Patient harm associated with serial phlebotomy and blood waste in the intensive care unit: A retrospective cohort study.

BACKGROUND: Intensive care unit (ICU) patients are at high risk of anemia, and phlebotomy is a potentially modifiable source of blood loss. Our objective was to quantify daily phlebotomy volume for ICU patients, including blood discarded as waste during vascular access, and evaluate the impact of phlebotomy volume on patient outcomes. METHODS: This was a retrospective observational cohort study between September 2014 and August 2015 at a tertiary care academic medical-surgical ICU. A prospective audit of phlebotomy practices in March 2018 was used to estimate blood waste during vascular access. Multivariable logistic regression was used to evaluate phlebotomy volume as a predictor of ICU nadir hemoglobin < 80 g/L, and red blood cell transfusion. RESULTS: There were 428 index ICU admissions, median age 64.4 yr, 41% female. Forty-four patients (10%) with major bleeding events were excluded. Mean bedside waste per blood draw (144 draws) was: 3.9 mL from arterial lines, 5.5 mL central venous lines, and 6.3 mL from peripherally inserted central catheters. Mean phlebotomy volume per patient day was 48.1 ± 22.2 mL; 33.1 ± 15.0 mL received by the lab and 15.0 ± 8.1 mL discarded as bedside waste. Multivariable regression, including age, sex, admission hemoglobin, sequential organ failure assessment score, and ICU length of stay, showed total daily phlebotomy volume was predictive of hemoglobin <80 g/L (p = 0.002), red blood cell transfusion (p<0.001), and inpatient mortality (p = 0.002). For every 5 mL increase in average daily phlebotomy the odds ratio for nadir hemoglobin <80 g/L was 1.18 (95% CI 1.07-1.31) and for red blood cell transfusion was 1.17 (95% CI 1.07-1.28). CONCLUSION: A substantial portion of daily ICU phlebotomy is waste discarded during vascular access. Average ICU phlebotomy volume is independently associated with ICU acquired anemia and red blood cell transfusion which supports the need for phlebotomy stewardship programs.

The Effect of Acupressure on Acute Pain During Venipuncture in Children: Implications for Evidence-Based Practice.

AIMS: The study was conducted as a randomized controlled trial in order to determine the effects of acupressure on acute pain during venipuncture in children. METHODS: The population of the study consisted of children, aged between 9 and 12 years, who received venipuncture between September 2015 and June 2016 at a university hospital in Istanbul. The sample consisted of a total of 90 children, including 45 children in the acupressure group and 45 children in the control group, who met the sample inclusion criteria. The results of the study were obtained by using an information form, the State Anxiety Inventory for Children (STAIC), the visual analog scale (VAS), and the Faces Pain Scale-Revised (FPS-R). Acupressure was applied to the children in the acupressure group for 10 min before the venipuncture procedure. Pain, heart rate, and oxygen saturation levels of the children in the acupressure and control groups were evaluated both before and after the venipuncture procedure. RESULTS: The children in the acupressure and control groups were found to be similar in terms of age, gender, parents' educational levels and working status, number of venipuncture procedures, and mean anxiety scores. In the evaluation that was conducted before the venipuncture procedure, no statistically significant differences were observed between the heat rates, oxygen saturation levels, and expected pain scores from the venipuncture procedure in the children in the acupressure and control groups. On the other hand, it was observed that the children in the acupressure group (VAS: 19.51 ± 4.98; FPS-R: 2.08 ± 0.41) experienced less pain than the children in the control group (VAS: 47.37 ± 9.89; FPS-R: 4.84 ± 1.08), and there was a significant difference between the two groups (p< .000). LINKING EVIDENCE TO ACTION: Acupressure administration is effective in reducing the pain that is experienced by children during a venipuncture procedure.

Reduced risk of vasovagal reactions in Australian whole blood donors after national implementation of applied muscle tension and water loading.

BACKGROUND: A new national donor safety initiative was introduced in Australia in 2018, which aimed to encourage all whole blood donors to water load and to use applied muscle tension. This study evaluated the effect of this initiative on the rate of vasovagal reactions (VVR). STUDY DESIGN AND METHODS: Routinely collected data were used to identify whole blood donations and any associated VVRs before (n = 167,056 donations) and after implementation (n = 215,572 donations). Multivariate logistic regression analyses were performed to evaluate the differences in VVR rates. RESULTS: The total rate of VVRs declined from 22.5 per 1000 donations to 20.6 per 1000 donations after implementation, a reduction of 8% (p < 0.001). The rate of presyncopal reactions decreased by 8% in new donors and 12% in repeat donors. No impact was observed on the rate of syncope in any of the groups. The multivariate logistic regression analysis demonstrated the odds of experiencing a presyncopal reaction was reduced by 13% following implementation, with no significant effects on syncope. CONCLUSION: The findings of this study support the use of water loading and applied muscle tension in routine whole blood collection to reduce the incidence of VVRs.

The benefits of limiting scheduled blood draws in children with a blunt liver or spleen injury.

BACKGROUND: Nonoperative management protocols of blunt liver and spleen injury in children usually call for serial monitoring of the child's hemoglobin and hematocrit (H/H) at scheduled intervals. We previously demonstrated that the need for emergent intervention is triggered by changes in vital signs, not the findings of scheduled blood draws and changed our protocol accordingly. The current aim is to evaluate the safety of this change. METHODS: We performed a retrospective review of all children admitted following blunt liver or spleen injury during two periods; the historic cohort 1/09-12/13 and the protocol cohort 8/15-7/17. Data evaluated included the need for intervention, number of H/H checks, and outcomes. RESULTS: 330 children were included (216 historic; 114 protocol). Groups did not differ in percentage of male patients, injury severity score, or GCS. Median age in the historic cohort was younger than the protocol cohort (9 vs 12 years; p = 0.02). More children in the protocol group had a grade 5 injury (1% vs 9%; p < 0.0001). Groups did not differ in the number who required intervention or discharge disposition (including mortality). The protocol group had fewer H/H checks (median 5 vs 4, p < 0.0001); the two groups did not differ in their nadir H/H. The historic group had a longer median hospital length of stay (3 days vs 2, p = 0.0007). CONCLUSIONS: Decreasing the number of scheduled blood draws following a blunt liver or spleen injury in children is safe. Additional benefits include a decrease in the number of blood draws and a decrease in length of hospital stay. STUDY TYPE: Cost-effectiveness. LEVEL OF EVIDENCE: Level III.

Diagnostic blood loss from phlebotomy and hospital acquired anemia in patients with severe burns.

PURPOSE: The study was performed to estimate the diagnostic blood loss (DBL) volume during hospitalization and investigate its relationship with the development of moderate to severe hospital acquired anemia (HAA) and increased number of red blood cell (RBC) transfusion following extensive burns. MATERIALS AND METHODS: This was a retrospective study of adult burned patients with total body surface area (TBSA) burn larger than 40%, who were admitted to burn center of Changhai hospital between January 2005 and December 2017. RESULTS: We included a final number of 157 patients in the present study. Moderate to severe HAA within the fourth week postburn was developed in 46 of 121 patients who stayed over 28-day hospitalization. Patients with moderate to severe HAA had both significantly higher total DBL volume [245 (IQR: 183.75, 325.25) mL vs 168 (119, 163) mL ; P = 0.001] and DBL volume per day [10.22 (IQR: 8.57, 12.38) mL vs 6.63 (5.22, 10.42) mL/day; P = 0.005]. Logistic regression analysis revealed that both DBL volume per day and TBSA burn were independent risk factors for the development of moderate to severe HAA. CONCLUSIONS: Severely burned patients appear to be prone to develop HAA during hospitalization. The DBL volume contribute to the occurrence of moderate to severe HAA, which might be a modifiable target for preventing HAA.

Patterns of phlebotomy blood loss and transfusions in extremely low birth weight infants.

OBJECTIVE: Characterize frequency and volume of blood draws and transfusions in extremely low birth weight infants in the first 10 weeks of life. STUDY DESIGN: We included infants with a birth weight <1000 g born 23 0/7-29 6/7 weeks gestational age (GA) and with a length of stay ≥10 weeks, admitted between 2014 and 2016 to a single neonatal intensive care unit. RESULTS: Of 54 infants, median (25th, 75th percentile) GA and birth weight were 25 weeks (24, 26) and 665 g (587, 822), respectively. Median number of blood draws per infant decreased from 57 (49, 65) in week 1 to 12 (8, 22) in week 10. Median volume of blood extracted was 83 mL (70, 97), and median number of blood transfusions was 8 (5, 10). CONCLUSIONS: This cohort experienced a high number and volume of blood draws. Draw frequency and transfusions decreased over the first 10 weeks of life.

"Rainbow Draws" in the Emergency Department: Clinical Utility and Staff Perceptions.

BACKGROUND: Collecting a predefined set of blood tubes (the "rainbow draw") is a common but controversial practice in many emergency departments (EDs), with limited data to support it. We determined the actual utilization of rainbow draw tubes at a single facility and evaluated the perceptions of ED staff regarding the utility of rainbow draws. METHODS: We analyzed 2 weeks of ED visits (1326 visits by 1240 unique patients) to determine blood tube utilization for initial and add-on testing, as well as the incidence of additional venipunctures. We also surveyed ED staff regarding aspects of ED phlebotomy and test ordering. Utilization data analysis was structured to satisfy specific concerns addressed in the ED staff survey. RESULTS: Observed tube utilization data showed that fluoride/oxalate, citrate, and serum separator tubes were frequently discarded unused, and that the actual utility of the rainbow draw for add-on testing and avoiding additional venipunctures was low. ED staff perceived that the rainbow draw was highly valuable, both to expedite add-on testing and to avoid additional venipunctures. Contrasting the objective (utilization data) and subjective (survey results) to drive changes in the standard ED blood collection reduced the estimated waste blood by 175 L/year. CONCLUSIONS: Comparison of perceptions and objective utilization data drove process changes that were mutually agreeable to ED and laboratory staff. Although specifics of ED and laboratory work flows vary between institutions, the principles and strategy of this study are widely applicable.

It's Not Just a Needlestick: Exploring Phlebotomists' Knowledge, Training, and Use of Comfort Measures in Pediatric Care to Improve the Patient Experience.

BACKGROUND: Blood draws are a routine element of the pediatric patient experience. They are also associated with the greatest fear and pain for a child. Because of the limited literature regarding phlebotomists' knowledge, experience, training, or stress related to their use of comfort techniques during pediatric blood draws, this study explored current practices and training methods. Phlebotomist training tends to focus on clinical technique rather than pediatric or patient comfort support. The study includes aims to develop a measurement for phlebotomists' use of comfort techniques for pediatric blood draws. METHOD: Focus groups of parent advocates (n = 24) and pediatric phlebotomists (n = 11) reviewed the survey questionnaire, and it was revised before being e-mailed to hospital system phlebotomists (n = 128). RESULTS: Almost half of the sample group lacked training in child development. The most frequently used comfort measures were words of explanation and reassurance, positioning of the child, and distraction. Requesting child life specialist support and using pain management devices or topical anesthetics were used less often. Primary challenges to performing pediatric blood draws were anxious patients and parents. CONCLUSION: Phlebotomists' use of available comfort measures occurs infrequently. Including child development and comfort techniques in training programs is essential to providing pediatric patients with a more satisfactory experience.

Perceptions on the feasibility of decentralizing phlebotomy services in community anti-retroviral therapy group model in Lusaka, Zambia.

BACKGROUND: The focus of the community anti-retroviral therapy Group model is on drug refill, adherence and support groups. However, laboratory services are completely neglected in this model, and stable patient still have to go to the clinic for blood draws after drugs refills from the community. Due to the introduction of new ART drugs, the guidelines now recommend the use of viral loads to guide decision in switching all patients from NNRTI to dolutegravir based first line ART regimens. But the national viral load testing coverage stands at 37% and and falls short of meeting the global UNAIDS and phlebotomy delivery system is congested. The purpose of this study was to identify the perceptions in decentralizing phlebotomy services into the community anti-retroviral therapy Group model. METHOD: A qualitative case study design was used. Data were collected through ten Focused group discussions among community anti-retroviral therapy Group members, community and health care workers at anti-retroviral therapy clinics and in-depth interviews with five key informants. Data were managed with the help of Nvivo version 10 and analyzed using thematic method. RESULTS: Positive perceptions were identified as those which contributed to decongesting phlebotomy rooms, reduced missing phlebotomy appointments, work Load, and lost results. Improved quality of phlebotomy service delivery and testing coverage, innovative access to laboratory services and encouraged patient's accountability. The negative perceptions were compromised sample integrity, inability to perform prevention control and patients less contact with clinicians. CONCLUSION: The study has demonstrated that decentralizing phlebotomy services within the CAG model has greater potential to improve the quality of services delivery for patients. In addition, it has perceived threats on the quality of specimen collected, patient's safety, and health care.

A contemporary description of patients' estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center.

BACKGROUND: Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospital-wide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations. STUDY DESIGN AND METHODS: Data were obtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients. RESULTS: Data were included on 59,715 subjects. Mean daily estimated blood loss varied from 8.5 ± 6.5 mL/day onward to 27.2 ± 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations). CONCLUSION: Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy.

Safe phlebotomy reduction in stable pediatric liver and spleen injuries.

PURPOSE: Pediatric blunt solid organ injury management based on hemodynamic monitoring rather than grade may safely reduce resource expenditure and improve outcomes. Previously we have reported a retrospectively validated management algorithm for pediatric liver and spleen injuries which monitors hemodynamics without use of routine phlebotomy. We hypothesize that stable blunt pediatric isolated splenic/liver injuries can be managed safely using a protocol reliant on vital signs and not repeat hemoglobin levels. METHODS: A prospective multi-institutional study was performed at three pediatric trauma centers. All pediatric patients from 07/2016-12/2017 diagnosed with liver or splenic injuries were identified. If appropriate for the protocol, only a baseline hemoglobin was obtained unless hemodynamic instability as defined in an age-appropriate fashion was determined by treating physician discretion. Descriptive statistics were conducted. RESULTS: One hundred four patients were identified of which 38 were excluded from the protocol. There was a significant difference in abnormal shock index, pediatric age-adjusted (SIPA) values, hematocrit, and percentage of patients with hemoglobin less than 10 between the excluded and included patients. Of the 66 patients managed on the protocol, four patients had to be removed, two each on day one and day two. Of those four patients, only one required intervention. There were no mortalities. CONCLUSION: A phlebotomy limiting protocol may be a safe option for stable pediatric splenic and liver injuries cared for in a pediatric trauma center with the resources for rapid intervention should the need arise. The differences in groups highlight the importance of utilizing this protocol in the correct patient population. Reduced phlebotomy offers the potential for reduced resource expenditure without any evidence of increased morbidity or mortality. LEVEL OF EVIDENCE: Level IV.

Reducing Phlebotomy Utilization With Education and Changes to Computerized Provider Order Entry.

INTRODUCTION: Daily phlebotomy is often a standard procedure in hospitalized patients. Recently, this practice has begun receiving attention as a potential target for efforts focused on eliminating overuse. Several organizations have published their efforts in this arena. Interventions have included education, feedback, and changes to computerized provider order entry (CPOE) but have yielded mixed results. METHODS: A quality improvement initiative to reduce the utilization of daily phlebotomy was conducted at a 505-bed Academic Medical Center. This project involved a combination of educational interventions and changes to CPOE. The primary end point evaluated was the daily performance of complete blood counts (CBCs) and basic metabolic profiles (BMPs) on medical and surgery units relative to the corresponding hospital census. RESULTS: Over the course of this project from August 1, 2013, to September 23, 2016, there was a 15.2% reduction in CBCs (p < .001 for linear trend) and 13.1% reduction in BMPs. DISCUSSION: Our results suggest that layering multimodal interventions that involve both "hard-wired" changes to CPOE and education and performance feedback can result in decreased utilization of phlebotomy.

Experience in management of porphyria cutanea tarda in a tertiary referral Brazilian hospital from 2002 to 2017.

BACKGROUND: Porphyria cutanea tarda (PCT) is the most common porphyria worldwide. The known acquired precipitating factors that induce PCT include alcoholism, hepatitis C virus infection, human immunodeficiency virus infection, and estrogen intake. Hereditary hemochromatosis is considered an inherited risk factor. The aim of this study was to describe and analyze precipitating factors and family history, with emphasis on PCT management. METHODS: A retrospective study of 87 patients with PCT was conducted between January 2002 and December 2017. RESULTS: A male predominance of 1.8 : 1 was found. The median age at diagnosis was 49 years (range 18-71). Family history of PCT was observed in 19.5% of patients. Two or more acquired precipitating factors were present in 42.5%. Patients were treated with antimalarial monotherapy (72.4%), antimalarial combined with phlebotomy (22.9%), and only with phlebotomy (4.6%). Acquired precipitating factors and inherited factors were not associated with treatment group. There was a difference in 24 h-UP normalization rate between treatment groups; combined therapy takes longer than antimalarial monotherapy, 38 months versus 15 months, respectively (CI 95%, 6.5-63.5 vs. 12.9-17) (log-rank test, P = 0.004). CONCLUSION: Precipitating factors did not seem to be associated with treatment choice; however, all acquired and inherited precipitating factors should be investigated, and the choice between phlebotomy and/or antimalarials should be individualized. All dermatologists treating PCT patients should observe transferrin saturation and ferritin levels to search for underlying hereditary hemochromatosis.

Improvement of blood culture contamination rate, blood volume, and true positive rate after introducing a dedicated phlebotomy team.

The introduction of dedicated phlebotomy teams certified for blood collection has been reported to be highly cost-effective by reducing contamination rates. However, data on their effects on blood volume and true positive rate are limited. Therefore, we investigated the effect of replacing interns with a phlebotomy team on blood culture results. We performed a 24-month retrospective, quasi-experimental study before and after the introduction of a phlebotomy team dedicated to collecting blood cultures in a 2700-bed tertiary-care hospital. The microbiology laboratory database was used to identify adult patients with positive blood culture results. During the study period, there were no changes in blood collection method, blood culture tubes, and the application of antiseptic measures. Blood volume was measured by the BACTEC™ FX system based on red blood cell metabolism. A total of 162,207 blood cultures from 23,563 patients were analyzed, comprising 78,673 blood cultures during the intern period and 83,534 during the phlebotomy team period. Blood volume increased from a mean of 2.1 ml in the intern period to a mean of 5.6 ml in the phlebotomy team period (p < 0.001). Introduction of the phlebotomy team also reduced contamination rate (0.27% vs. 0.45%, p < 0.001) and led to a higher true positive rate (5.87% vs. 5.01%, p < 0.05). The increased true positive rate associated with the phlebotomy team involved both gram-positive and gram-negative bacteria. The introduction of a dedicated phlebotomy team can increase blood volumes, reduce blood culture contamination rate, and increase true positive rate.

Hypermedia on peripheral venipuncture: effectiveness in teaching nursing students.

OBJECTIVE: To assess the effectiveness of an educational hypermedia in the knowledge of Nursing academics on peripheral venipuncture. METHOD: Quasi-experimental study with pre and post-test design. RESULTS: The mean number of right answers of the 73 individuals who participated in the study, in the pre-test, was 7.7 (DP = 1.05), and 8.3 in the post-test (DP = 0.74). The comparation of pre and post hypermedia mean number of right answers showed significant difference (p < 0.001). CONCLUSION: Hypermedia is a strategy that increases knowledge and is feasible in the teaching-learning process, being useful as a support tool for teachers and for the development of undergraduate Nursing students.

Hypermedia on peripheral venipuncture: effectiveness in teaching nursing students / Hipermedia sobre punción venosa periférica: la efectividad en la enseñanza de académicos de enfermería / Hipermídia sobre punção venosa periférica: efetividade no ensino de acadêmicos de enfermagem

ABSTRACT Objective: To assess the effectiveness of an educational hypermedia in the knowledge of Nursing academics on peripheral venipuncture. Method: Quasi-experimental study with pre and post-test design. Results: The mean number of right answers of the 73 individuals who participated in the study, in the pre-test, was 7.7 (DP = 1.05), and 8.3 in the post-test (DP = 0.74). The comparation of pre and post hypermedia mean number of right answers showed significant difference (p < 0.001). Conclusion: Hypermedia is a strategy that increases knowledge and is feasible in the teaching-learning process, being useful as a support tool for teachers and for the development of undergraduate Nursing students.

RESUMEN Objetivo: Evaluar la efectividad de una hipermedia educativa en el conocimiento de académicos de enfermería acerca de la punción venosa periférica. Método: Estudio casi-experimental con diseño pre y pos prueba. Resultados: El promedio de aciertos de los 73 individuos participantes del estudio, en el pre prueba, ha sido de 7,7 (DP = 1,05), y 8,3 en el pos prueba (DP = 0,74). La comparación en los promedios de aciertos pre y pos hipermedia ha presentado diferencia significativa (p < 0,001). Conclusión: La hipermedia es una estrategia que incrementa el conocimiento y es viable en el proceso enseñanza-aprendizaje, siendo útil como herramienta de apoyo para los profesores y para el desarrollo de los estudiantes de graduación en enfermería.

RESUMO Objetivo: Avaliar a efetividade de uma hipermídia educativa no conhecimento de acadêmicos de enfermagem acerca da punção venosa periférica. Método: Estudo quase-experimental com desenho pré e pós-teste. Resultados: A média de acertos dos 73 indivíduos participantes do estudo, no pré-teste, foi de 7,7 (DP = 1,05), e 8,3 no pós-teste (DP = 0,74). A comparação nas médias de acertos pré e pós hipermídia apresentou diferença significativa (p < 0,001). Conclusão: A hipermídia é uma estratégia que aumenta o conhecimento e é viável no processo ensino-aprendizagem, sendo útil como ferramenta de apoio para os professores e para o desenvolvimento de estudantes de graduação em enfermagem.

RBC Exposure in Pediatric Extracorporeal Membrane Oxygenation: Epidemiology and Factors Associated With Large Blood Transfusion Volume.

OBJECTIVES: To quantify and identify factors associated with large RBC exposure in children supported with extracorporeal membrane oxygenation. DESIGN: Retrospective cohort study. SETTING: Single tertiary care children's hospital. PATIENTS: One-hundred twenty-two children supported with extracorporeal membrane oxygenation for greater than 12 hours during January 1, 2015, to December 31, 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical, laboratory, and survival data were obtained from medical records. Only data from patients' first extracorporeal membrane oxygenation run were used. The primary outcome was RBC volume exposure during extracorporeal membrane oxygenation (mL/kg/d). Patients with RBC exposure volume greater than 75th percentile were categorized as "high RBC use" patients. A "bleeding day" was identified if mediastinum or cannula sites were explored and/or Factor VIIa administration, gastrointestinal, pulmonary, or intracranial hemorrhages occurred. Median age was 0.3 years (interquartile range, 0-3 yr). Congenital heart disease (n = 56; 46%) was the most common diagnosis. Median RBC volume transfused during extracorporeal membrane oxygenation was 39 mL/kg/d (interquartile range, 21-66 mL/kg/d). High RBC use patients were more likely be supported by venoarterial extracorporeal membrane oxygenation (100 vs 76%; p = 0.006), have congenital heart disease (68 vs 39%; p = 0.02), and experience bleeding (33 vs 11% d; p < 0.001). High RBC use patients showed a trend toward higher in-hospital mortality (58 vs 37%; p = 0.07). In the multivariable analysis, younger age (-9% per year; 95% CI, -10% to -7%; p < 0.001), more blood draws per day (+8%; 95% CI, 6-11%; p < 0.001), and higher proportion of bleeding days (+22% per 10% increase; 95% CI, 16-29%; p < 0.001) were associated with larger RBC exposure (model R = 0.66). CONCLUSIONS: Bleeding during extracorporeal membrane oxygenation, frequent laboratory draws, and younger age were associated with increased RBC exposure during extracorporeal membrane oxygenation. Higher transfusion volume was associated with increased mortality.

Cytoreductive treatment patterns among US veterans with polycythemia vera.

BACKGROUND: Polycythemia vera (PV) is a myeloproliferative neoplasm associated with increased thrombotic and cardiovascular risk, which are key contributors to patient morbidity and mortality. The Veterans Health Administration (VHA) is the largest integrative health network in the United States. Available data concerning patients with PV in this population are limited. METHODS: This retrospective observational study evaluated the characteristics, management, and outcomes of patients with PV in the VHA Medical SAS® Dataset (October 1, 2005, to September 30, 2012). Inclusion criteria were ≥ 2 claims for PV (ie, PV diagnostic code was recorded) ≥30 days apart during the identification period, age ≥ 18 years, and continuous health plan enrollment from ≥12 months before the index date until the end of follow-up. All data were analyzed using descriptive statistics. RESULTS: The analysis included 7718 patients (median age, 64 years; male, 98%; white, 64%). The most common comorbidities before the index date were hypertension (72%), dyslipidemia (54%), and diabetes (24%); 33% had a history of smoking. During the follow-up period (median, 4.8 years), most patients did not receive treatment with cytoreductive therapy, including phlebotomy (53%), or antiplatelet agents, such as aspirin (57%). The thrombotic and cardiovascular event rates per 1000 patient-years were 60.5 and 83.8, respectively. Among patients who received cytoreductive treatment, the thrombotic event rate was 48.9 per 1000 patient-years. The overall mortality rate was 51.2 per 1000 patient-years. CONCLUSION: The notable rates of thrombotic and cardiovascular events observed in this analysis, even among patients receiving cytoreductive treatment, highlight the important unmet clinical needs of patients with PV in the VHA.