Implementation of a Nurse-Empowered Renal Anemia Protocol in Children.

A high proportion of patients on hemodialysis persist with low hemoglobin levels despite receiving treatment with erythropoiesis-stimulating agents. A registered nurse-driven renal anemia protocol was designed and implemented by a team in a pediatric hemodialysis unit. We compared proportion of patients achieving the target hemoglobin (Hgb) and transferrin saturation (TSAT) before and after the implementation of the protocol. There was an increase in patients achieving the target Hgb and TSAT range, with an increase in the Hgb concentration. There were no differences in the proportion of patients with left ventricular hypertrophy, erythropoiesis-stimulating agents or intravenous iron dose, transfusion rates, or hospitalization rates. The implementation of a nurse-driven anemia protocol in a pediatric hemodialysis unit increased the proportion of patients achieving target Hgb and TSAT range without a rise in medication doses.

Evaluating the Effectiveness of an Educational Intervention for Care of Anemic Patients in a Long-Term Care Geropsychiatric Unit: A Pilot Study.

Anemia is one of the most common age-related health conditions. When concurrently present with psychiatric conditions, the problem is confounded. The primary objective of the current research was to evaluate the effectiveness of an educational intervention for geropsychiatric nurses about nutritional deficiency anemia, anemia of chronic disease, and unexplained anemia in older adults. Fifty nurses employed by an inpatient psychiatric facility participated in the pilot study. A 10-item knowledge evaluation questionnaire was administered prior to and following a 45-minute educational intervention. Analysis of a paired samples t test indicated a significant difference between pretest scores (mean = 36.8, SD = 16.3) and posttest scores (mean = 90.8, SD = 10.66) (p < 0.001). Despite initial knowledge gaps, significant improvement in nursing knowledge was noted following the intervention. As a result of improved knowledge, RNs may be better able to recognize and respond to signs and symptoms that commonly go unnoticed in geropsychiatric patients with anemia. [Journal of Gerontological Nursing, 46(8), 12-16.].

A nurse prescriber-led protocol for anaemia management in established haemodialysis patients: A retrospective study.

AIM AND OBJECTIVE: To evaluate the impact of a nurse prescriber-led protocol compared to a traditional physician-led nonprotocol-based approach had on maintaining targeted haemoglobin levels in patients on maintenance haemodialysis. BACKGROUND: Anaemia is a common complication of chronic kidney disease and has a profound impact on the patients' well-being. Current practices place a greater emphasis on the decision-making role of nurses in renal anaemia management. The introduction of nurse prescribing in this area is a relatively new concept. DESIGN: A retrospective cohort design, covering an eight-month period pre- and post introduction of a nurse prescriber-led anaemia protocol; study adheres to the STROBE Statement. METHODS: Using a nonprobability convenience sample, data extracted from the medical records and electronic patient records system (eMed) related to 74 patients at a single outpatient haemodialysis centre located within an acute general teaching hospital. The primary outcome was patients' haemoglobin level pre- and post introduction of the protocol. Secondary outcomes included erythropoietin-stimulating agent and iron dosage, and serum ferritin and transferrin saturation levels. RESULTS: There were no statistically significant differences between pre- and post protocol serum haemoglobin level and erythropoietin-stimulating agent dosage. Under the management of the nurse prescriber, patients experienced a significant improvement in serum ferritin and transferrin saturation levels and required significantly less intravenous iron dosage. CONCLUSIONS: This study, the first of its kind, found that patients receiving haemodialysis experience a significant improvement in iron indices while receiving a significantly lower amount of intravenous iron when managed by a nurse prescriber. Furthermore, the nurse prescribers' decision-making capacity is as effective as a physician-led nonprotocol-based approach in achieving haemoglobin target levels. RELEVANCE TO CLINICAL PRACTICE: Nurse prescribers have a role in implementing a safe, standardised and sustained approach to anaemia management in outpatient haemodialysis settings without compromising patient care.

Volumen de sangre extraído al paciente crítico las primeras 24h de ingreso / Blood volume extracted from the critical patient in the first 24 hours after admission

Objetivo: Calcular el número de analíticas y volumen de sangre extraído durante las primeras 24h de ingreso en la unidad de cuidados intensivos (UCI). Analizar valores de hemoglobina basal y a las 24h, relacionarlas con volumen de sangre extraído, balance ponderal e índices de gravedad. Método Estudio descriptivo, observacional y prospectivo. Variables de estudio: edad, sexo, diagnóstico de ingreso, analítica extraída, cantidad de desecho antes de la extracción de muestras, volumen de sangre total extraída en 24h, balance ponderal, índices de gravedad, hemoglobina basal y a las 24h. Análisis estadístico realizado mediante SPSS vs.20.0. Se han calculado las correlaciones de las variables sexo, balance, número de analíticas y variación de hemoglobina. Resultados La muestra estuvo formada por 100 pacientes. El número de extracciones medio por paciente/día fue de 7,2 (±2,6). La cantidad media de desecho fue de 32,61ml (±15,8). El volumen medio de sangre utilizado para determinaciones fue de 48,18ml (±16,74). El valor de la hemoglobina disminuyó las primeras 24h de ingreso, siendo mayor en los hombres (p<0,05). No se pudo demostrar que el número de analíticas estuviera relacionado con la diferencia de hemoglobina a las 24h. Los índices de gravedad tuvieron significación estadística en cuanto a los niveles de hemoglobina (Hb1: -0,3; p=0,001; Hb2: -0,4; p=0,001). Conclusiones: Del volumen total de sangre extraída en UCI, el 40% pertenece a volumen de desecho y el 60% a sangre utilizada para analíticas. Existe una disminución de la hemoglobina a las 24h de ingreso del paciente crítico, pero no se ha podido demostrar estadísticamente su relación con el número de analíticas (AU)

Objective: To calculate the number of analytical tests and blood volume drawn during the first 24hours of admission to the Intensive Care Unit (ICU). To analyse values of basal haemoglobin and at 24hours, relate them to blood loss, weight variation, and scoring system. Method: An observational descriptive pilot study. Variables studied: age, sex, diagnosis on admission, analytical tests extracted, waste quantity before the extraction of samples, total volume blood extracted in 24hours, weight variation, APACHE, SAPS, basal haemoglobin and at 24hours. Statistical analysis with SPSS vs 20.0. Variables correlation sex, weight variation, the number of analytical tests and haemoglobin change. Results: The study included 100 patients. The average number of extractions per patient/day was 7.2 (±2.6). The average waste quantity was 32.61ml (±15.8). The blood volume used for determinations was 48.18ml / 24h (±16.74). The haemoglobin value decreased in the first 24hours of admission, being higher in men (P<.05). The scoring systems were statistically significant for levels of haemoglobin (Hb1 -0.3; P=.001; Hb2 -0.4; P=.001). Conclusions: Of the total volume of blood extracted in ICU, 40% belongs to a volume of waste and 60% of blood is used for analytical tests. There is a decrease in haemoglobin exists 24hours after admission of the critical patient. Statistically, it has not been possible to demonstrate its relation with the number of analytical tests (AU)

Controlling Phlebotomy Volume Diminishes PICU Transfusion: Implementation Processes and Impact.

BACKGROUND AND OBJECTIVES: Phlebotomy excess contributes to anemia in PICU patients and increases the likelihood of red blood cell transfusion, which is associated with risk of adverse outcomes. Excessive phlebotomy reduction (EPR) strategies may reduce the need for transfusion, but have not been evaluated in a PICU population. We hypothesized that EPR strategies, facilitated by implementation science methods, would decrease excess blood drawn and reduce transfusion frequency. METHODS: Quantitative and qualitative methods were used. Patient and blood draw data were collected with survey and focus group data to evaluate knowledge and attitudes before and after EPR intervention. The Consolidated Framework for Implementation Research was used to interpret qualitative data. Multivariate regression was employed to adjust for potential confounders for blood overdraw volume and transfusion incidence. RESULTS: Populations were similar pre- and postintervention. EPR strategies decreased blood overdraw volumes 62% from 5.5 mL (interquartile range 1-23) preintervention to 2.1 mL (interquartile range 0-7.9 mL) postintervention (P < .001). Fewer patients received red blood cell transfusions postintervention (32.1% preintervention versus 20.7% postintervention, P = .04). Regression analyses showed that EPR strategies reduced blood overdraw volume (P < .001) and lowered transfusion frequency (P = .05). Postintervention surveys reflected a high degree of satisfaction (93%) with EPR strategies, and 97% agreed EPR was a priority postintervention. CONCLUSIONS: Implementation science methods aided in the selection of EPR strategies and enhanced acceptance which, in this cohort, reduced excessive overdraw volumes and transfusion frequency. Larger trials are needed to determine if this approach can be applied in broader PICU populations.

Ferropenia y anemia ferropénica. Tratamiento con hierro intravenoso a altas dosis / Iron deficiency and iron deficiency anemia. High-dose intravenous iron treatment

La anemia por déficit de hierro puede ser habitual en diferentes patologías agudas y crónicas. La vía de primera elección para la reposición de hierro es la oral. Sin embargo, cuando esta vía resulta ineficaz, es mal tolerada o está contraindicada o, cuando hay que tratar una anemia grave o existe la necesidad de recuperación rápida de los niveles de hierro corporal, se recomienda la repleción de hierro por vía endovenosa. El hierro administrado por vía intravenosa permite una rápida y eficiente corrección de los niveles de hierro. Los preparados intravenosos actuales presentan el hierro asociado a moléculas de polisacáridos que facilitan su liberación lenta y controlada, biodisponible para su unión a las proteínas específicas de almacenaje o transportadoras. Gracias a ello, se reduce la toxicidad por hierro libre y se hace posible la administración de altas dosis en intervalos cortos de tiempo. La introducción de preparados que permiten la administración de hierro sin dosis techo, como el hierro isomaltósido, además de reponer eficazmente los niveles de hierro, incide significativamente en la calidad de vida de los pacientes, ya que reduce el número de visitas y desplazamientos a los centros sanitarios, disminuye el número de punciones preservando los accesos venosos, minimiza las interferencias en sus actividades cotidianas y mejora los recursos sanitarios (AU)

Iron deficiency anemia is common in different acute and chronic diseases. The current first line of therapy is oral iron supplementation. However, when this method is ineffective, poorly tolerated, contraindicated, when dealing with severe anemia or facing the need for rapid recovery of iron levels, it is recommended to replete iron intravenously. Administering intravenous iron allows for a fast and efficient correction of iron levels. Current injectable solutions contain iron in combination with polysaccharide molecules which facilitate slow and controlled iron release, making it bioavailable to bind with transport and storage proteins. As a result, toxicity is reduced allowing for high-dose administration in short time intervals. Administering high-dose solutions of intravenous iron, such as iron isomaltoside, apart from effectively replenishing iron levels, significantly improves patients quality of life, reduces the frequency of hospital or clinic visits and decreases punctures preserving the venous access, minimizes interference with daily activities and benefits health care resources (AU)

Evaluación de la administración de carboximaltosa férrica intravenosa en la consulta de enfermedad renal crónica avanzada, para el control de la anemia / Evaluation of the intravenous administration of iron carboxymaltose for controlling anemia in advanced chronic kidney disease

La carboximaltosa férrica es una formulación de hierro endovenosa segura y de fácil dosificación, se puede administrar hasta 1 gramo iv en una sola sesión y permite ahorro de tiempo de los pacientes y de enfermería. Presentamos los resultados de su administración en una consulta de enfermedad renal crónica, analizando sus resultados y la repercusión en la carga de trabajo del personal de enfermería. Material y Métodos: Se analizaron todos los pacientes en seguimiento de la consulta de enfermedad renal crónica en nuestro centro desde Ene-11 hasta Dic-14 que recibieron carboximaltosa férrica iv. Se registraron sus datos basales y los resultados clínicos y analíticos a los seis meses. Resultados: Fueron identificados 85 pacientes en ese periodo. Edad media de 72±12 años, con un filtrado glomerular estimado basal de 28±11ml/min y a los seis meses de 30±11 (p:n.s). La hemoglobina basal y a los seis meses fueron de 10±4 y 11±3 g/dl respectivamente (p:<0,001). El hematocrito basal y final fueron: 34±4 vs 39±6 % (p:<0,001). Los niveles de ferritina e índice de saturación de transferrina basales vs seis meses fueron respectivamente: 88±97 vs 308±327 ng/ml (p:<0,001) y 11,2±6 vs 22,3±11 (p:<0,001). Dado que el tiempo medio de administración de cualquier formulación de hierro endovenoso es de 30 minutos, la estimación en base al número de administraciones es de un ahorro de 85 y 170 horas en estos 4 años si se compara con formulaciones que requieren de tres a cinco sesiones respectivamente. A su vez el número de punciones se ha reducido, sin observarse complicaciones asociadas. Conclusiones: La carboximaltosa férrica es segura y eficaz mostrando una recuperación de los niveles de hemoglobina y de los depósitos de hierro. Su facilidad de administración ha permitido ahorros sustanciales de tiempo. Esto junto a sus escasos efectos secundarios la hacen idónea para la administración ambulatoria (AU)

Ferric carboxymaltose is a safe and easy dosage of intravenous iron formulation; it can be administered intravenously up to 1 gram in a single session and allows time savings of patients and nursing. We present the results of his administration in a unit of chronic kidney disease, analyzing the results and the impact on the workload of the nursing staff. Materials and methods: All patients followed in the chronic kidney disease unit at our center from January 2011 to December 2014 and who received intravenous iron carboxymaltose were analyzed. Their baseline data and clinical and laboratory results at six months were recorded. Results: 85 patients were identified during this period. Mean age of 72 ± 12 years, with a baseline estimated glomerular filtration rate of 28 ± 11 ml / min and at six months of 30 ± 11 (p >0.05). Baseline and at six months hemoglobin levels were 10 ± 4 and 11 ± 3 g / dl, respectively (p <0.001). The basal and final hematocrit were: 34 ± 4 vs 39 ± 6% (p <0.001). Baseline ferritin levels and transferrin saturation index versus levels at six months were respectively: 88 ± 97 vs 308 ± 327 ng / ml (p <0.001) and 11.2 ± 6 vs 11 ± 22.3 (p <0.001 ). Since the average administration time by any formulation of intravenous iron is 30 minutes, the estimate based on the number of administrations is a saving of 85 and 170 hours on these four years when compared with formulations that require three to five respectively sessions. In turn, the number of punctures has been reduced without associated complications observed. Conclusion: Carboxymaltose iron is safe and effective showing a recovery of hemoglobin levels and iron deposits. Its ease of administration has allowed substantial time savings. This, together with its few side effects makes it ideal for outpatient administration (AU)

Chronic Anemia and the Role of the Infusion Therapy Nurse.

Chronic anemia develops over a course of weeks to months and is usually mild to moderate in nature. It is important to understand the etiology of the reduced number of circulating red blood cells to treat the anemia appropriately. Diagnosis is dependent on patient history and laboratory findings, such as complete blood counts, iron studies, a peripheral smear, and occasionally, a bone marrow biopsy. Treatment modalities frequently administered by infusion therapy nurses include treatment of the underlying chronic disease, replacement of deficiencies (iron, vitamin B12, folate, or erythropoietin), or transfusion of red blood cells. Infusion therapy nurses play a vital role in the assessment and delivery of medication therapy to patients with chronic anemia.

Anemias.

Anemias continue to present a challenge to the health care profession. Anemia is defined as a reduction in one or more of the RBC indices. Patients presenting with a mild form of anemia may be asymptomatic; however, in more serious cases the anemia can become life threatening. In many cases the clinical presentation also reflects the underlying cause. Anemia may be attributed to various causes, whereas autoimmune RBC destruction may be attributed to intrinsic and extrinsic factors. Laboratory tests are essential in facilitating early detection and differentiation of anemia.

Are haemoglobin levels adequate in patients with chronic kidney disease (CKD) stage 2-4?

BACKGROUND: Anaemia often goes unrecognised in people with early chronic kidney disease (CKD) resulting in under treatment until reaching the need for dialysis. OBJECTIVES: This study aimed to determine if anaemia is adequately treated in Australians with CKD, who do not require dialysis. DESIGN AND MEASUREMENT: Haemoglobin, ferritin and transferrin saturation (TSAT) data for patients with Stage 2-4 CKD were extracted from the Renal Anaemia Management database for the period 1999-2010. The data were compared with the target levels specified in the Caring for Australasians with Renal Impairment guidelines. RESULTS: Less than 50% of the patients achieved the recommended haemoglobin levels, and even fewer patients achieved the levels recommended for ferritin and TSAT. CONCLUSION AND APPLICATION TO PRACTICE: More emphasis should be placed on detection and treatment of anaemia in earlier stages of kidney disease. Poor response to erythropoiesis stimulating agent therapy should be investigated in this group and any identified causes of poor response treated.

Anaemia management protocols in the care of haemodialysis patients: examining patient outcomes.

AIMS AND OBJECTIVES: To determine whether the use of a nurse-driven protocol in the haemodialysis setting is as safe and effective as traditional physician-driven approaches to anaemia management. BACKGROUND: The role of haemodialysis nurses in renal anaemia management has evolved through the implementation of nurse-driven protocols, addressing the trend of exceeding haemoglobin targets and rising costs of erythropoietin-stimulating agents. DESIGN: Retrospective, non-equivalent case control group design. METHODS: The sample was from three haemodialysis units in a control group (n = 64) and three haemodialysis units in a protocol group (n = 43). The protocol group used a nurse-driven renal anaemia management protocol, while the control group used a traditional physician-driven approach to renal anaemia management. All retrospective data were obtained from a provincial renal database. Data were analysed using chi-square tests and t-tests. Patient outcomes examined were haemoglobin levels, transferrin saturation levels, erythropoietin-stimulating agents use and intravenous iron use. Cost comparisons were determined using average use of erythropoietin-stimulating agents and intravenous iron. RESULTS: Control and protocol groups reached haemoglobin target levels. In the protocol group, 75% reached transferrin saturation target levels in comparison with 25% of the control group. Use and costs for iron was higher in the control group, while use and costs for erythropoietin was higher in the protocol group. The higher usage of erythropoietin-stimulating agents was potentially related to comorbid conditions amongst the protocol group. CONCLUSIONS: A nurse-driven protocol approach to renal anaemia management was as effective as the physician-driven approach in reaching haemoglobin and transferrin saturation levels. Further examination of the use and dosing of erythropoietin-stimulating agents and intravenous iron, their impact on haemoglobin levels related to patient comorbidities and subsequent cost effectiveness of protocols is required. RELEVANCE TO CLINICAL PRACTICE: Using a nurse-driven protocol in practice supports the independent nursing role while contributing to safe patient outcomes.

Postpartum anaemia. Are we vigilant enough?

Anaemia in the immediate postnatal period can manifest itself physically in a number of ways. Amongst these are pallor, tiredness, dizziness, loss of appetite and oedema (Bewley 2004), all of which could be mistaken for commonly observed benign symptoms of the immediate postnatal period. However, left untreated, anaemia can severely impact on both the physical and emotional wellbeing of a woman and dramatically slow down her recovery (Bewley 2004). This altered state of health can also have a detrimental effect on a woman's ability to bond with her new child (Abbott et al 1997) and has been identified as a contributory factor in the initiation of postnatal depression (Corwin et al 2003). It is therefore imperative that, as midwives and student midwives, we take every opportunity to closely monitor the wellbeing of women in our care in order to facilitate their return to a normal haemoglobin level, promote infant bonding and reduce the risk of postnatal depression.

Packed red blood cell transfusions in critically ill patients.

Anemia, which is prevalent in critically ill patients, often requires frequent blood transfusions. These blood transfusions are not without risks. A critical review of 6 studies shows an association between red blood cell transfusion and increased mortality. However, when disease state was adjusted for in 2 studies, researchers found that red blood cell transfusion correlated with decreased mortality. Thus further research, particularly on leukoreduction and age of stored blood, must be done before a change in practice can be implemented. It is vital that nurses stay current on this research in order to improve patients' outcomes.

A prospective protocol-based trial of darbepoetin alfa therapy to correct the early anemia following renal transplantation.

Anemia is a common complication accompanying renal transplantation. The evaluation and therapy for posttransplant anemia (PTA) are not standardized and remain controversial. This was a prospective, protocol-driven attempt at early PTA evaluation and management by transplant nurse coordinators. Between 1 and 2 months posttransplantation, 75 consecutive recipients were evaluated for the presence and causes of anemia. Anemic patients were given standard doses of darbepoetin alfa (DA) for 3 months. Response to therapy and patient outcomes were evaluated over 15 months. Twenty-five (33%) of all patients were anemic, including 32% who were erythropoietin (EPO)-deficient and 68% with relative EPO resistance. No patient with early PTA showed an elevated EPO level or increased reticulocytes. Predisposing factors for early PTA included increased numbers of perioperative transfusions, deceased kidney donor, decrease reticulocyte count, and renal insufficiency. DA therapy corrected anemia in 20% of patients at 1 month and in 60% at 3 months. Patients unresponsive to standard DA doses were observed to display reduced renal function and new onset iron deficiency. Patients with prolonged PTA may represent a high-risk population requiring more intensive medical supervision. Nurses were able to efficiently direct DA therapy with only 1.7% protocol violations.