Nadir hemoglobin is associated with poor outcome from intracerebral hemorrhage

Christopher Burns,Karen C Albright,Amelia K Boehme,T Mark Beasley,Aimee Aysenne,Tiffany R Chang,Sheryl Martin-Schild

doi:10.1186/2193-1801-2-379

Abstract

ObjectiveExamine the relationship between anemia and outcomes from intracerebral hemorrhage (ICH).MethodsPatients admitted with spontaneous ICH between July 2008 and December 2010 were identified from our prospective stroke registry. Patients were divided into two groups based on admission hemoglobin (low vs. normal based on laboratory reference range for gender). Baseline characteristics were compared between groups using Chi-square, t-tests and Wilcoxon Rank Sum tests. Primary outcome was functional status at discharge, with modified Rankin Scale (mRS) 5–6 considered a poor outcome. Cumulative logit and logistic regression models were used to assess the relationships between baseline hemoglobin, nadir hemoglobin, and transfusion with outcomes.ResultsOf the 109 patients, 28% (n = 30) were anemic on admission. Baseline anemia did not predict the primary outcome. Nadir hemoglobin was associated with poor functional outcome at discharge (OR = 1.58, 95% CI 1.31-1.90, p < 0.0001) and remained significant after adjusting for age, baseline NIHSS, transfusion, and length of stay (OR = 1.43, 95% CI 1.06-1.94, p = 0.02). Patients who received a transfusion had 9 times greater odds of having a discharge mRS 5–6 (OR 9.37, 95% CI 2.84-30.88, p = 0.0002) compared with patients who did not receive transfusion. This was no longer statistically significant after adjusting for other factors impacting outcome (OR 4.01, 95% CI 0.64-25.32, p = 0.1392). Neither nadir hemoglobin nor transfusion was found to be independent predictors of in-hospital mortality.ConclusionThis study suggests that nadir hemoglobin, not admission hemoglobin, can be used to predict poor functional outcome. Transfusion was not an independent predictor of poor outcome from ICH.

Highlights

Anemia is a common problem in all critical care settings
Higher goals may be indicated in certain populations, such as patients with acute coronary syndromes. (Hebert et al 1999) anemia can be corrected by red blood cell transfusion, liberal transfusion strategies in the intensive care unit have been associated with worse outcomes in a number of studies. (Hebert et al 1999; Vincent et al 2002; Corwin et al 2004; Villanueva et al 2013) Treatment goals
The presence of anemia is common in patients with intracerebral hemorrhage (ICH), occurring in as high as 72% of patients during hospitalization. (Sheth et al 2011) Anemia has been associated with worse outcomes following ICH, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). (Diedler et al 2010; Naidech et al 2006; Naidech et al 2007; Kramer et al 2009; Duane et al 2008; Bussiere et al 2013) A retrospective study of supratentorial ICH showed that patients with poor neurological outcomes at discharge and at three months had lower average and nadir hemoglobin values during their hospital stay. (Diedler et al 2010) anemia has been associated with increased hematoma size, (Kumar et al 2009)

Summary

Introduction

Anemia is a common problem in all critical care settings. The World Health Organization (WHO) defines anemia as hemoglobin less than 13 g/dl in men and 12 g/dl in women. (WHO/UNICEF/UNU 2001) A hemoglobin level between 7–9 g/dl is generally well-tolerated. (Diedler et al 2010; Naidech et al 2006; Naidech et al 2007; Kramer et al 2009; Duane et al 2008; Bussiere et al 2013) A retrospective study of supratentorial ICH showed that patients with poor neurological outcomes (modified Rankin Scale, mRS 4–6) at discharge and at three months had lower average and nadir hemoglobin values during their hospital stay. There are conflicting reports regarding the association between transfusion and outcome after ICH, (Sheth et al 2011; Diedler et al 2010) and to our knowledge there is little published data evaluating the effect of aggressive treatment of anemia on hematoma volume or expansion following ICH. The aim of this study was to examine the relationship between hemoglobin values, transfusion, and short-term outcomes in acute ICH patients. We hypothesized that admission hemoglobin, nadir hemoglobin, and pRBC transfusion would all be significant independent predictors of poor outcome in this patient population

Methods

Results

Discussion

Conclusion