Treatment of anemia in patients with HIV Infection--Part 2: guidelines for management of anemia.

The key treatment goal for managing anemia in patients infected with HIV is to maintain an improved or normal hemoglobin level. Whenever possible, the identification and treatment of the underlying cause of anemia is the primary therapeutic strategy. After excluding other etiologies, the Nursing Guidelines Committee for Anemia in Patients With HIV Infection has recommended that patients with mild asymptomatic anemia (hemoglobin level = 1 g/dl below the lower limit of the normal range) receive nutritional support and more frequent screening. Recombinant human erythropoietin (epoetin alfa) therapy is an appropriate treatment option for patients with symptomatic mild anemia or moderate anemia (hemoglobin level = 2 g/dl below the lower limit of the normal range). An immediate blood transfusion may be required under specific instances for patients with severe anemia (hemoglobin level less than or equal to 8 g/dl).     

Reliability of HemoCue in patients with gastrointestinal bleeding

Objective HemoCue is routinely used to manage bleeding patients, but few studies have evaluated its accuracy in this population. We compared HemoCue with laboratory determination of blood hemoglobin in patients with gastrointestinal bleeding. Design and setting A prospective observational study in a 14-bed medicosurgical ICU and an emergency department in an urban general hospital. Patients 94 patients admitted to the emergency department or to the ICU for gastrointestinal bleeding. Interventions Blood was drawn at admission to measure laboratory hemoglobin and capillary hemoglobin was measured simultaneously by HemoCue. The unit of hospitalization and the presence or absence of impaired vital signs (tachycardia and/or hypotension and/or shock) were recorded. Measurements and results The mean difference between HemoCue and hemoglobin (bias) was −0.06 g/dl and standard deviation (precision) 0.87 g/dl. (95% CI −1.8 to 1.68). Discrepancies between HemoCue and hemoglobin were greater than 1 g/dl in 21% of cases. Bias was comparable between patients admitted to the ICU and those in the emergency department. The accuracy of HemoCue was not affected by the presence of impaired vital signs or by a hemoglobin level below 9 g/dl or 7 g/dl. Conclusions Although we demonstrated a low bias between HemoCue and blood hemoglobin determination, large HemoCue vs. hemoglobin differences may still occur, and therefore therapeutic decisions based upon capillary HemoCue alone should be very cautious.     

Blood transfusion policy among European pediatric intensive care physicians

The objective of this study was to define current blood transfusion practices among European pediatric intensive care physicians treating critically ill children. A questionnaire of case scenarios was administered to members of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Of the 258 members of the ESPNIC, 134 (51.9%) pediatric intensive care physicians completed the questionnaire. The suggested blood transfusion thresholds for case scenario 1 (post-orthopedic surgery child) ranged from <7.0 g/dl to 11 g/dl. A total of 57.3% suggested 7 g/dl, 33.6% suggested 8 g/dl, and 6.9% suggested 9 g/dl as a hemoglobin threshold for transfusion (mean, 7.54 +/- 0.75). For case scenarios 2 to 4, the suggested hemoglobin thresholds were 7 g/dl to 12 g/dl. For case scenario 2 (a child with acute respiratory distress syndrome), 22.4% suggested 8 g/dl, 15.7% suggested 9 g/dl, and 41% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 9.40 +/- 1.27 g/dl). For case scenario 3 (a post-cardiac surgery infant), 20.1% suggested 7 g/dl, 24.6% suggested 8 g/dl, 21.6% suggested 9 g/dl, and 23.9% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 8.72 +/- 1.24 g/dl). For case scenario 4 (a child with septic shock), 23.1% suggested 8 g/dl, 16.4% suggested 9 g/dl, and 41% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 9.45 +/- 1.24 g/dl). The threshold for transfusion was not statistically different (P >.05) between the physicians according to their subspecialty, years of experience, or country of origin. The suggested volume of transfused blood was 10 to 15 ml/kg in 427 responses (82.6%) and 20 ml/kg in 89 responses (17.2%). Most physicians, 78/128 (60.9%), did not consider the age of the transfused blood an important factor in their decision to transfuse. Of the 106 (79.1%) physicians who detailed their considerations for elevating the threshold for transfusion, 82 (77.3%) gave a general nonspecific indication, 47 (44.3%) stated hemodynamic instability and shock, and 40 (37.7%) an ongoing bleeding. The hemoglobin threshold for blood transfusion and transfusion volume varies among European pediatric intensive care physicians, for the same patient.     

Impact of anemia on outcome in critically ill patients with severe acute renal failure

Objective To evaluate the prognostic value of hemoglobin levels in critically ill patients with acute renal failure (ARF) requiring dialysis.Design and setting A prospective observational cohort study in two adult medical ICUs.Patients 206 consecutive patients with ARF who required dialysis. Overall 28-day mortality was 48%.Measurements and results At ICU admission mean hemoglobin level was 9.1±2.1 g/dl. By ROC curve analysis the threshold value of hemoglobin with the highest sensibility/specificity was 9 g/dl. At baseline 63% of patients had anemia, defined as initial hemoglobin below 9 g/dl. Kaplan-Meier analysis showed that these patients had lower survival rate than those with hemoglobin above 9 g/dl. By multivariable analysis three factors were independently associated with 28-day death: hemoglobin lower than 9 g/dl (adjusted odds ratio 2.4, 95% CI 1.1–5.2), age, and SOFA score. Based on age and SOFA a matched cohort analysis of 67 pairs of ARF patients with or without anemia found similar results regarding the negative impact of anemia on outcome. Finally, a multivariable logistic regression analysis on matched cohort identified hemoglobin level below 9 g/dl (adjusted odds ratio 1.32, 95%CI 1.15–1.46), continuous renal replacement therapy, and vasoactive therapy as independent predictors of 28-day death.Conclusions These results suggest that initial hemoglobin level could be helpful in identifying patients with ARF requiring dialysis at high risk of death.This article refers to the editorial     

Efficacy of recombinant human erythropoietin in critically ill patients admitted to a long-term acute care facility: a randomized, double-blind, placebo-controlled trial

CONTEXT: Anemia is common in the critically ill and results in a large number of red blood cell transfusions. Recent data have shown that red blood cell transfusions in critically ill patients can be decreased with recombinant human erythropoietin (rHuEPO) therapy during their intensive care unit stay. OBJECTIVE: To assess the efficacy of rHuEPO therapy in decreasing the occurrence of red blood cell transfusions in patients admitted to a long-term acute care facility (LTAC). DESIGN: A prospective, randomized, double-blind, placebo-controlled, multiple-center trial. SETTING: Two long-term acute care facilities. PATIENTS: A total of 86 patients who met eligibility criteria were enrolled in the study with 42 randomized to rHuEPO and 44 to placebo. INTERVENTIONS: Study drug (rHuEPO 40,000 units) or a placebo was administered by subcutaneous injection before day 7 of long-term acute care facility admission and continued weekly for up to 12 doses. MAIN OUTCOME MEASURES: The primary efficacy end point was cumulative red blood cell units transfused. Secondary efficacy end points were the percent of patients receiving any red blood cell transfusion; the percent of patients alive and transfusion independent; cumulative mortality; and change in hematologic variables from baseline. Logistic regression was used to adjust the odds ratio for red blood cell transfusion. All end points were assessed at both study day 42 and study day 84. RESULTS: The baseline hemoglobin level was higher in the rHuEPO group (9.9 +/- 1.15 g/dL vs. 9.3 +/- 1.41 g/dL, p = .02) as was the pretransfusion hemoglobin level (8.0 +/- 0.5 g/dL vs. 7.5 +/- 0.8 g/dL, p = .04). At day 84, patients receiving rHuEPO received fewer red blood cell transfusions (median units per patient 0 vs. 2, p = .05), and the ratio of red blood cell transfusion rates per day alive was 0.61 with 95% confidence interval of 0.2, 1.01, indicating a 39% relative reduction in transfusion burden for the rHuEPO group compared with placebo. There was also a trend at day 84 toward a reduction in the total units of red blood cells transfused in the rHuEPO group (113 units of placebo vs. 73 units of rHuEPO). Patients receiving rHuEPO were also less likely to be transfused (64% placebo vs. 41% rHuEPO, p = .05; adjusted odds ratio 0.47, 95% confidence interval 0.19, 1.16). Most of the transfusion benefit of rHuEPO occurred by study day 42. Increase in hemoglobin from baseline to final was greater in the rHuEPO group (1.0 +/- 2 g/dL vs. 0.4 +/- 1.7 g/dL, p < .001). Mortality rate (19% rHuEPO, 29.5% placebo, p = .17; relative risk, 0.55, 95% confidence interval 0.21-1.43) and serious adverse clinical events (38 % rHuEPO, 32% placebo, p = .65) were not significantly different between the two groups. CONCLUSIONS: In patients admitted to a long-term acute care facility, administration of weekly rHuEPO results in a significant reduction in exposure to allogeneic red blood cell transfusion during the initial 42 days of rHuEPO therapy, with little additional benefit achieved with therapy to 84 days. Despite receiving fewer red blood cell transfusions, patients treated with rHuEPO achieve a higher hemoglobin level.     

The effectiveness and tolerability of epoetin alfa in patients with multiple myeloma refractory to chemotherapy

Anemia is a frequent complication of multiple myeloma, becoming chronic in patients who are resistant to chemotherapy. This randomized, parallel, controlled multicenter study (71 patients receiving concomitant chemotherapy) evaluated the efficacy and safety of epoetin alfa in improving anemia and eliminating the need for transfusions in multiple myeloma patients refractory to conventional first- or second-line chemotherapy. Forty patients were treated with subcutaneous epoetin alfa (150 IU/kg per dose, increasing to 300 IU/kg per dose, every 3 weeks) for 6 months, and 31 entered a control group. The epoetin alfa group had a significantly (P≤0.001) greater percentage of patients (75% vs. 21%) with increases in hemoglobin levels and/or reduced transfusion requirements. In 44 non pre-transfused patients (20 controls, 24 in the epoetin alfa group), the mean increase in hemoglobin was significantly (P≤0.0001) greater in the epoetin alfa group (+2.1 vs. −0.2 g/dl). Increases in hematocrit and red blood cells were also significantly (P≤0.0001) greater in epoetin alfa-treated patients, with corresponding reductions in transfusion requirement. In the 27 pre-transfused patients (11 controls, 16 in the epoetin alfa group), there was a trend towards reduced transfusional need in epoetin alfa-treated patients. Thus, in patients with multiple myeloma refractory to chemotherapy epoetin alfa is a well-tolerated treatment which improves anemia in non pre-transfused patients and appears to reduce transfusion need in those previously transfused.     

Changes in regional blood flow and pCO(2) gradients during isolated abdominal aortic blood flow reduction

Objective pCO₂ gradients are used for the assessment of splanchnic regional and local mucosal blood flow changes in experimental and clinical research. pCO₂ gradients may not parallel blood flow changes because of concomitant changes in metabolism, hemoglobin, temperature, and the Haldane effect.Design and setting A randomized, controlled animal experiment in a university experimental research laboratory.Interventions An extracorporeal shunt with reservoir and roller pump was inserted between the proximal and the distal abdominal aorta in 16 pigs. In animals randomized to the low-flow group (n=8) splanchnic perfusion was reduced by running the roller pump. At baseline and after 45 min of stable shunt flow superior mesenteric artery, celiac trunk, spleen artery, and portal vein blood flows and regional venous-arterial and jejunal and gastric mucosal-arterial pCO₂ gradients were measured, and the respective regional O₂ consumption rates (VO₂) calculated.Measurements and results In the low-flow group all regional blood flows and the associated VO₂ decreased to roughly 50% of baseline values, and hemoglobin decreased from 7.3 (4.4–9.6) g/dl to 5.7 (4.1–8.9) g/dl. Decreasing regional blood flows were consistently associated with increasing regional and mucosal pCO₂ gradients.Conclusions During isolated reduction in abdominal aortic blood flow there is no preferential distribution to any splanchnic vascular bed and changes in regional pCO₂ gradients reflect consistently the associated blood blow changes.An editorial regarding this article can be found in the same issue ()This research was supported in part by grant 3200-061988 by the Swiss National Fund. The study was performed at the Surgical Research Unit, Department of Clinical Research and Clinic for Large Animals, University of Berne, Switzerland     

Erythropoietin as adjuvant to pre-operative autologous blood donation in total hip arthroplasty: new algorithm for use.

Erythropoietin (rhEPO) has been used in different surgical procedures as a method for saving allogeneic blood, with variable efficacy. Forty consecutive patients entered the pre-operative autologous blood donation (PABD) program, and during donations hemoglobin fell below 115 g/l; they received rhEPO 40,000 U every week for three or four weeks (group 1). As control group, 35 consecutive patients who entered the PABD program were studied; during donations, hemoglobin levels in these patients fell below 115 g/l, but rhEPO was not administered (group 2). Pre-surgery hemoglobin levels were higher in patients who received rhEPO (134 g/l vs. 121 g/l; p<0.0002), and an average of 3.47 doses were administered. The number of transfused autologous units was 1.6 in group 1 and 2.1 in group 2 (p<0.05), while the number of allogeneic units was 0.9 and 0.1, respectively (p<0.0005), so that only 5% of patients treated with rhEPO required some allogeneic unit, as compared to 40% of those who did not receive rhEPO (p<0.0005). There were no relevant adverse effects, but in two patients from group 1, rhEPO treatment had to be discontinued because the level of hemoglobin exceeded 150 g/l. The mean duration of hospital admission was shorter in the patients who received rhEPO than in those who only underwent PABD (8 days vs. 11.8 days; NS). When adequately used, rhEPO is an effective and safe alternative to the use of allogeneic blood.     

Autotransfusion with previously deposited blood units

This article analyzes the results obtained in the development of a Prior Deposited Self-Transfusion Program among patients who plan to have orthopedic or kidney surgery. The 69 patients in this program deposited 183 blood unit, 2.6 units/patients with a range of 1 to 5, of which 153 were transfused. The initial hemoglobin and hematocrit levels were 14.3 g/dl (range 11.4-16.8) and 43.3% (range 36-50) respectively; at the end of this self-transfusion program, these values were 12.4 g/dl (range 10.0-15.6) and 37.7% (range 31-48). A homologous transfusion was avoided in 88.4% of the cases. This Self-Transfusion Program is safe and effective, easy to implement, well-tolerated and can be carried out with an acceptable risk level for patients.     

Use of face mask by blood donors during the COVID-19 pandemic: Impact on donor hemoglobin concentration: A bane or a boon

BackgroundCOVID-19 virus has caused the world’s deadliest pandemic. Early April 2020, the Delhi Government made it compulsory for people to wear face masks while going outdoors to curb disease spread. Prolonged use of surgical masks during the pandemic has been reported to cause many adverse effects. Intermittent hypoxia has been shown to activate erythropoietin (EPO leading to increased hemoglobin mass.AimTo analyze whether face mask induced intermittent hypoxia has any effect on the hemoglobin levels of healthy blood donors.Materials and methodsWe retrospectively analyzed donor data from 1st July 2019-31st December 2020 for hemoglobin distribution across hemoglobin ranges and donor deferral on basis of hemoglobin. Study population was divided into two cohorts Group 1- (1st July 2019-31 st March 2020): before implementation of mandatory face masks Group 2- (1st April 2020-31 st December 2020): after implementation of mandatory face masksResultsMean Hb of blood donors in Group 2 (15.01 ± 1.1 g/dl) was higher than Group1 (14.49 ± 1.15 g/dl), (p < 0.0001). 47.1 % group2 donors had Hb of 16.1−18 g/dl compared to group1 (38.4 %). 52.9 % group 2 donors had Hb between 12.5−15 g/dl compared to 61.6 % Group 1 (p < 0.05). Deferral due to anemia was lesser in group 2 compared to group 1 (p < 0.00001). Group 2 had significantly higher deferral due to high Hb (>18 gm/dl) was than Group 1 (p = 0.0039).ConclusionThis study including 19504 blood donors spanning over one and a half year shows that prolonged use of face mask by blood donors may lead to intermittent hypoxia and consequent increase in hemoglobin mass.     

Postoperative transfusion hemoglobin threshold and functional recovery after high-risk oncologic surgery: A randomized controlled pilot study

Background

Robust evidence to inform best transfusion management after major oncologic surgery, where postoperative recovery might impact treatment regimens for cancer, is lacking. We conducted a study to validate the feasibility of a larger trial comparing liberal versus restrictive red blood cells (RBC) transfusion strategies after major oncologic surgery.

Study Design and Methods

This was a two-center, randomized, controlled, study of patients admitted to the intensive care unit after major oncologic surgery. Patients whose hemoglobin level dropped below 9.5 g/dL, were randomly assigned to immediately receive a 1-unit RBC transfusion (liberal) or delayed until the hemoglobin level dropped below 7.5 g/dL (restrictive). The primary outcome was the median hemoglobin level between randomization to day 30 post-surgery. Disability-free survival was evaluated by the WHODAS 2.0 questionnaire.

Results

30 patients were randomized (15 patients/group) in 15 months with a mean recruitment rate of 1.8 patients per month. The median hemoglobin level was significantly higher in the liberal group than in the restrictive group: 10.1 g/dL (IQR 9.6–10.5) versus 8.8 g/dL (IQR 8.3–9.4), p < .001, and RBC transfusion rates were 100% versus 66.7%, p = .04. The disability-free survival was similar between groups: 26.7% versus 20%, p = 1.

Discussion

Our results support the feasibility of a phase 3 randomized controlled trial comparing the impact of liberal versus restrictive transfusion strategies on the functional recovery of critically ill patients following major oncologic surgery.     

Administration of recombinant human erythropoietin alpha before autologous stem cell transplantation reduces transfusion requirement in multiple myeloma patients

Recombinant human erythropoietin administered after peripheral blood stem cell transplantation (PBSCT) has been ineffective for the treatment of anemia. We administered recombinant human erythropoietin alpha (rHuEPO) prior to high-dose therapy after peripheral blood stem cell (PBSC) collection to evaluate its efficacy on transfusion requirements and hematological parameters during the post-transplant aplastic phase. Twenty-two multiple myeloma patients (EPO-MM) were included in the trial to receive rHuEPO 10,000 IU subcutaneous daily starting 30 days before PBSCT. Forty hemoglobin (Hb)-matched patients who had not received rHuEPO before transplant were retrospectively selected (Ctr-MM) for comparative data. None of the patients received transfusions at study entry. All but one patient responded to rHuEPO. However, no significant differences in Hb levels were obtained between the two groups at the time of transplantation. At nadir, the EPO-MM cases had a significantly higher Hb level (median 10 g/dl versus 7.6 g/d; p=0.001). Consequently, less than 20% of EPO-MM patients required packed red blood cell (PRBC) transfusions compared to more than half the Ctr-MM patients (p=0.007). Furthermore, the number of PRBC transfusions performed in the EPO-MM group was significantly lower (median 0 versus 1; p=0.008). Independently of Hb levels at PBSCT, rHuEPO therapy was significantly associated with a lower risk of transfusion requirement. In conclusion, rHuEPO is shown to be effective when administered prior to high-dose therapy in MM.     

Important role of nondiagnostic blood loss and blunted erythropoietic response in the anemia of medical intensive care patients

OBJECTIVE: To determine incidence, severity, characteristics, and causes of anemia and transfusion requirements in medical intensive care patients. DESIGN AND SETTING: Open prospective clinical study in a 24-bed medical intensive care unit in a tertiary-care university hospital. PATIENTS: Patients (N = 96) treated in the intensive care unit for >3 days. INTERVENTIONS: None. MEASUREMENTS: Parameters of erythropoiesis and red blood cell metabolism, including hemoglobin, reticulocyte counts, serum iron, transferrin, ferritin, haptoglobin, vitamin B12, folic acid, and erythropoietin concentrations were determined serially. Diagnostic blood loss and red blood cell transfusions were recorded, and the total blood loss was estimated from changes in hemoglobin concentrations and the amount of hemoglobin transfused. MAIN RESULTS: The median hemoglobin concentration was 12.1 g/dL at admission and 11.2 g/dL at the end of the intensive care unit stay. A total of 74 patients (77%) suffered from anemia and received 257 red blood cell units, approximately half of which were given within the first 5 days. Three patients who received 19 red blood cell units were admitted with acute gastrointestinal bleeding, but in the remainder, a median total blood loss of 128 mL/d was not (n = 60) or not solely (n = 11) a result of overt bleeding. Diagnostic blood loss declined from a median of 41 mL on day 1 to <20 mL after 3 wks and contributed 17% (median) to total blood loss. Acute renal failure, fatal outcome, and simplified acute physiology score >38 on admission were associated with a 5.8-, 7.0-, and 2.8-fold increase in total blood loss. Reticulocyte counts and erythropoietin concentrations were inappropriately low for the degree of anemia, and plasma transferrin saturation was mostly <20%. CONCLUSIONS: Anemia is frequent and results in a high requirement for red blood cell transfusions in the medical intensive care setting. A major proportion of blood loss is not caused by overt bleeding or diagnostic blood sampling but, rather, may result from various other reasons, e.g., occult gastrointestinal bleeding and renal replacement therapy. The erythropoietic response to anemia is blunted, probably as a consequence of an inappropriate increase in erythropoietin production and diminished iron availability. (Crit Care Med 1999; 27:2630-2639) KEY WORDS: anemia; iatrogenic; blood loss; red blood cell transfusion; transfusion prediction; erythropoietin; reticulocytes; hemolysis; hemoglobin; iron; critical care; intensive care     

Value of the plasma protein and hemoglobin concentration in the diagnosis of pulmonary edema in scorpion sting patients

OBJECTIVE: To investigate the value of measuring total plasma protein and hemoglobin concentrations for the diagnosis of pulmonary edema secondary to scorpion envenomation. DESIGN AND SETTING: Retrospective study over a 4-year period in the medical intensive care unit of a university hospital. PATIENTS: 67 patients older than 3 years admitted in the intensive care unit for scorpion envenomation and stratified into two groups according to the presence of pulmonary edema assessed by a medical committee that took into account clinical, radiological, and blood gas data at admission and after treatment. Total plasma protein and hemoglobin concentrations were analyzed separately. RESULTS: At admission all patients with and without pulmonary edema exhibited polypnea and tachycardia. The mean plasma protein and hemoglobin concentrations were higher in patients with pulmonary edema (74+/-6 and 14.2+/-2.0 g/dl, respectively) than in those without pulmonary edema (64+/-6 and 12.3+/-1.4 g/dl). After 24 h plasma protein and hemoglobin concentrations decreased in the pulmonary edema group (-11 and -1.9 g/dl) despite a negative fluid balance (-500 ml). A plasma protein concentration of 70 g/l or more predicted the presence of pulmonary edema with a sensitivity of 80% a specificity of 96%, a positive predictive value of 97%, and negative predictive value of 77%. CONCLUSIONS: In scorpion-envenomed patients with cardiorespiratory manifestations high plasma protein and hemoglobin concentrations suggest the presence of pulmonary edema.     

Relationship of thyroid function to post-traumatic S-100b serum levels in survivors of severe head injury: preliminary results

Objective To assess thyroid function abnormalities in survivors of severe head trauma and to examine their relationship with indices of brain injury severity.Design Prospective study.Setting General intensive care unit (ICU) in a university hospital.Patients and participants Twenty-two (21 men) head-injured patients, with a median age of 25.5 years at the time of injury, were investigated. Severity of brain trauma was assessed by Glasgow Coma Scale (GCS) score, Marshall Computerized Tomographic Classification, intracranial pressure levels and serum S-100b concentrations measured over a 6-day period.Interventions Thyroid function testing was performed 1 year after ICU discharge and included the measurement of free thyroxine, triiodothyronine and thyrotropin.Measurements and results On admission to the ICU, GCS ranged from 3 to 8. Peak S-100b was 1.49 µg/l (range: 0.37–5.26 µg/l). Median triiodothyronine and thyrotropin were 123 ng/dl and 1.60 IU/ml, respectively. Free thyroxine was 1.08±0.22 ng/dl (range: 0.7–1.5 ng/dl). Overall, 7 of the 22 patients (32%) had thyroid dysfunction. Four patients had central hypothyroidism and three patients had subclinical hypothyroidism. Peak S-100b correlated negatively with free thyroxine (r=–0.47, p=0.02). There were no correlations between other brain injury severity indices and thyroid hormone levels.Conclusions A significant subset of brain injury patients presents with changes in thyroid function 1 year after ICU discharge; these depend upon biochemical serum markers of head trauma severity.     

Advantages and disadvantages of different nasal CPAP systems in newborns

Objective To compare three different systems of continuous positive airway pressure (CPAP): the naso-pharyngeal tube and two-prong systems in newborns, focusing on duration of CPAP, side effects and cost.Design Randomized clinical study.Patients Between July 2000 and September 2001 newborns were randomized to three different CPAP systems. Forty infants in two weight groups (>2500 g and 1250–2500 g; 20 patients in each group) were included.Results In the group >2500 g the median duration of CPAP was 1.1 days (range 0.25–14.3 days). The median time on a naso-pharyngeal CPAP was 1 day (range 0.25–14.3 days), on Hudson prongs 1.6 days (range 0.5–3.3 days) and on the Infant Flow system 0.7 days (range 0.3–13.6 days; p>0.05 for comparison between groups, Fishers exact test). With naso-pharyngeal CPAP, 2 patients developed moderate nasal injuries. On Hudson, 2 patients developed moderate and three mild nasal injuries. One patient on the Infant Flow showed mild and one moderate nasal injuries. In the weight group 1250–2500 g the median duration of CPAP was 1.1 days (range 0.1–7.0 days). The median time on the naso-pharyngeal tube was 0.9 days (range 0.1–7 days), on Hudson prongs 1.1 days (range 0.7–6.6 days) and on the Infant Flow system 1.3 days (range 0.25–5.9 days; p>0.05 for comparison between groups, Fishers exact test). With a naso-pharygeal tube, one infant developed mild and one moderate nasal injuries. On Hudson prongs, two had moderate nasal injuries. On Infant Flow, one newborn showed a severe nasal injury and two mild injuries. None of the patients developed a pneumothorax.Conclusion The naso-pharyngeal tube is an easy, safe and economical CPAP system usable with every common ventilator. For very low birth weight newborns, a prong system may have advantages.     

TRANSFUSION IN THE MANAGEMENT OF PATIENTS WITH MEGALOBLASTIC ANAEMIA

Transfusion has been associated with significant morbidity and mortality in megaloblastic anaemia (MA). This retrospective study was undertaken to examine the usefulness of transfusion in the management of MA. Fifty-two patients with MA were identified. Of the 20 transfused patients 13 were treated with diuretics and six with potassium supplements. The mean haemoglobin (Hb) of the transfused group was 6.5 g/dl (range 4.8-10.4 g/dl), and of the 32 non-transfused patients 10.5 g/dl (range 5.6-17.0 g/dl). The Hb and packed cell volume (PCV) were significantly lower in the transfused group. Only two of 32 non-transfused group were given potassium supplements. In this small group of patients with MA, transfusion appeared to be safe and no complications of transfusion were identified. However, advice was not being followed. We would suggest that, although transfusion has a minor role in the management of MA, consideration must be given to the general hazards of transfusion.     

A pilot randomized trial comparing symptomatic vs. hemoglobin-level- driven red blood cell transfusions following hip fracture

BACKGROUND: The indications for transfusion have never been evaluated in an adequately sized clinical trial. A pilot study was conducted to plan larger clinical trials. STUDY DESIGN AND METHODS: Hip fracture patients undergoing surgical repair who had postoperative hemoglobin levels less than 10 g per dL were randomly assigned to receive 1) symptomatic transfusion: that is, transfusion for symptoms of anemia or for a hemoglobin level that dropped below 8 g per dL or 2) threshold transfusion: that is, patients receive 1 unit of packed RBCs at the time of random assignment and as much blood as necessary to keep the hemoglobin level above 10 g per dL. Outcomes were 60-day mortality, morbidity, functional status, and place of residence. RESULTS: Among 84 eligible patients enrolled, mean (± SD) prerandomization hemoglobin was 9.1 (± 0.6) g/ dL. The median number of units transfused in the threshold transfusion group was 2 (interquartile range, = 1–2), and that in the symptomatic transfusion group was 0 (6; interquartile range, = 0–2) (p < 0.001). Mean hemoglobin levels were approximately 1 g per dL higher in the threshold group than in the symptomatic group: for example, on Day 2, 10.3 (± 0.9) g per dL versus 9.3 (± 1.2) g per dL, respectively (p < 0.001). At 60 days, death or inability to walk across the room without assistance occurred in 16 (39.0%) of the symptomatic transfusion group and 19 (45.2%) of the threshold transfusion group. Death occurred by 60 days in 5 (11.9%) of the symptomatic transfusion group and 2 (4.8%) in the threshold transfusion group (relative risk = 2.5; 95% CI, 0.5–12.2). Other outcomes were similar for the two groups. CONCLUSIONS: Symptomatic transfusion may be an effective blood-sparing protocol associated with the transfusion of appreciably fewer units of RBCs and lower mean hemoglobin levels than are associated with the threshold transfusion policy. However, it is unknown whether these two clinical strategies have comparable mortality, morbidity, or functional status. A definitive trial is needed.     

Determinants of empiric transfusion in gastrointestinal bleeding in the emergency department

IntroductionCurrent guidelines for the management of GI bleeding (GIB) recommend restrictive transfusion triggers unless patients have shock or specific comorbidities. However, these studies may not be applicable to Emergency Department (ED) patients. Factors determining transfusion decisions in the ED are poorly understood. We compared baseline characteristics and outcomes between ED patients with GI bleeding transfused at lower or higher empiric hemoglobin levels.MethodsSingle center, retrospective analysis of hospital records from a large tertiary care center of ED patients diagnosed with GIB who underwent red blood cell transfusion in the ED. A pre-transfusion hemoglobin cutoff of 7 g/dl was used to divide patients into restrictive and empirically transfused groups. Demographics, mortality, hospital length-of-stay, and mortality risk estimates were compared between groups.Results175 patients met inclusion criteria, with 120 restrictive patients (68.5%) and 55 liberal patients (31.4%). The sample was 49.7% male, with mean age 67.2 years, similar between groups. Patients in the empiric transfusion group had more acute emergency severity index scores (2.09 vs. 2.3). No difference was found between groups in triage vital signs, pre-endoscopy Rockall scores or mortality estimates, or length of stay. Most common reasons for empiric transfusion from chart review were hypotension and witnessed large hemorrhage.ConclusionsPatients that were empirically transfused had similar presentations to patients meeting restrictive guidelines, based on review of triage data. Transfusions above restrictive thresholds occurred frequently in our population. Additional studies are required to clarify appropriate criteria to guide transfusions for GIB in the ED.     

Low-Titer Group O Whole-Blood Resuscitation in the Prehospital Setting in Israel: Review of the First 2.5 Years' Experience

IntroductionThe Israeli Defense Forces Medical Corps (IDF-MC) implemented the use of low-titer group O whole blood (LTOWB) as the first-choice resuscitation fluid in the IDF airborne Combat Search and Rescue Unit (IDF-CSAR) for aerial evacuation of both military and civilian casualties in June 2018 for injured patients with hemorrhagic shock and at least one of the following: systolic blood pressure <90 mm Hg, heart rate >130 beats/min, deterioration of consciousness without head injury or hemoglobin concentration ≤7 g/dL.MethodAll casualties treated with LTOWB by IDF-CSAR providers from June 2018 to January 2021 were included. Demographic and prehospital treatment data were collected in order to check compliance and adherence to the IDF-MC guidelines. This is a follow-up retrospective report.ResultsOverall, 1,608 LTOWB units were supplied to the IDF-CSAR during the study period. Of these, 33 were transfused to 27 casualties; 17 (69%) with blunt injury, 8 (29.6%) with penetrating injuries, and 1 (3.7%) with gastrointestinal bleeding without trauma. The leading cause of injury was motor vehicle accidents. A total of 23 casualties received 1 unit of LTOWB, 3 received 2 units and 1 patient received 4 units. Two casualties were children. The median heart rate was 120 beats/min, 8 (29.6%) casualties had heart rates >130 beats/min. Median systolic blood pressure was 95 mm Hg, 7 (26%) casualties had blood pressure <90 mm Hg. The median Glasgow Coma Score was 14. No adverse reactions were documented following the administration of LTOWB. 77.8% of patients received LTOWB in adherence to the guidelines.ConclusionAppropriate administration of LTOWB has improved over time in IDF-CSAR. Using LTOWB is feasible and simpler than administering packed red blood cells and plasma concurrently. Further efforts are needed to introduce LTOWB in other prehospital and in-hospital scenarios, with an increase in the maximum antibody titer threshold, to meet the expected increase in demand.