Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 975
Filtrar
1.
Anaesthesia ; 76(1): 19-26, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32406071

RESUMO

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Reoperação/mortalidade , Reoperação/estatística & dados numéricos , Esternotomia/mortalidade , Esternotomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Extubação , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/cirurgia , Cuidados Críticos/estatística & dados numéricos , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/cirurgia , Terapia de Substituição Renal/mortalidade , Terapia de Substituição Renal/estatística & dados numéricos , Reino Unido/epidemiologia
2.
Nutrients ; 12(12)2020 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-33321828

RESUMO

Despite the importance of early recognition of metabolic bone disease (MBD) of prematurity, there is still significant variability in screening practices across institutions. We conducted an observational study of infants born at ≤32 weeks of gestation with a birth weight of ≤1500 g (n = 218) to identify clinical factors associated with biochemical indicators of MBD. Bone mineral status was assessed by measuring alkaline phosphatase and phosphate levels between weeks 3 and 5 of life. Two comparisons were performed after classifying infants as either MBD (cases) or non-MBD (controls), and as either high or low risk for MBD, as determined based on the results of MBD screening. In total, 27 infants (12.3%) were classified as cases and 96 (44%) as high-risk. Compared with controls, MBD infants had a significantly lower gestational age and birth weight, and a longer duration of parenteral nutrition and hospital stay. Respiratory outcomes were significantly poorer in high- versus low-risk infants. Multivariate logistic regression showed that birth weight was the only independent risk factor for MBD (odds ratio [OR]/100 g, 0.811; confidence interval [CI95%], 0.656-0.992; p = 0.045) and that birth weight (OR/100 g, 0.853; CI95%, 0.731-0.991; p = 0.039) and red blood cell transfusion (OR, 2.661; CI95%, 1.308-5.467; p = 0.007) were independent risk factors for high risk of MBD. Our findings provide evidence of risk factors for MBD that could help clinicians to individualize perinatal management. The association of red blood cell transfusion with MBD is a novel finding that may be related to iron overload and that merits further study.


Assuntos
Doenças Ósseas Metabólicas/diagnóstico , Doenças do Prematuro/diagnóstico , Recém-Nascido Prematuro/sangue , Triagem Neonatal/métodos , Fosfatase Alcalina/sangue , Peso ao Nascer , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Nutrição Parenteral/estatística & dados numéricos , Fosfatos/sangue , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
3.
Pediatrics ; 146(5)2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33087550

RESUMO

BACKGROUND: Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs). METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion. RESULTS: A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63-2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55-2.55; P < .01). In a propensity score-matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29-1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24-2.01; P = .01). CONCLUSIONS: In a propensity score-matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.


Assuntos
Transfusão de Sangue/mortalidade , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Operatórios/mortalidade , Transfusão de Sangue/estatística & dados numéricos , Comorbidade , Intervalos de Confiança , Bases de Dados Factuais , Transfusão de Eritrócitos/efeitos adversos , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro/sangue , Masculino , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Melhoria de Qualidade , Análise de Regressão , Resultado do Tratamento
4.
JAMA ; 324(6): 560-570, 2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32780138

RESUMO

Importance: Red blood cell transfusions are commonly administered to infants weighing less than 1000 g at birth. Evidence-based transfusion thresholds have not been established. Previous studies have suggested higher rates of cognitive impairment with restrictive transfusion thresholds. Objective: To compare the effect of liberal vs restrictive red blood cell transfusion strategies on death or disability. Design, Setting, and Participants: Randomized clinical trial conducted in 36 level III/IV neonatal intensive care units in Europe among 1013 infants with birth weights of 400 g to 999 g at less than 72 hours after birth; enrollment took place between July 14, 2011, and November 14, 2014, and follow-up was completed by January 15, 2018. Interventions: Infants were randomly assigned to liberal (n = 492) or restrictive (n = 521) red blood cell transfusion thresholds based on infants' postnatal age and current health state. Main Outcome and Measures: The primary outcome, measured at 24 months of corrected age, was death or disability, defined as any of cognitive deficit, cerebral palsy, or severe visual or hearing impairment. Secondary outcome measures included individual components of the primary outcome, complications of prematurity, and growth. Results: Among 1013 patients randomized (median gestational age at birth, 26.3 [interquartile range {IQR}, 24.9-27.6] weeks; 509 [50.2%] females), 928 (91.6%) completed the trial. Among infants in the liberal vs restrictive transfusion thresholds groups, respectively, incidence of any transfusion was 400/492 (81.3%) vs 315/521 (60.5%); median volume transfused was 40 mL (IQR, 16-73 mL) vs 19 mL (IQR, 0-46 mL); and weekly mean hematocrit was 3 percentage points higher with liberal thresholds. Among infants in the liberal vs restrictive thresholds groups, the primary outcome occurred in 200/450 (44.4%) vs 205/478 (42.9%), respectively, for a difference of 1.6% (95% CI, -4.8% to 7.9%; P = .72). Death by 24 months occurred in 38/460 (8.3%) vs 44/491 (9.0%), for a difference of -0.7% (95% CI, -4.3% to 2.9%; P = .70), cognitive deficit was observed in 154/410 (37.6%) vs 148/430 (34.4%), for a difference of 3.2% (95% CI, -3.3% to 9.6%; P = .47), and cerebral palsy occurred in 18/419 (4.3%) vs 25/443 (5.6%), for a difference of -1.3% (95% CI, -4.2% to 1.5%; P = .37), in the liberal vs the restrictive thresholds groups, respectively. In the liberal vs restrictive thresholds groups, necrotizing enterocolitis requiring surgical intervention occurred in 20/492 (4.1%) vs 28/518 (5.4%); bronchopulmonary dysplasia occurred in 130/458 (28.4%) vs 126/485 (26.0%); and treatment for retinopathy of prematurity was required in 41/472 (8.7%) vs 38/492 (7.7%). Growth at follow-up was also not significantly different between groups. Conclusions and Relevance: Among infants with birth weights of less than 1000 g, a strategy of liberal blood transfusions compared with restrictive transfusions did not reduce the likelihood of death or disability at 24 months of corrected age. Trial Registration: ClinicalTrials.gov Identifier: NCT01393496.


Assuntos
Transtornos Cognitivos/etiologia , Transfusão de Eritrócitos/efeitos adversos , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Displasia Broncopulmonar/etiologia , Paralisia Cerebral/etiologia , Enterocolite Necrosante/etiologia , Enterocolite Necrosante/cirurgia , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Transtornos da Audição/etiologia , Hematócrito/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido de Peso Extremamente Baixo ao Nascer/crescimento & desenvolvimento , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Retinopatia da Prematuridade/terapia , Sensibilidade e Especificidade , Transtornos da Visão/etiologia
5.
Cochrane Database Syst Rev ; 8: CD012451, 2020 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-32790892

RESUMO

BACKGROUND: Approximately 30% of adults undergoing non-cardiac surgery suffer from preoperative anaemia. Preoperative anaemia is a risk factor for mortality and adverse outcomes in different surgical specialties and is frequently the reason for blood transfusion. The most common causes are renal, chronic diseases, and iron deficiency. International guidelines recommend that the cause of anaemia guide preoperative anaemia treatment. Recombinant human erythropoietin (rHuEPO) with iron supplementation has frequently been used to increase preoperative haemoglobin concentrations in patients in order to avoid the need for perioperative allogeneic red blood cell (RBC) transfusion. OBJECTIVES: To evaluate the efficacy of preoperative rHuEPO therapy (subcutaneous or parenteral) with iron (enteral or parenteral) in reducing the need for allogeneic RBC transfusions in preoperatively anaemic adults undergoing non-cardiac surgery. SEARCH METHODS: We searched CENTRAL, Ovid MEDLINE(R), Ovid Embase, ISI Web of Science: SCI-EXPANDED and CPCI-S, and clinical trial registries WHO ICTRP and ClinicalTrials.gov on 29 August 2019. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) that compared preoperative rHuEPO + iron therapy to control treatment (placebo, no treatment, or standard of care with or without iron) for preoperatively anaemic adults undergoing non-cardiac surgery. We used the World Health Organization (WHO) definition of anaemia: haemoglobin concentration (g/dL) less than 13 g/dL for males, and 12 g/dL for non-pregnant females (decision of inclusion based on mean haemoglobin concentration). We defined two subgroups of rHuEPO dosage: 'low' for 150 to 300 international units (IU)/kg body weight, and 'high' for 500 to 600 IU/kg body weight. DATA COLLECTION AND ANALYSIS: Two review authors collected data from the included studies. Our primary outcome was the need for RBC transfusion (no autologous transfusion, fresh frozen plasma or platelets), measured in transfused participants during surgery (intraoperative) and up to five days after surgery. Secondary outcomes of interest were: haemoglobin concentration (directly before surgery), number of RBC units (where one unit contains 250 to 450 mL) transfused per participant (intraoperative and up to five days after surgery), mortality (within 30 days after surgery), length of hospital stay, and adverse events (e.g. renal dysfunction, thromboembolism, hypertension, allergic reaction, headache, fever, constipation). MAIN RESULTS: Most of the included trials were in orthopaedic, gastrointestinal, and gynaecological surgery and included participants with mild and moderate preoperative anaemia (haemoglobin from 10 to 12 g/dL). The duration of preoperative rHuEPO treatment varied across the trials, ranging from once a week to daily or a 5-to-10-day period, and in one trial preoperative rHuEPO was given on the morning of surgery and for five days postoperatively. We included 12 trials (participants = 1880) in the quantitative analysis of the need for RBC transfusion following preoperative treatment with rHuEPO + iron to correct preoperative anaemia in non-cardiac surgery; two studies were multiarmed trials with two different dose regimens. Preoperative rHuEPO + iron given to anaemic adults reduced the need RBC transfusion (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.38 to 0.80; participants = 1880; studies = 12; I2 = 84%; moderate-quality evidence due to inconsistency). This analysis suggests that on average, the combined administration of rHuEPO + iron will mean 231 fewer individuals will need transfusion for every 1000 individuals compared to the control group. Preoperative high-dose rHuEPO + iron given to anaemic adults increased the haemoglobin concentration (mean difference (MD) 1.87 g/dL, 95% CI 1.26 to 2.49; participants = 852; studies = 3; I2 = 89%; low-quality evidence due to inconsistency and risk of bias) but not low-dose rHuEPO + iron (MD 0.11 g/dL, 95% CI -0.46 to 0.69; participants = 334; studies = 4; I2 = 69%; low-quality evidence due to inconsistency and risk of bias). There was probably little or no difference in the number of RBC units when rHuEPO + iron was given preoperatively (MD -0.09, 95% CI -0.23 to 0.05; participants = 1420; studies = 6; I2 = 2%; moderate-quality evidence due to imprecision).  There was probably little or no difference in the risk of mortality within 30 days of surgery (RR 1.19, 95% CI 0.39 to 3.63; participants = 230; studies = 2; I2 = 0%; moderate-quality evidence due to imprecision) or of adverse events including local rash, fever, constipation, or transient hypertension (RR 0.93, 95% CI 0.68 to 1.28; participants = 1722; studies = 10; I2 = 0%; moderate-quality evidence due to imprecision). The administration of rHuEPO + iron before non-cardiac surgery did not clearly reduce the length of hospital stay of preoperative anaemic adults (MD -1.07, 95% CI -4.12 to 1.98; participants = 293; studies = 3; I2 = 87%; low-quality evidence due to inconsistency and imprecision). AUTHORS' CONCLUSIONS: Moderate-quality evidence suggests that preoperative rHuEPO + iron therapy for anaemic adults prior to non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient. There were no important differences in the risk of adverse events or mortality within 30 days, nor in length of hospital stay. Further, well-designed, adequately powered RCTs are required to estimate the impact of this combined treatment more precisely.


Assuntos
Anemia/tratamento farmacológico , Eritropoetina/uso terapêutico , Ferro/uso terapêutico , Cuidados Pré-Operatórios/métodos , Procedimentos Cirúrgicos Operatórios , Adulto , Anemia/sangue , Procedimentos Cirúrgicos do Sistema Digestório , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Procedimentos Cirúrgicos em Ginecologia , Hemoglobina A/metabolismo , Humanos , Tempo de Internação , Masculino , Procedimentos Ortopédicos , Placebos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/uso terapêutico , Procedimentos Cirúrgicos Operatórios/mortalidade
6.
Br J Haematol ; 191(3): 382-385, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32640484

RESUMO

There has been a significant surge in admissions to critical care during the coronavirus disease 2019 (COVID-19) pandemic. At present, the demands on blood components have not been described. We reviewed their use during the first 6 weeks of the outbreak from 3 March 2020 in a tertiary-level critical care department providing venovenous extracorporeal membrane oxygenation (vv-ECMO). A total of 265 patients were reviewed, with 235 not requiring ECMO and 30 requiring vv-ECMO. In total, 50 patients required blood components during their critical care admission. Red cell concentrates were the most frequently transfused component in COVID-19-infected patients with higher rates of use during vv-ECMO. The use of fresh frozen plasma, cryoprecipitate and platelet transfusions was low in a period prior to the use of convalescent plasma.


Assuntos
Betacoronavirus , Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Infecções por Coronavirus/terapia , Cuidados Críticos/estatística & dados numéricos , Pneumonia Viral/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/sangue , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/métodos , Bases de Dados Factuais , Transfusão de Eritrócitos/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Fator VIII/uso terapêutico , Feminino , Fibrinogênio/uso terapêutico , Hemorragia/epidemiologia , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Londres/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Plasma , Transfusão de Plaquetas/estatística & dados numéricos , Pneumonia Viral/sangue , Pneumonia Viral/epidemiologia , Utilização de Procedimentos e Técnicas
7.
Am J Cardiol ; 129: 79-86, 2020 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-32540167

RESUMO

According to the Valve Academic Resortium, underweight is one parameter in the definition of frailty, which is associated with increased mortality after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Aims of our study were (1) to examine the impact of underweight on mortality after TAVI and SAVR and (2) to determine the effect of intervention mode (TAVI vs SAVR) on mortality in underweight patients from the German Aortic Valve Registry. Overall, 35,109 patients treated with TAVI or SAVR were studied. Outcomes of underweight (body mass index [BMI] <20 kg/m2) TAVI and SAVR patients were compared using propensity score weighting. Prevalence of underweight was 5.7% in patients who underwent TAVI and 2.9% in patients who underwent SAVR. Underweight patients had significantly increased mortality rates for both treatment strategies compared with normal weight patients (BMI 20 to 30 kg/m2). Comparing underweight TAVI and SAVR-patients using propensity score weighting, no statistically significant differences regarding mortality rates were observed. Subgroup analysis of severely underweight patients (BMI <18.5 kg/m²) revealed no significant increase of mortality after TAVI compared with underweight patients (BMI <20 kg/m2), whereas severely underweight SAVR patients showed twofold increased mortality rates. In conclusion, underweight in patients who underwent TAVI or SAVR is rare, but it is associated with increased mortality. Especially severely underweight SAVR patients showed excess mortality rates.


Assuntos
Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Complicações Pós-Operatórias/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Magreza/epidemiologia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/epidemiologia , Índice de Massa Corporal , Baixo Débito Cardíaco/epidemiologia , Doença da Artéria Coronariana/epidemiologia , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Alemanha/epidemiologia , Humanos , Hipertensão Pulmonar/epidemiologia , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Mortalidade , Prevalência , Prognóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Diálise Renal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Índice de Gravidade de Doença , Volume Sistólico
8.
Saudi Med J ; 41(6): 628-634, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32518930

RESUMO

OBJECTIVES: To assess and enhance the efficiency of transfusion services in maternity hospitals. METHODS: A case control study was conducted from January to December 2016. A corrective policy of replacing preoperative type and hold step with blood transfusion request (BTR) hold was used only on healthy patients undergoing elective cesarean sections (c-section). The crossmatch/transfusion (C:T) ratio and a cost comparison were the evaluating factors. Data were analyzed using an Excel spreadsheet and SPSS statistical software. RESULTS: A total of 1,200 BTRs were analyzed, comprising 659 before implementation of the corrective policy and 541 blood transfusion requests after implementation of the corrective policy. From January to March, the C:T ratio of c-sections was nearly 7 times the American Association of Blood Banks recommended limit of 2.5. Most of the blood units (94%) were damaged due to repeated booking. After implementation, the cost-e ectiveness of erythrocyte transfusion was greatly enhanced as all the ordered blood units were used and the C:T ratio was reduced to the ideal limit of one. The number of destroyed units was drastically decreased from 450 units to zero; as a result, 83% of the transfusion costs were saved. CONCLUSION: The policy enhances the cost-effectiveness of erythrocyte transfusion and laboratory testing, and saves on additional, unnecessary costs.


Assuntos
Eficiência , Transfusão de Eritrócitos/economia , Transfusão de Eritrócitos/normas , Maternidades , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Políticas , Tipagem e Reações Cruzadas Sanguíneas , Estudos de Casos e Controles , Cesárea , Análise Custo-Benefício , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Gravidez
9.
Ann Hematol ; 99(7): 1505-1514, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32390114

RESUMO

The International Paroxysmal Nocturnal Hemoglobinuria (PNH) Registry (NCT01374360) was initiated to optimize patient management by collecting data regarding disease burden, progression, and clinical outcomes. Herein, we report updated baseline demographics, clinical characteristics, disease burden data, and observed trends regarding clone size in the largest cohort of Registry patients. Patients with available data as of July 2017 were stratified by glycosylphosphatidylinositol (GPI)-deficient granulocyte clone size (< 10%, ≥ 10%-< 50%, and ≥ 50%). All patients were untreated with eculizumab at baseline, defined as date of eculizumab initiation or date of Registry enrollment (if never treated with eculizumab). Outcomes assessed in the current analysis included proportions of patients with high disease activity (HDA), history of major adverse vascular events (MAVEs; including thrombotic events [TEs]), bone marrow failure (BMF), red blood cell (RBC) transfusions, and PNH-related symptoms. A total of 4439 patients were included, of whom 2701 (60.8%) had available GPI-deficient granulocyte clone size data. Among these, median clone size was 31.8% (1002 had < 10%; 526 had ≥ 10%-< 50%; 1173 had ≥ 50%). There were high proportions of patients with HDA (51.6%), history of MAVEs (18.8%), BMF (62.6%), RBC transfusion (61.3%), and impaired renal function (42.8%). All measures except RBC transfusion history significantly correlated with GPI-deficient granulocyte clone size. A large proportion of patients with GPI-deficient granulocyte clone size < 10% had hemolysis (9.7%), MAVEs (10.2%), HDA (9.1%), and/or PNH-related symptoms. Although larger GPI-deficient granulocyte clone sizes were associated with higher disease burden, a substantial proportion of patients with smaller clone sizes had history of MAVEs/TEs.


Assuntos
Hemoglobinúria Paroxística/diagnóstico , Hemoglobinúria Paroxística/epidemiologia , Adulto , Transtornos da Insuficiência da Medula Óssea/diagnóstico , Transtornos da Insuficiência da Medula Óssea/epidemiologia , Transtornos da Insuficiência da Medula Óssea/etiologia , Efeitos Psicossociais da Doença , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Granulócitos/patologia , Hemoglobinúria Paroxística/patologia , Hemoglobinúria Paroxística/terapia , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Sistema de Registros , Índice de Gravidade de Doença , Adulto Jovem
10.
J Card Surg ; 35(6): 1220-1227, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32353903

RESUMO

BACKGROUND AND AIM OF THE STUDY: Transfusion of blood products after coronary artery bypass grafting (CABG) is associated with increased morbidity and mortality. We evaluated the perioperative use of blood products in patients undergoing CABG in our institution over the past two decades. METHODS: The study included 18 992 patients who underwent isolated CABG at our hospital between 1998 and 2017. Baseline characteristics of patients and the number of perioperative transfusions during their hospital stay (including red blood cells [RBCs], platelets, and fresh frozen plasma [FFP]) were assessed. Logistic regression models were used to identify risk factors for perioperative transfusion. RESULTS: The rates of perioperative RBC transfusion decreased for all patients undergoing isolated CABG (52.1% in 1998 vs 18.6% in 2017) in our institution. The mean number of transfused RBC units was significantly higher in women than in men (1.57 ± 2.2 vs 0.68 ± 1.84; P < .005); this difference remained significant over the years. After adjusting the results for other risk factors, female sex was a significant independent risk factor for perioperative RBC transfusion. The platelet transfusion rate increased over the past two decades (1.4% in 1998 vs 9.7% in 2017). The number of FFP transfusions remained unchanged. CONCLUSIONS: Over the past two decades, we observed a decrease in the incidence of perioperative RBC transfusions in patients undergoing isolated CABG, whereas platelet transfusions increased. Female sex was an independent predictor of perioperative RBC transfusion.


Assuntos
Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/tendências , Transfusão de Eritrócitos/estatística & dados numéricos , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Transfusão de Plaquetas/estatística & dados numéricos , Idoso , Transfusão de Eritrócitos/efeitos adversos , Transfusão de Eritrócitos/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/tendências , Transfusão de Plaquetas/efeitos adversos , Transfusão de Plaquetas/tendências , Fatores de Risco , Fatores Sexuais
11.
Transfusion ; 60(5): 922-931, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32358836

RESUMO

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.


Assuntos
Transfusão de Sangue/economia , Transfusão de Sangue/métodos , Adolescente , Adulto , Contagem de Células Sanguíneas/economia , Plaquetas/citologia , Transfusão de Sangue/mortalidade , Transfusão de Sangue/estatística & dados numéricos , Análise Custo-Benefício , Contagem de Eritrócitos , Transfusão de Eritrócitos/economia , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Eritrócitos/citologia , Feminino , Hemorragia/sangue , Hemorragia/mortalidade , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Plasma/citologia , Transfusão de Plaquetas/economia , Transfusão de Plaquetas/métodos , Transfusão de Plaquetas/mortalidade , Transfusão de Plaquetas/estatística & dados numéricos , Ressuscitação/mortalidade , Ressuscitação/estatística & dados numéricos , Adulto Jovem
12.
J Cardiothorac Surg ; 15(1): 98, 2020 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-32410683

RESUMO

BACKGROUND: Major bleeding and allogeneic transfusion leads to negative outcomes in patients receiving cardiac surgery with cardiopulmonary bypass (CPB). Ulinastatin, a urine trypsin inhibitor, relieves systemic inflammation and improves coagulation profiles with however sparse evidence of its effects on blood loss and allogeneic transfusion in this specific population. METHODS: In this prospective randomized controlled trial, 426 consecutive patients receiving open heart surgery with CPB were randomly assigned into three groups to receive ulinastatin (group U, n = 142), tranexamic acid (group T, n = 143) or normal saline (group C, n = 141). The primary outcome was the total volume of post-operative bleeding and the secondary outcome included the volume and exposure of allogeneic transfusion, the incidence of stroke, post-operative myocardial infarction, renal failure, respiratory failure and all-cause mortality. A ten-year follow-up was carried on to evaluate long-term safety. RESULTS: Compared with placebo, ulinastatin significantly reduced the volume of post-operative blood loss within 24 h (688.39 ± 393.55 ml vs 854.33 ± 434.03 ml MD - 165.95 ml, 95%CI - 262.88 ml to - 69.01 ml, p < 0.001) and the volume of allogeneic erythrocyte transfusion (2.57 ± 3.15 unit vs 3.73 ± 4.21 unit, MD-1.16 unit, 95%CI - 2.06 units to - 0.26 units, p = 0.002). The bleeding and transfusion outcomes were comparable between the ulinastatin group and the tranexamic acid group. In-hospital outcomes and 10-year follow-up showed no statistical difference in mortality and major morbidity among groups. CONCLUSIONS: Ulinastatin reduced post-operative blood loss and allogeneic erythrocyte transfusion in heart surgery with CPB. The mortality and major morbidity was comparable among the groups shown by the 10-year follow-up. TRIAL REGISTRATION: The trial was retrospectively registered on February 2, 2010. TRIAL REGISTRATION NUMBER: https://www.clinicaltrials.gov Identifier: NCT01060189.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Transfusão de Eritrócitos/estatística & dados numéricos , Glicoproteínas/uso terapêutico , Hemorragia Pós-Operatória/prevenção & controle , Inibidores da Tripsina/uso terapêutico , Adolescente , Adulto , Idoso , Antifibrinolíticos/uso terapêutico , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/diagnóstico , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/terapia , Estudos Prospectivos , Ácido Tranexâmico/uso terapêutico , Resultado do Tratamento , Adulto Jovem
13.
Lancet Haematol ; 7(6): e469-e478, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32470438

RESUMO

BACKGROUND: Transfusion-dependent haemoglobinopathies require lifelong iron chelation therapy with one of the three iron chelators (deferiprone, deferasirox, or deferoxamine). Deferasirox and deferiprone are the only two oral chelators used in adult patients with transfusion-dependent haemoglobinopathies. To our knowledge, there are no randomised clinical trials comparing deferiprone, a less expensive iron chelator, with deferasirox in paediatric patients. We aimed to show the non-inferiority of deferiprone versus deferasirox. METHODS: DEEP-2 was a phase 3, multicentre, randomised trial in paediatric patients (aged 1 month to 18 years) with transfusion-dependent haemoglobinopathies. The study was done in 21 research hospitals and universities in Italy, Egypt, Greece, Albania, Cyprus, Tunisia, and the UK. Participants were receiving at least 150 mL/kg per year of red blood cells for the past 2 years at the time of enrolment, and were receiving deferoxamine (<100 mg/kg per day) or deferasirox (<40 mg/kg per day; deferasirox is not registered for use in children aged <2 years so only deferoxamine was being used in these patients). Any previous chelation treatment was permitted with a 7-day washout period. Patients were randomly assigned 1:1 to receive orally administered daily deferiprone (75-100 mg/kg per day) or daily deferasirox (20-40 mg/kg per day) administered as dispersible tablets, both with dose adjustment for 12 months, stratified by age (<10 years and ≥10 years) and balanced by country. The primary efficacy endpoint was based on predefined success criteria for changes in serum ferritin concentration (all patients) and cardiac MRI T2-star (T2*; patients aged >10 years) to show non-inferiority of deferiprone versus deferasirox in the per-protocol population, defined as all randomly assigned patients who received the study drugs and had available data for both variables at baseline and after 1 year of treatment, without major protocol violations. Non-inferiority was based on the two-sided 95% CI of the difference in the proportion of patients with treatment success between the two groups and was shown if the lower limit of the two-sided 95% CI was greater than -12·5%. Safety was assessed in all patients who received at least one dose of study drug. This study is registered with EudraCT, 2012-000353-31, and ClinicalTrials.gov, NCT01825512. FINDINGS: 435 patients were enrolled between March 17, 2014, and June 16, 2016, 393 of whom were randomly assigned to a treatment group (194 to the deferiprone group; 199 to the deferasirox group). 352 (90%) of 390 patients had ß-thalassaemia major, 27 (7%) had sickle cell disease, five (1%) had thalassodrepanocytosis, and six (2%) had other haemoglobinopathies. Median follow-up was 379 days (IQR 294-392) for deferiprone and 381 days (350-392) for deferasirox. Non-inferiority of deferiprone versus deferasirox was established (treatment success in 69 [55·2%] of 125 patients assigned deferiprone with primary composite efficacy endpoint data available at baseline and 1 year vs 80 [54·8%] of 146 assigned deferasirox, difference 0·4%; 95% CI -11·9 to 12·6). No significant difference between the groups was shown in the occurrence of serious and drug-related adverse events. Three (2%) cases of reversible agranulocytosis occurred in the 193 patients in the safety analysis in the deferiprone group and two (1%) cases of reversible renal and urinary disorders (one case of each) occurred in the 197 patients in the deferasirox group. Compliance was similar between treatment groups: 183 (95%) of 193 patients in the deferiprone group versus 192 (97%) of 197 patients in the deferisirox group. INTERPRETATION: In paediatric patients with transfusion-dependent haemoglobinopathies, deferiprone was effective and safe in inducing control of iron overload during 12 months of treatment. Considering the need for availability of more chelation treatments in paediatric populations, deferiprone offers a valuable treatment option for this age group. FUNDING: EU Seventh Framework Programme.


Assuntos
Deferasirox/uso terapêutico , Deferiprona/uso terapêutico , Transfusão de Eritrócitos/métodos , Hemoglobinopatias/tratamento farmacológico , Quelantes de Ferro/uso terapêutico , Sobrecarga de Ferro/tratamento farmacológico , Administração Oral , Adolescente , Agranulocitose/induzido quimicamente , Agranulocitose/epidemiologia , Albânia/epidemiologia , Anemia Falciforme/terapia , Técnicas de Imagem Cardíaca/métodos , Criança , Pré-Escolar , Chipre/epidemiologia , Deferasirox/administração & dosagem , Deferasirox/economia , Deferiprona/administração & dosagem , Deferiprona/economia , Egito/epidemiologia , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Ferritinas/sangue , Ferritinas/efeitos dos fármacos , Grécia/epidemiologia , Hemoglobinopatias/terapia , Humanos , Lactente , Quelantes de Ferro/administração & dosagem , Quelantes de Ferro/economia , Sobrecarga de Ferro/sangue , Itália/epidemiologia , Imageamento por Ressonância Magnética , Masculino , Cooperação do Paciente , Resultado do Tratamento , Tunísia/epidemiologia , Reino Unido/epidemiologia , Doenças Urológicas/induzido quimicamente , Doenças Urológicas/epidemiologia , Talassemia beta/terapia
14.
J Surg Res ; 252: 139-146, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278968

RESUMO

BACKGROUND: Age and massive transfusion are predictors of mortality after trauma. We hypothesized that increasing age and high-volume transfusion would result in progressively elevated mortality rates and that a transfusion "ceiling" would define futility. METHODS: The Trauma Quality Improvement Program (TQIP) database was queried for 2013-2016 records and our level I trauma registry was reviewed from 2013 to 2018. Demographic, mortality, and blood transfusion data were collected. Patients were grouped by decade of life and by packed red blood cell (pRBC) transfusion requirement (zero units, 1-3 units, or ≥4 units) within 4 h of admission. RESULTS: TQIP analysis demonstrated an in-hospital mortality risk that increased linearly with age, to an odds ratio of 10.1 in ≥80 y old (P < 0.01). Mortality rates were significantly higher in older adults (P < 0.01) and those with more pRBCs transfused. In massively transfused patients, the transfusion "ceiling" was dependent on age. Owing to the lack granularity in the TQIP database, 230 patients from our institution who received ≥4 units of pRBCs within 4 h of admission were reviewed. On arrival, younger patients had significantly higher heart rates and more severe derangements in lactate levels, base deficits, and pH compared with older patients. There were no differences among age groups in injury severity score, systolic blood pressure, or mortality. CONCLUSIONS: In massively transfused patients, mortality increased with age. However, a significant proportion of older adults were successfully resuscitated. Therefore, age alone should not be considered a contraindication to high-volume transfusion. Traditional physiologic and laboratory criteria indicative of hemorrhagic shock may have reduced reliability with increasing age, and thus providers must have a heightened suspicion for hemorrhage in the elderly. Early transfusion requirements can be combined with age to establish prognosis to define futility to help counsel families regarding mortality after traumatic injury.


Assuntos
Transfusão de Eritrócitos/normas , Futilidade Médica , Ressuscitação/normas , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Adulto , Fatores Etários , Idoso , Tomada de Decisão Clínica/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Sistema de Registros/estatística & dados numéricos , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
15.
N Engl J Med ; 382(13): 1219-1231, 2020 03 26.
Artigo em Inglês | MEDLINE | ID: mdl-32212518

RESUMO

BACKGROUND: Patients with transfusion-dependent ß-thalassemia need regular red-cell transfusions. Luspatercept, a recombinant fusion protein that binds to select transforming growth factor ß superfamily ligands, may enhance erythroid maturation and reduce the transfusion burden (the total number of red-cell units transfused) in such patients. METHODS: In this randomized, double-blind, phase 3 trial, we assigned, in a 2:1 ratio, adults with transfusion-dependent ß-thalassemia to receive best supportive care plus luspatercept (at a dose of 1.00 to 1.25 mg per kilogram of body weight) or placebo for at least 48 weeks. The primary end point was the percentage of patients who had a reduction in the transfusion burden of at least 33% from baseline during weeks 13 through 24 plus a reduction of at least 2 red-cell units over this 12-week interval. Other efficacy end points included reductions in the transfusion burden during any 12-week interval and results of iron studies. RESULTS: A total of 224 patients were assigned to the luspatercept group and 112 to the placebo group. Luspatercept or placebo was administered for a median of approximately 64 weeks in both groups. The percentage of patients who had a reduction in the transfusion burden of at least 33% from baseline during weeks 13 through 24 plus a reduction of at least 2 red-cell units over this 12-week interval was significantly greater in the luspatercept group than in the placebo group (21.4% vs. 4.5%, P<0.001). During any 12-week interval, the percentage of patients who had a reduction in transfusion burden of at least 33% was greater in the luspatercept group than in the placebo group (70.5% vs. 29.5%), as was the percentage of those who had a reduction of at least 50% (40.2% vs. 6.3%). The least-squares mean difference between the groups in serum ferritin levels at week 48 was -348 µg per liter (95% confidence interval, -517 to -179) in favor of luspatercept. Adverse events of transient bone pain, arthralgia, dizziness, hypertension, and hyperuricemia were more common with luspatercept than placebo. CONCLUSIONS: The percentage of patients with transfusion-dependent ß-thalassemia who had a reduction in transfusion burden was significantly greater in the luspatercept group than in the placebo group, and few adverse events led to the discontinuation of treatment. (Funded by Celgene and Acceleron Pharma; BELIEVE ClinicalTrials.gov number, NCT02604433; EudraCT number, 2015-003224-31.).


Assuntos
Receptores de Activinas Tipo II/uso terapêutico , Transfusão de Eritrócitos/estatística & dados numéricos , Hematínicos/uso terapêutico , Fragmentos Fc das Imunoglobulinas/uso terapêutico , Proteínas Recombinantes de Fusão/uso terapêutico , Talassemia beta/tratamento farmacológico , Receptores de Activinas Tipo II/efeitos adversos , Adolescente , Adulto , Idoso , Método Duplo-Cego , Feminino , Ferritinas/sangue , Hematínicos/efeitos adversos , Humanos , Fragmentos Fc das Imunoglobulinas/efeitos adversos , Análise de Intenção de Tratamento , Análise dos Mínimos Quadrados , Masculino , Pessoa de Meia-Idade , Razão de Chances , Proteínas Recombinantes de Fusão/efeitos adversos , Esplenectomia , Adulto Jovem , Talassemia beta/genética , Talassemia beta/cirurgia , Talassemia beta/terapia
16.
Br J Radiol ; 93(1110): 20190413, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32142365

RESUMO

OBJECTIVE: Iatrogenic hemorrhages occur in 0.5-16% of medical procedures. A retrospective study was conducted to analyze technical and clinical outcome of transarterial embolization (TAE) used for acute iatrogenic hemorrhage and to identify factors predicting outcome. METHODS: All patients undergoing TAE for acute iatrogenic bleeding from 2006 to 2013 were retrospectively analyzed. Primary end points were technical and clinical success or failure and 30 day mortality. RESULTS: A total of 153 patients underwent 182 TAEs. Factors associated with clinical failure were lower blood hemoglobin concentration, use of higher number of units of red blood cell concentrate, TAE performed at night or weekend, embolization of more than one vessel, shock state before digital subtraction angiography (DSA), and intensive care before TAE. In multivariate analysis, independent factors for clinical success were hemoglobin concentration, number of units of red blood cell concentrate, and TAE of more than one vessel. Technical failure was associated with female gender, failure to detect signs of bleeding in DSA, TAE of more than one vessel, and shock state before DSA. Bleeding related to anticoagulation medication resulted in a significantly higher mortality rate compared with bleeding due to the remaining causes (30% vs 15%, p < 0.05). CONCLUSION: Despite excellent technical success, the mortality rate was significant. The only factors affecting clinical success were bleeding intensity and extent of injury. Bleeding attributed to anticoagulation is related to high mortality and therefore requires special attention. ADVANCES IN KNOWLEDGE: This study gives insights into morbidity and mortality of iatrogenic bleedings and the technical and clinical success rates of TAE in a large study population.


Assuntos
Embolização Terapêutica/métodos , Hemorragia Pós-Operatória/terapia , Doença Aguda , Idoso , Angiografia Digital , Anticoagulantes/efeitos adversos , Causas de Morte , Cuidados Críticos , Embolização Terapêutica/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Hemoglobina A/análise , Humanos , Doença Iatrogênica , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/mortalidade , Estudos Retrospectivos , Resultado do Tratamento
17.
Pediatrics ; 145(4)2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32198293

RESUMO

BACKGROUND AND OBJECTIVES: Annual incidence of venous thromboembolism (VTE) including postoperative VTE in hospitalized children is rising significantly. A growing body of evidence supports the role of red blood cells (RBCs) in pathologic thrombosis. In this study, we examined the association of perioperative RBC transfusion with postoperative VTE in pediatric patients. METHODS: The pediatric databases of the American College of Surgeons' National Surgical Quality Improvement Project from 2012 to 2017 were used. Multivariable logistic regression was used to examine the association between perioperative RBC transfusion status and the development of new or progressive VTE within 30 days of surgery. The analyses were age stratified, as follows: neonates (≤28 days), infants (>28 days and <1 year), and children (≥1 year). RESULTS: In this study, we included 20 492 neonates, 79 744 infants, and 382 862 children. Postoperative development of VTE was reported in 99 (0.48%) neonates, 147 (0.2%) infants, and 374 (0.1%) children. In all age groups, development of VTE was significantly more common among patients with a perioperative RBC transfusion than patients without a perioperative RBC transfusion (neonates: adjusted odds ratio [aOR] = 4.1, 95% confidence interval [CI] = 2.5-6.7; infants: aOR = 2.4, 95% CI = 1.7-3.6; children: aOR = 2.2, 95% CI = 1.7-2.9). Among children who received an intra- or postoperative transfusion, the weight-based volume of RBCs (mL/kg) transfused was associated with postoperative VTE in a dose-dependent manner: second tertile (odds ratio = 2.3, 95% CI = 1.3-4.1) and third tertile (odds ratio = 4.1, 95% CI = 2.3-7.4) versus first tertile. CONCLUSIONS: Perioperative RBC transfusions are independently associated with development of new or progressive postoperative VTE in children, infants, and neonates. These findings need further validation in prospective studies and emphasize the need for evidence-based perioperative pediatric blood transfusion decisions.


Assuntos
Transfusão de Eritrócitos/efeitos adversos , Tromboembolia Venosa/etiologia , Adolescente , Criança , Pré-Escolar , Intervalos de Confiança , Bases de Dados Factuais , Transfusão de Eritrócitos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Razão de Chances , Assistência Perioperatória , Análise de Regressão , Tromboembolia Venosa/epidemiologia
18.
J Surg Res ; 252: 47-56, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32222593

RESUMO

BACKGROUND: Perioperative blood transfusions in children are associated with patient morbidity and are often overutilized. In this study, we identify procedures most commonly associated with the use of red blood cells (RBC) in childrens surgery and develop risk-adjusted models for benchmarking. METHODS: Data from the 2012-2015 National Surgical Quality Improvement Program-Pediatric participant use data files were used. CPT (Current Procedural Terminology) codes were grouped to identify the procedures where transfusions were allocated and associated patient demographics and comorbidities. Patients were stratified in two age groups (0-3 mo and 3 mo to 18 y), and a logistic regression model was developed for each age group. RESULTS: Of 369,176 total cases, 21,410 (5.8%) were associated with a perioperative transfusion. 659 CPT codes were grouped in 207 clusters according to their similarities. The most common procedures associated with transfusion were arthrodesis for spinal deformity (n = 9533, 44.5%), followed by craniectomy for craniosynostosis (n = 1853, 8.7%). The logistic regression model for patients <3 mo included 18 variables and had excellent discriminatory performance (area under the curve 0.866). The model for patients ≥3 mo to 18 y had 21 variables and an area under the curve of 0.911. CONCLUSIONS: The majority of transfusions used in children's surgery are concentrated within a relatively few procedural groups. These findings can help centers in focusing blood optimization efforts on common surgeries with high transfusion rates. In addition, multiple preoperative factors have been built into a risk-adjusted model that can be used for benchmarking blood transfusions among hospitals.


Assuntos
Benchmarking/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Hospitais Pediátricos/organização & administração , Complicações Intraoperatórias/terapia , Complicações Pós-Operatórias/terapia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Austrália , Criança , Pré-Escolar , Transfusão de Eritrócitos/efeitos adversos , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Complicações Intraoperatórias/etiologia , Modelos Logísticos , Masculino , Modelos Organizacionais , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Emirados Árabes Unidos , Estados Unidos
19.
Pediatr Cardiol ; 41(5): 932-938, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32170329

RESUMO

A restrictive blood transfusion strategy has emerged in adult cardiac surgery. However, the feasibility in children is poorly investigated. 352 consecutive patients undergoing open-heart surgery were retrospectively reviewed, excluding patients requiring extracorporeal membrane oxygenation. Patient demographics, perioperative blood product usage, and clinical outcome parameters were investigated. Variables predicting the need for blood products were delineated. Of the 352 study patients, 148 patients (42%) underwent bloodless surgery and 204 (58%) were transfused. Of the 204 transfused patients, 170 (83.4%) patients received one blood transfusion and 34 (16.6%) received two or more blood transfusions. Patient's weight and preoperative hematocrit (Hct) were statistically significant in predicting the need for blood priming the CPB circuit (AUC 0.99, p < 0.001, sensitivity 96.6%, specificity 95.2%). A body weight of 8.5 kg carried a sensitivity of 100% and specificity of 94.5% (p < 0.001) for a blood prime. Among patients with a weight less than 8.5 kg (n = 171), only 27 patients (15.8%, p < 0.001) required additional transfusion of PRBCs. Factors impacting the need for a blood transfusion during CPB included redo surgery [odds ratio (OR) 4.61, p = 0.001] and the highest lactate level on CPB (OR 1.65, p = 0.006). Redo surgery had the highest impact (OR 7.27, p = 0.012) for requiring a postoperative PRBC transfusion. A restrictive transfusion strategy can be safely implemented in pediatric cardiac surgery. The majority of children with a BW > 8.5 kg required no blood products and those with a BW ≤ 8.5 kg required only 1 unit of blood, to prime the cardiopulmonary bypass circuit.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Cardiopatias Congênitas/cirurgia , Peso Corporal , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos
20.
BJOG ; 127(9): 1154-1164, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32175668

RESUMO

OBJECTIVE: Data regarding low maternal haemoglobin concentration and severe maternal morbidity (SMM) are limited and potentially biased. This study evaluated the relation between early maternal haemoglobin concentration and SMM or maternal mortality. DESIGN: Population-based cohort study. SETTING: Ontario, Canada, in a public healthcare system. POPULATION: 737 393 births with a routine outpatient haemoglobin measured at a calculated gestational age of 2-16 weeks. METHODS: The relation between early-pregnancy outpatient blood haemoglobin concentration and each study outcome was expressed as adjusted relative risks (aRR) and absolute risk differences (aRD), with 95% confidence intervals (CI), generated by modified Poisson regression. MAIN OUTCOME MEASURES: The primary outcome was SMM or maternal mortality, from 23 weeks' gestation to 42 days postpartum. RESULTS: The mean (SD) haemoglobin concentration was 126.9 (9.3) g/l. Overall, SMM or death occurred in 13 514 pregnancies (1.8%). Relative to a haemoglobin level of 125-129 g/l, the aRR was 1.07 (95% CI 1.02-1.13) and aRD (0.09%, 95% CI 0.01-0.18) at 120-124 g/l; aRR 1.31 (95% CI 1.17-1.46) and aRD 0.47% (95% CI 0.24-0.69) at 105-109 g/l; and aRR 4.53 (95% CI 3.59-5.72) and aRD 5.94% (95% CI 4.12-7.76) at <90 g/l. In all, 5961 women (0.8%) required red cell transfusion, with significantly higher risks at all haemoglobin concentrations below 125-129 g/l, peaking at a haemoglobin level <90 g/l (aRR 11.82, 95% CI 9.30-15.03). CONCLUSION: There is a gradual increase in the risk of SMM or death, as well as red cell transfusion, starting from the lower level of the normal range of haemoglobin of non-pregnant women. TWEETABLE ABSTRACT: Women with low haemoglobin in early pregnancy are at higher future risk of morbidity, death and blood transfusion.


Assuntos
Anemia/sangue , Anemia/epidemiologia , Transfusão de Eritrócitos/estatística & dados numéricos , Hemoglobinas/metabolismo , Complicações na Gravidez/sangue , Complicações na Gravidez/epidemiologia , Adulto , Anemia/mortalidade , Anemia/terapia , Feminino , Humanos , Mortalidade Materna , Ontário/epidemiologia , Gravidez , Complicações na Gravidez/mortalidade , Complicações na Gravidez/terapia , Primeiro Trimestre da Gravidez/sangue , Estudos Retrospectivos , Fatores de Risco
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...