The Year in Coagulation and Transfusion: Selected Highlights from 2022.

This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.

Awake Spinal Fusion Is Associated with Reduced Length of Stay, Opioid Use, and Time to Ambulation Compared to General Anesthesia: A Matched Cohort Study.

OBJECTIVE: There is increasing interest in performing awake spinal fusion under spinal anesthesia (SA). Evidence supporting SA has been positive, albeit limited. The authors set out to investigate the effects of SA versus general anesthesia (GA) for spinal fusion procedures on length of stay (LOS), opioid use, time to ambulation (TTA), and procedure duration. METHODS: The authors performed a retrospective review of a single surgeon's patients who underwent lumbar fusions under SA versus GA from June of 2020 to June of 2022. SA patients were compared to demographically matched GA counterparts undergoing comparable procedures. Analyzed outcomes include operative time, opioid usage in morphine milligram equivalents, TTA, and LOS. RESULTS: Ten SA patients were matched to 10 GA counterparts. The cohort had a mean age of 66.77, a mean body mass index of 27.73 kg/m2, and a median American Society of Anesthesiologists Physical Status Score of 3.00. LOS was lower in SA versus GA patients (12.87 vs. 50.79 hours, P = 0.001). Opioid utilization was reduced in SA versus GA patients (10.76 vs. 31.43 morphine milligram equivalents, P = 0.006). TTA was reduced in SA versus GA patients (7.22 vs. 29.87 hours, P = 0.022). Procedure duration was not significantly reduced in SA patients compared to GA patients (139.3 vs. 188.2 minutes, P = 0.089). CONCLUSIONS: These preliminary retrospective results suggest the use of SA rather than GA for lumbar fusions is associated with reduced hospital LOS, reduced opioid utilization, and reduced TTA. Future randomized prospective studies are warranted to determine if SA usage truly leads to these beneficial outcomes.

Awake spinal anesthesia facilitates spine surgery in poor surgical candidates: A case series.

BACKGROUND: Annually, hundreds of thousands of patients undergo surgery for degenerative spine disease (DSD). This represents only a fraction of patients that present for surgical consideration. Procedures are often avoided due to comorbidities that make patients poor candidates for general anesthesia (GA) and its associated risks. With increasing interest in awake surgery under spinal anesthesia (SA), the authors have observed that SA may facilitate spine surgery in patients with relative contraindications to GA. With this in mind, the authors set out to summarize the outcomes of a series of highly comorbid patients who received surgery under SA. METHODS: Case logs of a single surgeon were reviewed, and patients undergoing spine surgery under SA were identified. Within this group, patients were identified with relative contraindications to GA, such as advanced age and medical comorbidities. For these patients, for whom surgery was facilitated by SA, the medical records were consulted to report demographic information and patient outcomes. RESULTS: Ten highly comorbid patients were identified who received lumbar spine surgery for DSD under SA. Comorbidities included octogenarian status, obesity, and chronic health conditions such as heart disease. The cohort had a mean age of 75.5 and a mean American Society of Anesthesiologists Physical Status (ASA-PS) score of 3.1. The patients were predicted to have a 2.74-fold increase of serious complications compared to the average patient. There were no adverse events. CONCLUSION: For patients with symptomatic, refractory DSD and relative contraindications to GA, SA may facilitate safe surgical intervention with excellent outcomes.

Validity and Reliability Evidence for Assessments Based in Applied Behavior Analysis: A Systematic Review.

The current article presents the findings from a systematic review of the available reliability and validity evidence supporting the use of criterion-referenced assessments based on the applied behavior analysis framework. We identified 46 studies that reported reliability and/or validity evidence for six assessments, 37 of which presented reliability evidence and 43 presented validity evidence. Additionally, we extracted and summarized information related to participant characteristics (e.g., age, sex, diagnosis), geographic location, and research setting (e.g., residential facility, home). Overall, we found conflicting support for the use of the assessments. When coupled with the reported usage by behavior analysis professionals, our findings suggest a misalignment between the reportedly used assessments and the number of published studies providing validity and/or reliability evidence. We found inconsistent use of measurement-related vocabulary and that many studies could have been strengthened by conducting different statistical analyses. We provide a summary of studies, findings, and offer recommendations for clinical practice and future measurement research.

Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients.

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

A Meta-Analysis of Phonemic Awareness Instruction Provided to Children Suspected of Having a Reading Disability.

PURPOSE: The present meta-analysis sought to investigate the effects of phonemic awareness instruction provided to children suspected of having a reading disability. METHOD: Seven databases were systematically searched, and 1,643 unique manuscripts were reviewed for inclusion. Data were extracted from 138 included manuscripts to evaluate the use of phonemic awareness instruction with children suspected of having a reading disability. A random effects model was then used to conduct a meta-analysis of these data with regard to child outcomes. RESULTS: Gains in this population associated with phonemic awareness instruction can vary as a function of the outcome being used. On average, phonemic awareness instruction had a medium effect on composite (g = 0.511) and segmentation (g = 0.571) outcomes and a small effect on outcomes measuring blending (g = 0.341), first sound identification (g = 0.428), and deletion (g = 0.248). Instruction effects were strongest in kindergarten and first grade, but positive outcomes were also found for older children. There was not a significant relationship between cumulative intervention intensity and child performance. CONCLUSIONS: The present meta-analysis confirms that phonemic awareness instruction can be effective with children of varying ages and that significant gains can be observed on the key outcome measures of segmentation and blending. Graphemes should be incorporated into phonemic awareness instruction, and future studies need to provide information on dosage beyond just the length and frequency of sessions to clarify which aspects of these interventions are most efficient. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20277714.

Controversies in enhanced recovery after cardiac surgery.

Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery-Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.

Treatment through a preoperative anemia clinic is associated with a reduction in perioperative red blood cell transfusion in patients undergoing orthopedic and gynecologic surgery.

BACKGROUND: Preoperative anemia is associated with increased morbidity, mortality, and risk of transfusion. Treatment through a preoperative anemia clinic (PAC) may improve outcomes. STUDY DESIGN AND METHODS: Adult patients undergoing elective orthopedic and gynecologic surgery with preoperative anemia were identified and referred for hemoglobin optimization with iron and/or erythropoietin from a single-site academic health center. Treated patients were propensity matched to untreated controls and compared on outcomes of erythrocyte transfusion, length of stay (LOS), and readmission. Changes in hemoglobin relative to treatment time before surgery were also measured in the treated cohort. RESULTS: One thousand three hundred thirty-two patients were evaluated between July 2015 and March 2021, of which 161 underwent optimization through the PAC. After propensity matching, 127 (98 orthopedic and 29 gynecology) PAC-treated patients were compared to 127 (98 orthopedic and 29 gynecology) control patients who did not undergo treatment. The primary outcome of perioperative transfusion was significantly lower in treated patients compared with matched controls (12.60% vs. 26.77%, p = .005). A lower LOS was demonstrated in the gynecologic PAC subgroup (2.2 [1.5, 2.4] vs. 3.1 [2.2, 3.4], p = .002). Each day of treatment time before surgery was associated with an increase of 0.040 g/dL hemoglobin (p < .001) until 65 days, after which further time did not increase hemoglobin. CONCLUSION: Treatment through a preoperative anemia clinic is associated with a reduction in perioperative transfusion and possible reduction in LOS and readmission compared with matched controls. Additionally, treatment time before surgery is correlated with a greater increase in hemoglobin up until 2 months prior to surgery.

The association between intravenous iron for antenatal anemia and postnatal depression: a retrospective cohort study.

PURPOSE: Determine if intravenous iron for antenatal anemia is associated with reduced incidence of postnatal depression (PND) within 12 months. METHODS: This retrospective cohort study included adult women with antenatal anemia (hemoglobin value of < 11.0 g/dL within 3 months before delivery). PND was defined as Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire-9 (PHQ-9) ≥ 10. Data on intravenous iron, lowest hemoglobin concentration, EPDS and PHQ-9 scores, insurance status, history of anxiety, depression, chronic pain, and substance use, obstetric complications, labor analgesia, and mode of delivery were obtained. Standardized mean difference (SMD) was estimated and multivariable logistic regression models were constructed with adjustment for potential confounders with absolute SMD of ≥ 0.1. RESULTS: Data from 3988 women were analyzed. The 368 (9.2%) women who received intravenous iron therapy had lower antenatal hemoglobin levels, were more likely to be African American or single/widowed women, and more commonly had  Medicaid coverage, repeat cesarean delivery, and history of depression compared to those who did not receive intravenous iron therapy. Unadjusted analysis showed women who received intravenous iron had higher incidence of PND (18.5%) than those who did not (13.4%) (p = 0.008). Multivariable analysis showed no significant association between intravenous iron and PND incidence (aOR 1.21, 95%CI 0.89-1.63, p = 0.232), although history of depression (aOR 2.42, 95%CI 1.91-3.08, p < 0.001), higher gravidity (aOR 1.09, 95%CI 1.02-1.17, p = 0.016), and Medicaid insurance (aOR 1.44, 95%CI 1.16-1.80, p = 0.001) were independently associated with PND. CONCLUSION: Intravenous iron for antenatal anemia was not associated with significant change in the incidence of PND.

Blood Substitutes and Oxygen Therapeutics: A Review.

Despite the exhaustive search for an acceptable substitute to erythrocyte transfusion, neither chemical-based products such as perfluorocarbons nor hemoglobin-based oxygen carriers have succeeded in providing a reasonable alternative to allogeneic blood transfusion. However, there remain scenarios in which blood transfusion is not an option, due to patient's religious beliefs, inability to find adequately cross-matched erythrocytes, or in remote locations. In these situations, artificial oxygen carriers may provide a mortality benefit for patients with severe, life-threatening anemia. This article provides an up-to-date review of the history and development, clinical trials, new technology, and current standing of artificial oxygen carriers as an alternative to transfusion when blood is not an option.

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.