A further update on mortality and morbidity in patients with very low hemoglobin levels who decline blood transfusion.

BACKGROUND: In the past two decades, researchers have published mortality and morbidity rates in patients with very low hemoglobin levels declining blood transfusion. The clinical knowledge and tools available for the management of patients who decline transfusions have grown since these publications. The aim of our study was to provide a further update on outcomes associated with severe anemia in these patients. STUDY DESIGN AND METHODS: A retrospective observational study of patients declining allogeneic blood transfusions with nadir hemoglobin levels ≤8 g/dL treated at The Institute for Blood Management, HELIOS Klinikum Gotha, Germany. Outcomes were in-hospital mortality within 30 days and composite morbidity or mortality, with morbidity events defined as acute myocardial infarction, cardiac failure, wound infection, arrhythmia, and pneumonia. RESULTS: Between June 2008 and June 2021, The Institute for Blood Management treated 2841 admissions of which 159 (5.6%) recorded nadir hemoglobin levels ≤8 g/dL. Of these, five (3.1%) patients died in hospital within 30 days, including four (4.8%) patients admitted for surgical procedures and one (1.4%) medical admission. There was a significant increase in the unadjusted proportion of composite morbidity or mortality events with severity of nadir hemoglobin, with each gram decrease in hemoglobin associated with a 1.48 (95% confidence interval = 1.05-2.09; p = .025) times increase. CONCLUSION: Our comparatively lower proportion of patients reaching hemoglobin levels ≤8 g/dL and lower mortality rates suggest outcomes in patients with severe anemia is modifiable with the application of current patient blood management and bloodless medicine and surgery strategies.

Sensitivity and Specificity of Diagnostic Algorithms of Preoperative Anemia.

OBJECTIVES: Preoperative management of anemia is one of the pillars of patient blood management. Diagnostic algorithms developed to support an anemia diagnosis have not yet been validated. The aim of this study was to validate and compare three commonly used diagnostic algorithms for preoperative anemia. METHODS: We performed a prospective diagnostic study to detect the types of anemia present and compare the specificity and sensitivity of three diagnostic algorithms for preoperative anemia in patients scheduled to undergo major abdominal surgery. We used Cohen κ to compare the interrater reliability (agreement) of the diagnostic anemia algorithms with its standard reference. RESULTS: Of the 10 tested types of anemia, six had a prevalence of >10% in the studied patients, namely iron deficiency, vitamin B12 deficiency, anemia of chronic disease, renal anemia, thyroid-related anemia, and anemia of bleeding. The Network for the Advancement of Transfusion Alternatives algorithm had substantial agreement with the standard reference for renal anemia but performed less appropriately for the other types of anemia. The Society for the Advancement of Blood Management algorithm displayed moderate agreement with the standard reference for deficiency of iron and B12 and for renal anemia and had substantial agreement detecting anemia of bleeding, whereas the other types of anemia were detected less appropriately. The Institute for Blood Management, Gotha, Germany algorithm had a moderate agreement with the standard reference for anemia of bleeding and near perfect agreement for all other types of anemia. CONCLUSIONS: We were able to show that the diagnostic anemia algorithm of the Institute for Blood Management, Gotha, Germany is superior to those of the Network for the Advancement of Transfusion Alternatives and the Society for the Advancement of Blood Management in its ability to detect the six common types of preoperative anemia in patients scheduled to undergo abdominal surgery, the presence of multiple types of anemias in a given patient, and its ability to detect rare anemias that have a clinical implication for management.

Use of autologous fibrin glue for endoscopic treatment of esophageal lesions.

BACKGROUND AND STUDY AIMS: Esophageal leaks are a potentially life-threatening condition. One treatment option is injection therapy with commercially available fibrin glue. We describe herein a method to close esophageal leaks by injecting autologous fibrin glue prepared exclusively with the patient's own blood.

Use of a hemoglobin-based oxygen carrier in the treatment of severe anemia.

BACKGROUND: Hemoglobin-based oxygen carriers hold promise for the treatment of acute anemia. CASE: We report a patient with severe dysfunctional uterine bleeding. During her hospitalization, her lowest hemoglobin level was 3.1 g/dL, with a hematocrit of 9.3%. An investigational product, o-raffinose cross-linked human hemoglobin solution (hemoglobin raffimer), was infused along with ongoing high-dose recombinant human erythropoietin and estrogen. The time until the patient's own hematopoiesis provided sufficient red blood cell mass was successfully managed by reducing oxygen demand and providing multiple hemoglobin-based oxygen carrier infusions. After hemoglobin-based oxygen carrier administration, transient pulmonary hypertension and fever were noted. She was discharged after corrective surgery 7 days after hemoglobin-based oxygen carrier administration with a hemoglobin level of 7.8 g/dL. CONCLUSION: The hemoglobin level-based oxygen carrier improved oxygen delivery and permitted uterine corrective surgery.