found that 22 patients (4.3%) had at least one serious adverse event. The maximum and mean storage duration of transfused red blood cells did not differ significantly between patients with and without serious adverse events (maximum, p = 0.89; mean, p = 0.81). In our study of pediatric cardiac surgery patients, the storage duration of transfused red blood cells was not significantly associated with the risk of serious adverse events.
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Affiliation(s)
- Hirokazu Kawase
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama 700-8558, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan.
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama 700-8558, Japan
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama 700-8558, Japan
| | - Yuichiro Toda
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki City, Okayama 701-0192, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama 700-8558, Japan
| | - Kiyoshi Morita
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama 700-8558, Japan
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Lynch AM, Respess M, Boll AE, Bozych M, McMichael M, Fletcher DJ, De Laforcade AM, Rozanski EA. Hospital-acquired Anemia in Critically Ill Dogs and Cats: A Multi-Institutional Study. J Vet Intern Med 2016; 30:141-6. [PMID: 26578290 PMCID: PMC4913629 DOI: 10.1111/jvim.13650] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 08/17/2015] [Accepted: 09/21/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hospital-acquired anemia is commonly described in people but limited information currently is available regarding its prevalence in animals. HYPOTHESIS/OBJECTIVES Assess the prevalence of hospital-acquired anemia in hospitalized critically ill dogs and cats, and examine its relationship with phlebotomy practices, transfusion administration, and survival to discharge. ANIMALS Eight hundred and fifty-one client-owned animals (688 dogs and 163 cats). METHODS A multicenter, observational study was conducted in which packed cell volume (PCV) was recorded at the time of admission and on subsequent hospitalization days. Signalment, number of blood samples obtained, underlying disease, whether or not blood products were administered, duration of hospitalization, and survival to discharge were recorded. RESULTS Admission anemia prevalence was 32%, with overall prevalence during the hospitalization period of 56%. The last recorded PCV was significantly lower than the admission PCV for both dogs (admission PCV, 42% [range, 6-67%]; last recorded PCV, 34% [range, 4-64%], P < .0001) and cats (admission PCV, 31% [range, 6-55%]; last recorded PCV, 26% [range, 10-46%], P < .0001). Patients that developed anemia had significantly more blood samples obtained (nonanemic, 5 blood samples [range, 2-54]; anemic, 7 blood samples [range, 2-49], P < .0001). Hospitalized cats were significantly more likely to develop anemia compared to dogs (P < .0001), but anemic dogs were significantly less likely to survive to discharge (P = .0001). Surgical patients were at higher risk of developing hospital-acquired anemia compared to medical patients (OR, 0.63; 95% CI, 0.4-0.9; P = .01). CONCLUSIONS AND CLINICAL RELEVANCE Hospital-acquired anemia occurred frequently, especially in surgical patients. Additional studies focused on the direct effect of phlebotomy practices on the likelihood of anemia development in hospitalized animals are warranted.
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Affiliation(s)
- A M Lynch
- Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA
- College of Veterinary Medicine, University of Florida, Gainesville, FL
| | | | - A E Boll
- Cornell University College of Veterinary Medicine, Ithaca, NY
| | - M Bozych
- College of Veterinary Medicine at the University of Illinois, Urbana, IL
| | - M McMichael
- College of Veterinary Medicine at the University of Illinois, Urbana, IL
| | - D J Fletcher
- Cornell University College of Veterinary Medicine, Ithaca, NY
| | - A M De Laforcade
- Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA
| | - E A Rozanski
- Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA
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Riessen R, Behmenburg M, Blumenstock G, Guenon D, Enkel S, Schäfer R, Haap M. A Simple "Blood-Saving Bundle" Reduces Diagnostic Blood Loss and the Transfusion Rate in Mechanically Ventilated Patients. PLoS One 2015; 10:e0138879. [PMID: 26421920 PMCID: PMC4589283 DOI: 10.1371/journal.pone.0138879] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 09/04/2015] [Indexed: 01/28/2023] Open
Abstract
Introduction Aim of this study was to reduce blood loss caused by diagnostic blood sampling and to minimize the development of anemia in a high-risk group of mechanically ventilated medical intensive care patients. We therefore implemented a “blood-saving bundle” (BSB) combining a closed-loop arterial blood sampling system, smaller sampling tubes, reduced frequency of blood drawings, and reduced sample numbers. Methods The study included all patients from our medical ICU who were ventilated for more than 72 hours. Exclusion criteria were: acute or chronic anemia on admission, bleeding episode(s) during the ICU stay, or end-of-life therapy. The BSB was introduced in 2009 with training and educational support. Patients treated in 2008, before the introduction of the BSB, served as a control group (n = 41, 617 observation days), and were compared with patients treated in 2010 after the introduction of the BSB (BSB group, n = 50, 559 observation days). Primary endpoints were blood loss per day, and development of anemia. Secondary endpoints were numbers of blood transfusions, number of days on mechanical ventilation, and length of the ICU stay. Results Mean blood loss per ICU day was decreased from 43.3 ml (95% CI: 41.2 to 45.3 ml) in the controls to 15.0 ml (14.3 to 15.7 ml) in the BSB group (P < 0.001). The introduction of a closed-loop arterial blood sampling system was the major contributor to this effect. Mean hemoglobin concentrations showed no significant differences in both groups during the ICU stay. Hemoglobin values <9 g/dl, however, were recorded in 21.2% of observation days in the controls versus 15.4% in the BSB group (P = 0.01). Units of transfused red blood cells per 100 observation days decreased from 7 to 2.3 (P < 0.001). The mean number of ventilation days was 7.1 days (6.1 to 8.3 days) in the controls and 7.5 days (6.6 to 8.5 days) in the BSB group (P = NS). In total, patients in the BSB group stayed in ICU for a mean of 9.9 days (8.6 to 11.3 days), compared to a mean ICU stay of 13.0 days (10.9 to 15.4 days) in the control group (P = 0.014). Due to the longitudinal study design, however, we cannot exclude uncontrolled confounders affecting the transfusion frequency and mean ICU stay. Conclusion Our BSB could be easily implemented and was able to reduce diagnostic blood loss.
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Affiliation(s)
- Reimer Riessen
- Department of Internal Medicine, Medical Intensive Care Unit, University of Tübingen, Tübingen, Germany
- * E-mail:
| | - Melanie Behmenburg
- Department of Internal Medicine, Medical Intensive Care Unit, University of Tübingen, Tübingen, Germany
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Doris Guenon
- Department of Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Sigrid Enkel
- Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany
| | - Richard Schäfer
- Institute for Transfusion Medicine and Immunohaematology, German Red Cross Blood Donor Service Baden-Württemberg-Hessen GmbH, Johann-Wolfgang-Goethe-University Hospital, Frankfurt/Main, Germany
| | - Michael Haap
- Department of Internal Medicine, Medical Intensive Care Unit, University of Tübingen, Tübingen, Germany
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Aokage T, Palmér K, Ichiba S, Takeda S. Extracorporeal membrane oxygenation for acute respiratory distress syndrome. J Intensive Care 2015; 3:17. [PMID: 27408728 PMCID: PMC4940971 DOI: 10.1186/s40560-015-0082-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/10/2015] [Indexed: 01/11/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) can be a lifesaving therapy in patients with refractory severe respiratory failure or cardiac failure. Severe acute respiratory distress syndrome (ARDS) still has a high-mortality rate, but ECMO may be able to improve the outcome. Use of ECMO for respiratory failure has been increasing since 2009. Initiation of ECMO for adult ARDS should be considered when conventional therapy cannot maintain adequate oxygenation. ECMO can stabilize gas exchange and haemodynamic compromise, consequently preventing further hypoxic organ damage. ECMO is not a treatment for the underlying cause of ARDS. Because ARDS has multiple causes, the diagnosis should be investigated and treatment should be commenced during ECMO. Since ECMO is a complicated and high-risk therapy, adequate training in its performance and creation of a referring hospital network are essential. ECMO transport may be an effective method of transferring patients with severe ARDS.
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Affiliation(s)
- Toshiyuki Aokage
- ECMO Centre Karolinska, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Kenneth Palmér
- ECMO Centre Karolinska, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Shingo Ichiba
- Department of Community and Emergency Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558 Japan
| | - Shinhiro Takeda
- Department of Intensive Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603 Japan
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Changes in gene expression following trauma are related to the age of transfused packed red blood cells. J Trauma Acute Care Surg 2015; 78:535-42. [PMID: 25710424 DOI: 10.1097/ta.0000000000000534] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of packed red blood cells (PRBCs) is associated with an increased incidence of nosocomial infections and an increased risk of death. The duration of storage before transfusion may influence these outcomes. Here, we explore the association between the age of transfused PRBCs and specific patterns of inflammatory gene expression in severely injured trauma patients. METHODS Severely injured trauma patients requiring intensive care unit treatment and receiving transfusion of PRBCs within 24 hours of the injury were recruited. Blood samples were obtained within 2 hours of the trauma, at 24 hours, and at 72 hours. Messenger RNA was extracted from whole blood, and gene expression was quantified using quantitative polymerase chain reaction. The median age of the units of PRBCs transfused to each patient was recorded. The primary outcome measure was the change in candidate gene expression over the initial 72 hours. RESULTS Sixty-four patients were studied. Fifty-three patients (83%) were male, and the median age was 40.5 years (interquartile range [IQR], 31-59). Median Injury Severity Score (ISS) was 31.5 (IQR, 23-43), and 55 patients (86%) experienced a blunt injury. Forty-one patients (64%) developed a nosocomial infection, and 15 patients (23%) died before hospital discharge. Each patient received a median of 5 U of PRBCs (IQR, 4-9.8 U) during the first 24 hours of hospital admission. The median age of the units of PRBCs transfused in each patient was 20 days (IQR, 17-22 days). Older blood was associated with greater decreases in interleukin 12 (IL-12), IL-23, and RORγt (all p's < 0.05) gene expression over the initial 24 hours, greater decreases in IL-12 gene expression over 72 hours, and a rise in transforming growth factor β gene expression over the first 72 hours. A multivariate analysis confirmed the independence of these associations. CONCLUSION Increasing the duration of storage of PRBCs before transfusion is associated with a pattern of gene expression consistent with more severe immunosuppression. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Brouse C, Ortiz D, Su Y, Oronsky B, Scicinski J, Cabrales P. Impact of hemoglobin nitrite to nitric oxide reductase on blood transfusion for resuscitation from hemorrhagic shock. Asian J Transfus Sci 2015; 9:55-60. [PMID: 25722574 PMCID: PMC4339933 DOI: 10.4103/0973-6247.150952] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Transfusion of blood remains the gold standard for fluid resuscitation from hemorrhagic shock. Hemoglobin (Hb) within the red blood cell transports oxygen and modulates nitric oxide (NO) through NO scavenging and nitrite reductase. Aims: This study was designed to examine the effects of incorporating a novel NO modulator, RRx-001, on systemic and microvascular hemodynamic response after blood transfusion for resuscitation from hemorrhagic shock in a hamster window chamber model. In addition, to RRx-001 the role of low dose of nitrite (1 × 10−9 moles per animal) supplementation after resuscitation was studied. Materials and Methods: Severe hemorrhage was induced by arterial controlled bleeding of 50% of the blood volume (BV) and the hypovolemic state was maintained for 1 h. The animals received volume resuscitation by an infusion of 25% of BV using fresh blood alone or with added nitrite, or fresh blood treated with RRx-001 (140 mg/kg) or RRx-001 (140 mg/kg) with added nitrite. Systemic and microvascular hemodynamics were followed at baseline and at different time points during the entire study. Tissue apoptosis and necrosis were measured 8 h after resuscitation to correlate hemodynamic changes with tissue viability. Results: Compared to resuscitation with blood alone, blood treated with RRx-001 decreased vascular resistance, increased blood flow and functional capillary density immediately after resuscitation and preserved tissue viability. Furthermore, in RRx-001 treated animals, both mean arterial pressure (MAP) and met Hb were maintained within normal levels after resuscitation (MAP >90 mmHg and metHb <2%). The addition of nitrite to RRx-001 did not significantly improve the effects of RRx-001, as it increased methemoglobinemia and lower MAP. Conclusion: RRx-001 alone enhanced perfusion and reduced tissue damage as compared to blood; it may serve as an adjunct therapy to the current gold standard treatment for resuscitation from hemorrhagic shock.
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Affiliation(s)
| | - Daniel Ortiz
- Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Yan Su
- Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA
| | | | | | - Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA
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Ilancheran A, Rahman F, Mitra B. Indications for blood transfusion following trauma - a pilot study. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2015. [DOI: 10.5339/jemtac.2015.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation. Design and method: This was a prospective, observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion. Results: Complete data on 37 individual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of < 100 mm Hg (65%), pre-hospital tachycardia (38%) or estimated blood loss of >1 L (30%) by paramedics. On arrival to hospital, the activation of a massive transfusion protocol was the commonest indication for transfusion, followed by a positive FAST examination (43%), low systolic blood pressure (35%), tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy. Conclusions: A combination of objective pre- and in-hospital vital signs, together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury.
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Affiliation(s)
- Arun Ilancheran
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
| | - Fatima Rahman
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
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Agerstrand CL, Burkart KM, Abrams DC, Bacchetta MD, Brodie D. Blood Conservation in Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. Ann Thorac Surg 2015; 99:590-5. [DOI: 10.1016/j.athoracsur.2014.08.039] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 08/18/2014] [Accepted: 08/25/2014] [Indexed: 01/28/2023]
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da SilveiraCavalcante L, Acker JP, Holovati JL. Differences in Rat and Human Erythrocytes Following Blood Component Manufacturing: The Effect of Additive Solutions. Transfus Med Hemother 2015. [PMID: 26195928 DOI: 10.1159/000371474] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Small animal models have been previously used in transfusion medicine studies to evaluate the safety of blood transfusion products. Although there are multiple studies on the effects of blood banking practices on human red blood cells (RBCs), little is known about the effect of blood component manufacturing on the quality of rat RBCs. METHODS Blood from Sprague-Dawley rats and human volunteers (n = 6) was collected in CPD anticoagulant, resuspended in SAGM or AS3, and leukoreduced. In vitro quality was analyzed, including deformability, aggregation, microvesiculation, phosphatidylserine (PS) expression, percent hemolysis, ATP, 2,3-DPG, osmotic fragility, and potassium concentrations. RESULTS Compared to human RBCs, rat RBCs had decreased deformability, membrane rigidity, aggregability, and microvesiculation after component manufacturing process. Rat RBCs in SAGM showed higher hemolysis compared to human RBCs in SAGM (rat 4.70 ± 0.83% vs. human 0.34 ± 0.07%; p = 0.002). Rat RBCs in AS3 had greater deformability and rigidity than in SAGM. The number of microparticles/µl and the percentage PS expression were lower in rat RBCs in AS3 than in rat RBCs in SAGM. Hemolysis was also significantly lower in AS3 compared to SAGM (2.21 ± 0.68% vs. 0.87 ± 0.39%; p = 0.028). CONCLUSION Rat RBCs significantly differ from human RBCs in metabolic and membrane-related aspects. SAGM, which is commonly used for human RBC banking, causes high hemolysis and is not compatible with rat RBCs.
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Affiliation(s)
- Luciana da SilveiraCavalcante
- Canadian Blood Services Centre for Innovation, Edmonton, AB, Canada ; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Jason P Acker
- Canadian Blood Services Centre for Innovation, Edmonton, AB, Canada ; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Jelena L Holovati
- Canadian Blood Services Centre for Innovation, Edmonton, AB, Canada ; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
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Transfusion de concentrés globulaires en réanimation : moins, c’est mieux ! MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-014-1015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Patients in the perioperative period and intensive care unit are commonly exposed to blood transfusion (BT). They are at increased risk of transfusion transmitted bacterial, viral and protozoal diseases. The risk of viral transmission has decreased steadily, but the risk of bacterial transmission remains same. Bacterial contamination is more in platelet concentrates than in red cells and least in plasma. The chances of sepsis, morbidity and mortality depend on the number of transfusions and underlying condition of the patient. Challenges to safe BT continue due to new emerging pathogens and various management problems. Strategies to restrict BT, optimal surgical and anaesthetic techniques to reduce blood loss and efforts to develop transfusion alternatives should be made. Literature search was performed using search words/phrases blood transfusion, transfusion, transfusion transmitted diseases, transfusion transmitted bacterial diseases, transfusion transmitted viral diseases, transfusion transmitted protozoal diseases or combinations, on PubMed and Google Scholar from 1990 to 2014.
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Affiliation(s)
- Rekha Das
- Department of Anaesthesiology, Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India
| | - Upendra Hansda
- Department of Anaesthesiology, Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India
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Zheng Y, Lu C, Wei S, Li Y, Long L, Yin P. Association of red blood cell transfusion and in-hospital mortality in patients admitted to the intensive care unit: a systematic review and meta-analysis. Crit Care 2014; 18:515. [PMID: 25394759 PMCID: PMC4256753 DOI: 10.1186/s13054-014-0515-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/28/2014] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Previous research has debated whether red blood cell (RBC) transfusion is associated with decreased or increased mortality in patients admitted to the intensive care unit (ICU). We conducted a systematic review and meta-analysis to assess the relationship of RBC transfusion with in-hospital mortality in ICU patients. METHODS We carried out a literature search on Medline (1950 through May 2013), Web of Science (1986 through May 2013) and Embase (1980 through May 2013). We included all prospective and retrospective studies on the association between RBC transfusion and in-hospital mortality in ICU patients. The relative risk for the overall pooled effects was estimated by random effects model. Sensitivity analyses were conducted to assess potential bias. RESULTS The meta-analysis included 28,797 participants from 18 studies. The pooled relative risk for transfused versus nontransfused ICU patients was 1.431 (95% CI, 1.105 to 1.854). In sensitivity analyses, the pooled relative risk was 1.211 (95% CI, 0.975 to 1.505) if excluding studies without adjustment for confounders, 1.178 (95% CI, 0.937 to 1.481) if excluding studies with relative high risk of bias, and 0.901 (95% CI, 0.622 to 1.305) if excluding studies without reporting hazard ratio (HR) or relative risk (RR) as an effect size measure. Subgroup analyses revealed increased risks in studies enrolling patients from all ICU admissions (RR 1.513, 95%CI 1.123 to 2.039), studies without reporting information on leukoreduction (RR 1.851, 95%CI 1.229 to 2.786), studies reporting unadjusted effect estimates (RR 3.933, 95%CI 2.107 to 7.343), and studies using odds ratio as an effect measure (RR 1.465, 95%CI 1.049 to 2.045). Meta-regression analyses showed that RBC transfusion could decrease risk of mortality in older patients (slope coefficient -0.0417, 95%CI -0.0680 to -0.0154). CONCLUSIONS There is lack of strong evidence to support the notion that ICU patients who receive RBC transfusion have an increased risk of in-hospital death. In studies adjusted for confounders, we found that RBC transfusion does not increase the risk of in-hospital mortality in ICU patients. Type of patient, information on leukoreduction, statistical method, mean age of patient enrolled and publication year of the article may account for the disagreement between previous studies.
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Affiliation(s)
- Yi Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Caihong Lu
- Department of ENT department, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Shiqing Wei
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Ye Li
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Lu Long
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
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