How do I develop a process to effectively treat parturients with iron deficiency anemia?

Anemia is common in pregnant women and is associated with increased morbidity for the mother and the fetus, including increased risk of allogeneic blood transfusion. Iron deficiency is the most common etiology for anemia during pregnancy. Oral iron therapy remains the standard treatment but is often poorly tolerated due to its gastrointestinal side effects. Intravenous iron has been shown to be a safe and effective way to treat iron deficiency anemia but may be challenging to do in the outpatient setting given the need for an indwelling venous catheter and a small risk of infusion reactions. To improve outcomes associated with anemia, we launched a program to refer and treat obstetric patients with iron deficiency anemia for outpatient intravenous iron therapy through our preoperative anemia clinic. Here, we describe the process and successes of our program, including the clinical outcomes (change in hemoglobin and transfusion rates) from the first 2 years of the program.

Severe anemia associated with increased risk of death and myocardial ischemia in patients declining blood transfusion.

BACKGROUND: There are limited data on morbidity and mortality in severely anemic patients for whom blood transfusion is not an option, with most data coming only from surgical patients and no data on the rate of myocardial ischemia associated with severe anemia. We sought to determine rates of all-cause mortality and myocardial ischemia in severely anemic hospitalized patients declining transfusion. STUDY DESIGN AND METHODS: With institutional review board approval, we conducted a retrospective review of all hospital admissions for adult blood refusal patients between January 2004 and September 2015 at a single institution. Severe anemia was defined as hemoglobin (Hb) level of not more than 8.0 g/dL at any time during hospital admission. Outcomes measured included all-cause mortality within 30 days of nadir Hb and myocardial ischemia as defined by abnormal troponin (>0.10 ng/mL). We studied the association of patient's nadir Hb with outcomes via multivariable repeated measures generalized estimating equations (GEEs). RESULTS: Of 1306 blood refusal patients with hospital admissions during the study period, 263 had at least one admission with Hb level of not more than 8.0 g/dL. The rate of all-cause mortality within 30 days was 19.8%, and the multivariable GEE model indicated a 55% increase in odds of mortality per 1 g/dL decrease in nadir Hb (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.25-1.91; p < 0.0001). Rate of myocardial ischemia was 10.5% and in the multivariable model risk increased with decreasing nadir Hb (per 1 g/dL decrease; OR, 1.42; 95% CI, 1.07-1.90; p = 0.016). CONCLUSIONS: Severe anemia is associated with increased myocardial ischemia and mortality in patients declining transfusion, with risk increasing with decreasing nadir Hb.

Outcomes in Patients Undergoing Cardiac Surgery Who Decline Transfusion and Received Erythropoietin Compared to Patients Who Did Not: A Matched Cohort Study.

BACKGROUND: Erythropoiesis-stimulating agents, such as erythropoietin (EPO), can be used to treat preoperative anemia. Some studies suggest an increased risk of mortality and thrombotic events, and use in cardiovascular surgery remains off-label. This study compares outcomes in cardiac surgery patients declining blood transfusion who received EPO with a matched cohort who did not. METHODS: After institutional review board approval, we conducted a retrospective review of all patients who decline blood transfusion who underwent cardiac surgery and received EPO between January 1, 2004, and June 15, 2015, at a single institution. Control patients who did not receive EPO and were not transfused allogeneic red blood cells perioperatively were identified during the same period. Two controls were matched to each EPO patient using an optimal matching algorithm based on age, date of surgery, gender, operative procedure, and surgeon. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) and baseline characteristics remaining unbalanced in the matched cohorts were controlled for in assessing patient outcomes. The primary outcome was a composite of mortality and thrombotic events, and secondary outcomes included change in hemoglobin (Hb) from baseline to discharge, acute kidney injury (AKI), sternal wound infection, atrial fibrillation, time to extubation, intensive care unit, and hospital length of stay (LOS). RESULTS: Fifty-three patients who decline transfusion and received EPO were compared to 106 optimally matched control patients who did not receive EPO or red blood cell transfusion in the perioperative period. The median additive EuroSCORE was similar between the EPO and control group [6 (4, 9) vs 5 (3, 7), respectively; P = .39]. There was no difference in the primary outcome (P = .12) and mortality was zero in both groups. The EPO group had a higher mean preoperative Hb (13.91 g/dL vs 13.31; P = .02) and a smaller change in Hb from baseline (-2.65 vs -3.60; P = .001). The incidence of AKI (47.17% vs 41.51%; P = .49) was similar and there was no significant difference in all other outcomes, including time to extubation, hospital LOS, or intensive care unit LOS. CONCLUSIONS: In this retrospective matched cohort study of patients declining transfusion and receiving EPO matched to control patients, there were no clinically meaningful differences in the outcomes.

No association between donor age and recipient outcomes: transfusion of plasma in patients undergoing coronary artery bypass grafting surgery.

BACKGROUND: Recent animal studies suggest that transfusion of plasma from young donors reverses age-related neurologic and cardiac changes in older recipients. Associations between age of blood product donors and corresponding outcomes in recipients have not been studied in humans. Therefore, our primary objective was to examine this relationship between donor age and recipient outcomes among patients that received plasma during and after coronary artery bypass grafting (CABG) surgery. STUDY DESIGN AND METHODS: This retrospective cohort included patients undergoing CABG surgery who received plasma during or after surgery. All plasma units transfused were evenly divided into tertiles based on the plasma donor age (17-37, 38-50, and 51-86 years), and CABG patients receiving all perioperative plasma within a single donor tertile were studied. Patient demographics and outcomes including mortality, length of stay (LOS), and acute kidney injury (AKI) were measured. RESULTS: Overall, 1306 patients (24% of 5339) received American Red Cross plasma perioperatively, with a median dose of 2 units. In a multivariate model of 1-year mortality, transfusion of a greater number of plasma units (p = 0.0007) and EuroSCORE (p < 0.0001) were significantly associated with patient mortality while donor age was not. There was no difference in mortality between patients receiving plasma from donors in the youngest, middle, or oldest age tertile (10.2 and 8.1% vs. 7.8%, respectively, p = 0.76). Other outcomes, including rates of AKI or LOS, were also independent of plasma donor age. CONCLUSIONS: We did not observe an association between donor age and recipient outcomes among patients who received plasma perioperatively while undergoing CABG surgery.

Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study.

BACKGROUND: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. RESEARCH QUESTION: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? STUDY DESIGN AND METHODS: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao2 to Fio2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. RESULTS: A total of 2,466 patients were enrolled. Median baseline Pao2 to Fio2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. INTERPRETATION: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov.

Lower hemoglobin concentration decreases time to death in severely anemic patients for whom blood transfusion is not an option.

BACKGROUND: Anemia in patients who decline transfusion has been associated with increased morbidity and mortality. We hypothesized that the time to death decreases with increasing severity of anemia in patients for whom transfusion is not an option. METHODS: With institutional review board approval, a retrospective review of registered adult blood refusal patients with at least one hemoglobin (Hb) value of 12.0 g/dL or less during hospital admission at a single institution from January 2004 to September 2015 was performed. The association of nadir Hb category and time to death (all-cause 30-day mortality) was determined using Kaplan-Meier plots, log rank tests, and Cox proportional hazard models. We investigated if there was a nadir Hb level between the values of 5.0 and 6.0 g/dL at which mortality risk significantly increased and then categorized nadir Hb by the traditional cut points and the newly identified "critical" cut point. RESULTS: The study population included 1,011 patients. The Cox proportional hazard models showed a more than 50% increase in hazard of death per 1 g/dL decrease in Hb (adjusted hazard ratio [confidence interval], 1.55 [1.40-1.72]; p < 0.001). A Hb value of 5.0 g/dL was identified as defining "critical anemia." We found a strong association between anemia severity level and mortality (p < 0.001). Time to death was shorter (median, 2 days) in patients with critical anemia than in those having higher Hb (median time to death of 4 or 6 days, in severe or moderate anemia). CONCLUSION: In anemic patients unable to be transfused, critical anemia was associated with a significantly and clinically important reduced time to death. LEVEL OF EVIDENCE: Prognostic, level III.