A simple program to improve the appropriateness of red blood cell transfusions in non-bleeding hospital patients: a before-and-after study.

Introduction: Transfusion of red blood cells (RBCs) is not devoid of risks; nor is anemia. The aim of the study was to assess the usefulness of a program designed to improve the appropriateness of RBC transfusions in hospital patients.Methods: We retrospectively analyzed time periods before and after program implementation. Results: Before program implementation 415 out of 23492 (1.8%) patients received at least 1 RBC, whereas after implementation 162 out of 25062 (0.6%) did so. The percentage of appropriate RBC transfusions increased from 23.6 to 37.1%. Conclusions: A simple program may lead to a 3-fold decrease in transfusion rate and a significant increase in the percentage of appropriate RBC transfusions.

Let Us Know Transfusion Triggers for Prophylactic Use of Platelet Concentrate-Analysis of Compliance with Recent Transfusion Guidelines in a Large Academic Medical Center.

Platelet concentrate (PC) is a blood component that is used to prevent or manage bleeding associated with thrombocytopenia or impaired platelet function. The aim of our study was to assess the compliance of ordering physicians with the most recent PC transfusion guidelines in our academic medical center. All PC transfusions performed between January 2019 and December 2022 were analyzed. The appropriateness of PC transfusions was assessed based on the most recent PC transfusion guidelines. During 2019-2022, there were 362 (0.2%) PC recipients out of 161,762 hospitalized patients. There were 971 PCs transfused during the analyzed period. Inappropriate transfusions accounted for 53.3% of cases, and most of them were given prophylactically (80.2%). Compliance with platelet transfusion guidelines varied among departments. The overall percentage of inappropriately transfused PC ranged from 50.7% to 60.8% in successive years. Educational activities should target clinicians performing procedures associated with high rates of inappropriate PC transfusions. Implementing clinical decision support systems can help reduce unnecessary PC transfusions and associated costs. The majority of inappropriate PC transfusions in our medical center were given as prophylaxis against bleeding. Prescribers should be educated about evidence-based transfusion triggers for the prophylactic use of PC in various clinical scenarios.

Appropriateness of Allogeneic Red Blood Cell Transfusions in Non-Bleeding Patients in a Large Teaching Hospital: A Retrospective Study.

In hemodynamically stable patients, both anemia and red blood cell (RBC) transfusion may be detrimental to patients; hence, a decision regarding RBC transfusion should be based on thorough risk-benefit assessment. According to hematology and transfusion medicine organizations, RBC transfusion is indicated when recommended hemoglobin (Hb) triggers are met, and symptoms of anemia are present. The aim of our study was to examine the appropriateness of RBC transfusions in non-bleeding patients at our institution. We performed a retrospective analysis of all RBC transfusions performed between January 2022 and July 2022. The appropriateness of RBC transfusion was based on the most recent Association for the Advancement of Blood and Biotherapies (AABB) guidelines and some additional criteria. The overall incidence of RBC transfusions at our institution was 10.2 per 1000 patient-days. There were 216 (26.1%) RBC units appropriately transfused and 612 (73.9%) RBC units that were transfused with no clear indications. The incidence of appropriate and inappropriate RBC transfusions were 2.6 and 7.5 per 1000 patient-days, respectively. The most frequent clinical situations when RBC transfusion was classified as appropriate were: Hb < 70 g/L plus cognitive problems/headache/dizziness (10.1%), Hb < 60 g/L (5.4%), and Hb < 70 g/L plus dyspnea despite oxygen therapy (4.3%). The most frequent causes of inappropriate RBC transfusions were: no Hb determination pre-RBC transfusion (n = 317) and, among these, RBC transfused as a second unit in a single-transfusion episode (n = 260); absence of anemia sings/symptoms pre-transfusion (n = 179); and Hb concentration ≥80 g/L (n = 80). Although the incidence of RBC transfusions in non-bleeding inpatients in our study was generally low, the majority of RBC transfusions were performed outside recommended indications. Red blood cell transfusions were evaluated as inappropriate mainly due to multiple-unit transfusion episodes, absence of anemia signs and/or symptoms pre- transfusion, and liberal transfusion triggers. There is still the need to educate physicians on appropriate indications for RBC transfusion in non-bleeding patients.

Hospital-Acquired Anemia in Patients Hospitalized in the Intensive Care Unit: A Retrospective Cohort Study.

Hospital-acquired anemia (HAA) is prevalent in patients hospitalized in the intensive care unit (ICU). Iatrogenic blood loss (IBL) may aggravate existing anemia or lead to a need for red blood cell (RBC) transfusion. The aim of our study was to analyze hemoglobin (Hb) concentration changes in up to 14 days, as well as all potential sources of IBL, in consecutive patients admitted to the intensive care unit (ICU) in the years 2020−2021. Patients admitted due to bleeding were excluded. Anemia on admission was present in 218 (58.8%) patients­47 (48.9%) surgical and 171 (62.2%) non-surgical (p = 0.02). Gradual decrease in Hb was seen in all ICU patients. Eighty-one (21.8%) patients required RBC transfusion. The first unit of RBC was transfused on day 7 (IQR 2−13) and the second on day 11 (IQR 4−15) of ICU hospitalization. The median admission Hb in patients who required RBC transfusion was 10.2 (IQR 8.5−11.8) and, in those who did not require transfusion, it was 12.0 (IQR 10.2−13.6) g/dL (p < 0.01). Anemia on admission was associated with a need for RBC transfusion (p < 0.01). Average decrease in Hb during the first week of ICU hospitalization in patients with and without anemia on admission was 1.2 (IQR 0.2−2.3) and 2.8 (IQR 1.1−3.8) g/dL (p < 0.01), respectively. Percentage of patients who bled at the insertion site of invasive devices was as follows: percutaneous tracheostomy­46.7%, therapeutic plasma exchange (TPE) catheter­23.8%, dialysis catheter­13.3%, gastrostomy­9.5%, central venous catheter­7.8%. Moreover, circuit clotting occurred in 17.7 and 9.5% of patients undergoing dialysis and TPE, respectively. Median blood loss for repeated laboratory testing in our study population was 13.7 (IQR 9.9−19.3) mL per patient daily. Anemia is highly prevalent among medical and surgical patients on admission to ICU and is associated with RBC transfusion. Patients who required RBC transfusion had significantly lower daily Hb concentrations. Severity of disease did not seem to have impact on Hb concentration. IBL associated with invasive devices and extracorporeal therapies is frequent in ICU patients and may lead to a gradual decrease in Hb concentration. Further studies are required to analyze causes of HAA in the ICU.

Hematologic System Dysregulation in Critically Ill Septic Patients with Anemia-A Retrospective Cohort Study.

Sepsis can affect various organs as well as the hematologic system. Systemic dysregulation, present in sepsis, affects particularly red blood cells (RBCs). One of the widely available RBC indices is RBC distribution width (RDW). Sepsis may also affect hemostasis, with septic patients presenting with coagulopathy or disseminated intravascular coagulation. The aim of our study was to analyze the impact of sepsis on RBC indices and coagulation parameters on admission to the intensive care unit (ICU) and their association with presence of sepsis and sepsis outcomes in anemic critically ill patients. We performed a retrospective observational study covering consecutive patients admitted to a 10-bed mixed ICU in the years 2020−2021. We found significant differences between septic and non-septic patients for the following parameters: RDW (p = 0.02), INR (p < 0.01), aPTT (p < 0.01), D-dimers (p < 0.01), fibrinogen (p = 0.02), platelets (p = 0.04). International normalized ratio was the only parameter with adequate sepsis predictive value (AUROC = 0.70; 95% CI 0.63−0.76; p < 0.01), with an optimal cut-off value of >1.21. Combination of INR with fibrinogen and a severity of disease score improved INR's predictive value (AUROC 0.74−0.77). Combination of INR with a severity of disease score was an adequate ICU mortality predictor in septic patients (AUROC 0.70−0.75). Sepsis significantly affects RDW and most coagulation parameters. Increased INR can be used for sepsis screening, whereas combination of INR with a severity of disease score can be a predictor of short-term mortality in septic patients.

If Not Insulin Resistance so What? - Comparison of Fasting Glycemia in Idiopathic Parkinson's Disease and Atypical Parkinsonism.

Background: Parkinson's disease (PD) is a synucleinopathy, which presents dysautonomia, as its common non-motor symptom. Some research suggests the existing interplay between the autonomic nervous system dysfunction and glucose metabolism dysregulation in PD. Objective: To determine the prevalence of metabolic disorders with particular emphasis on glucose metabolism in patients with PD and atypical parkinsonism (AP). Patients and Methods: A retrospective study was performed by analyzing 461 clinical data of consecutive patients diagnosed with PD, multiple system atrophy (MSA) and progressive supranuclear palsy (PSP) hospitalized from 2019 to 2021 in the authors' institution. The study group included 350 patients (303 PD, 14 MSA, 33 PSP), aged 65.8 ± 9.7 years (42% were female). Laboratory results (fasting glycemia, lipid parameters, TSH, homocysteine and vitamin D3 levels) were collected. The patient's clinical condition was assessed in III part of Unified Parkinson's Disease Rating Scale (UPDRS p. III), Hoehn-Yahr scale, Mini Mental State Examination (MMSE) and Beck Depression Inventory (BDI). Results: Impaired fasting glycemia (IGF) was more prevalent in PD than in the PSP (43.43% vs 18.18%; p = 0.043). Similarly, PD presented a higher level of fasting glycemia (102.4 ± 16.7 mg/dl vs 92.2 ± 16.1mg/dl; p = 0.042). According to lipid parameters, patients with PD showed lower LDL cholesterol (92.3 ± 44.3mg/dl vs 119 ± 61.0mg/dl; p = 0.016) and lower BMI compared to patients with PSP (26.1 ± 4.0kg/m2 vs 29.3 ± 4.4 kg/m2; p = 0.024), but there were no statistically significant differences in triglycerides (TG) and HDL cholesterol levels. Males with PD presented greater frequency of IFG (35.05% vs 50.6%; p = 0.042), higher fasting glycemia (99.1 ± 14.3mg/dl vs 103.7 ± 14.7mg/dl; p = 0.006), lower total cholesterol, HDL cholesterol, and BMI compared to women with PD. Conclusion: Our investigation supports an association between synucleinopathies and glucose metabolism dysregulation.

The Impact of Red Blood Cell Transfusion on Blood Lactate in Non-Bleeding Critically Ill Patients-A Retrospective Cohort Study.

Anemia should preferably be managed without red blood cell transfusion (RBCT); instead, therapy should be focused on causes of anemia along with efforts to minimize blood loss. Lactate could potentially be used as a physiologic RBCT trigger, although there are some limitations to its interpretation. The aim of our study was to analyze the impact of RBCT on blood lactate with consideration of factors known to increase its concentration and to assess the usefulness of blood lactate as a potential physiologic RBCT trigger. We performed a retrospective analysis of all RBCT episodes in non-bleeding critically ill patients. We retrieved demographic data, data on RBCT itself (duration, type of RBC, volume of RBC, age of RBC), laboratory parameters (lactate, hemoglobin, glucose, total bilirubin), and factors potentially increasing lactate. We analyzed 77 RBCTs with elevated pre-RBCT lactate. The median age of patients was 66 (IQR 57-73) years and the distribution of sexes was even. The named factors potentially influencing lactate had no impact on its concentration. The median pre-post RBCT lactate was 2.44 (IQR 2.08-3.27) and 2.13 (IQR 1.75-2.88) mmol/L, respectively (p < 0.01); the median decrease was 0.41 (IQR 0.07-0.92) mmol/L. We conclude that RBCT did not normalize mildly elevated lactate. Common causes of elevated lactate probably had no impact on its concentration. Therefore lactate may have a limited role as a physiologic RBCT trigger in non-bleeding severely anemic critically ill patients.