Iatrogenic Blood Loss Research Articles

Reducing Iatrogenic Blood Losses in Premature Infants.

Iatrogenic blood losses from repetitive laboratory testing are a leading cause of anemia of prematurity and blood transfusions. We used an implementation science approach to decrease iatrogenic blood losses during the first 3 postnatal weeks among very low birth weight infants. We performed qualitative interviews of key stakeholders to assess implementation determinants (ie, barriers and facilitators to reducing iatrogenic blood losses), guided by the Consolidated Framework for Implementation Research. Next, we selected implementation strategies matched to these implementation determinants to de-implement excess laboratory tests. The number of laboratory tests, amount of blood taken (ml/kg), and laboratory charges were compared before and after implementation using quasi-Poisson and multi-variable regression models. Qualitative interviews with 14 clinicians revealed implementation-related themes, including provider-specific factors, recurring orders, awareness of blood loss and cost, and balance between over- and under-testing. Implementation strategies deployed included resident education, revised order sets, blood loss and cost awareness, audit and feedback, and the documentation of blood out. There were 184 and 170 infants in the pre- and postimplementation cohorts, respectively. There was an 18.5% reduction in laboratory tests (median 54 [36 - 80] versus 44 [29 - 74], P = .01) in the first 3 postnatal weeks, a 17% decrease in blood taken (mean 18.1 [16.4 - 20.1] versus 15 [13.4 - 16.8], P = .01), and an overall reduction of $290 328 in laboratory charges. No difference was noted in the number of blood transfusions. Postimplementation interviews showed no adverse events attributable to implementation strategies. An implementation science approach combining qualitative and quantitative methods reduced laboratory tests, blood loss, and charges.

Cord blood utilization as a blood conservation measure in the neonatal intensive care unit

Extremely low birth weight (ELBW) and very low birth weight (VLBW) infants are often exposed to several laboratory blood draws throughout their neonatal intensive care unit (NICU) stay, particularly at admission. Required routine admission labs place patients at risk for iatrogenic blood loss and need for treatment. Studies have demonstrated that blood collected from an umbilical cord segment may be used to obtain admission labs rather than drawing blood directly from the patient. The purpose of the quality improvement (QI) project was to determine if the utilization of umbilical cord blood for routine admission labs compared to the standard practice of infant phlebotamization result in fewer cases of iatrogenic anemia and the need for treatment in ELBW and VLBW infants. The following outcomes were monitored pre/post-implementation: number of blood transfusions, intra-ventricular hemorrhage (IVH) diagnosis, IVH severity, and vasopressor use. Despite a small sample size, statistically significant results were obtained.

Management of refined and personalized newborn blood specimen collection

BackgroundIatrogenic blood loss is an important cause of neonatal anemia. In this study, a spreadsheet tool was developed to reduce blood collection, providing a new idea for the prevention of iatrogenic blood loss in newborns. MethodsBased on hematocrit, minimum test volume and dead volume, a new tool was to calculate the minimum blood collection volume and the number of containers required for the test portfolio. We collected data from October 2022 to October 2023 from Xiamen Maternal and Child Health Hospital for analysis and validation. ResultsDuring this year, there were 16,434 patients and 13,696 plasma/serological samples in the neonatology department. Among them, there were 8 test combinations of greater than 1%, and 9490 samples in total. According to the hospital manual, the recommended amount of blood collection is 27,534 ml and 9490 containers. Through the analysis of this tool, total blood collection was 8864.77 ml, marked qnantity of upward containers (closest level to the calculated blood collection volume) was 10301 ml, and the amount of containers was 8835, which decreased by 67.8%, 62.58% and 6.9% respectively. Besides, if the hematocrit information cannot be obtained in advance and the high hematocrit is calculated as 0.8, the recommended amount of blood collection is 14334.3 ml, and the marked amount of the upward container markering is 17340 ml, decreasing by 47.9% and 37.02% respectively. ConclusionWe have developed an auxiliary tool that can manage neonatal blood specimen collection in a fine and personalized way and can be applied among different laboratory instruments by parameters modification.

Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management.

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

Mechanisms and treatment of anemia related to cardiac arrest.

Cardiac arrest is a common and fatal emergency situation. Recently, an increasing number of studies have shown that anemia in patients with cardiac arrest is closely related to high mortality rates and poor neurological outcomes. Anemia is prevalent among patients with post-cardiac arrest syndrome (PCAS), but its specific pathogenesis remains unclear. The mechanisms may involve various factors, including reduced production of erythropoietin, oxidative stress/inflammatory responses, gastrointestinal ischemic injury, hepcidin abnormalities, iatrogenic blood loss, and malnutrition. Measures to improve anemia related to cardiac arrest may include blood transfusions, administration of erythropoietin, anti-inflammation and antioxidant therapies, supplementation of hematopoietic materials, protection of gastrointestinal mucosa, and use of hepcidin antibodies and antagonists. Therefore, exploring the latest research progress on the mechanisms and treatment of anemia related to cardiac arrest is of significant guiding importance for improving secondary brain injury caused by anemia and the prognosis of patients with cardiac arrest.

Iatrogenic blood loss from phlebotomy during adult extracorporeal membrane oxygenation: A retrospective cohort study.

Adult extracorporeal membrane oxygenation (ECMO) patients are at high risk for allogeneic blood transfusion. Few studies have characterized iatrogenic blood loss from phlebotomy in adult ECMO patients. We hypothesized that iatrogenic phlebotomy would be a significant source of blood loss during ECMO. Adults who had their entire ECMO run at our medical center between 2020 and 2022 were included. Average daily phlebotomy volume and total phlebotomy volume during ECMO were estimated based on the total number of laboratory tests that were processed. In addition, the crude and adjusted association between total phlebotomy volume during ECMO and RBC transfusion during ECMO was evaluated using linear regression and Loess curve analysis. A total of 161 patients who underwent 162 ECMO runs were included. Of the 162 ECMO runs, 88 (54.3%) were veno-arterial and 74 (45.7%) were veno-venous ECMO. Median duration of ECMO was 5 days [25th, 75th percentile = 2, 11]. Median daily phlebotomy volume was 130 mLs [25th, 75th percentile = 94, 170] and median total phlebotomy volume during ECMO was 579 mLs [25th, 75th percentile = 238, 1314]. There was a significant crude and adjusted association between total phlebotomy volume and RBC transfusion during ECMO (beta coefficient = 0.0023 and 0.0024 respectively, both p < .001) based on linear regression analysis. Phlebotomy for laboratory testing is a significant source of blood loss during ECMO in adults. Comprehensive patient blood management for adult ECMO patients should include strategies to reduce laboratory testing and/or phlebotomy volume during ECMO.

Концепция «Менеджмент крови пациенток» в практике акушера-гинеколога: на что обратить внимание?

Aim. To present literature and own data on the implementation of the concept of patient blood management (PBM) in obstetrics and gynecology. Key points. PBM involves “the timely, interdisciplinary application of evidence-based, multimodal medical and surgical concepts aimed at screening, diagnosing and appropriately treating anemia, minimizing surgical, procedural, iatrogenic blood loss, and managing coagulopathy bleeding to improve health outcomes through patient-centered care”. As part of the PBM, it is important for the obstetrician-gynecologist to first screen for iron deficiency (ID) and identify iron deficiency anemia (IDA), prescribe treatment with modern iron preparations. A new generation of ferrous iron preparation with prolonged release is proposed, which minimizes the side effects of therapy. The second aspect is to screen and treat identified coagulation disorders using treatment algorithms based on thromboelastometry data, the third is in the postpartum/postoperative period, screen for and treat iron deficiency and anemia, control coagulation, monitor blood loss and rational use of allogeneic blood components. The results of the introduction of PBM into clinical practice of the National Medical Research Center for Obsterics, Gynecology and Perinatology named after Academician V.I. Kulakov, which allows for timely diagnosis of ID and IDA at the “Anemia-STOP!” Center, rational transfusion of allogeneic blood components, which contributed to a reduction in the volume of procured and transfused donor blood components. Conclusion. The implementation of the PBM concept helps to improve the effectiveness and safety of treatment, while promoting the best use of economic resources. Keywords: patient blood management, obstetrics, gynecology, iron deficiency anemia, new generation ferrous sulfate, coagulation control, efficiency, safety.

Remote Blood Hemoglobin Monitoring with Hyperspectral Color Truthing for Advancing Sickle Cell Care

Introduction: An urgent need exists for a noninvasive telemedicine approach to alleviate the burdensome reliance on frequent invasive blood draws for monitoring blood hemoglobin (Hgb) levels in sickle cell disease (SCD) patients. SCD is the most common genetic blood disorder, impacting over 20 million people worldwide, resulting in frequent emergency healthcare use. A blood Hgb level is pivotal in managing SCD and understanding the pathophysiology of SCD including anemia. Even low blood Hgb levels may indicate painful vaso-occlusion crises (Blood 2021;137:2010). Thus, a remote noninvasive monitoring ability of blood Hgb in at-home settings can potentially enhance SCD management without iatrogenic blood loss. Advanced machine learning and spectroscopic analyses can enable digital colorimetric diagnostics for noninvasive blood Hgb quantification with high fidelity, empowering SCD patients. However, one of the key challenges in diagnostic photography is that clinical photos exhibit significant variations in colors, depending on devices, light conditions, and image file formats, hampering reliable colorimetric diagnostics. Methods: We have developed colorimetric analyses of peripheral tissue perfusion to offer remote monitoring and cost-effective blood Hgb readings for SCD patients. A specially designed diagnostic color reference chart, which is highly sensitive to blood Hgb and peripheral perfusion, allowed us to noninvasively predict blood Hgb levels from digital photos of the palpebral conjunctiva (inner eyelid) across diverse smartphone models, light conditions, and file formats. Specifically, a pilot human study of fifteen SCD patients aged 14 to 73 years generated 156 photos from both left and right eyelids juxtaposed with the diagnostic color reference chart, using Samsung Galaxy S21 and Apple iPhone 12 Pro, taken immediately before or after blood draws. Combining a blood Hgb computation (Optica 2020;7:563), blood Hgb levels were computed involving three primary machine learning algorithms (Figure 1): color recovery of the palpebral conjunctiva, hyperspectral learning to reconstruct a spectrum, and spectroscopic blood Hgb quantification. Results: Using our specially designed color chart (Figure 2a), the linear correlation between the computed blood Hgb levels and venous blood Hgb levels shows a high correlation coefficient of 0.88 and 0.81 for Samsung Galaxy S21 and Apple iPhone 12 Pro, respectively. The Bland-Altman plot as a non-parametric statistical method reveal that the 95% limits of agreement (95% LOA) are [-2.68, 2.10 g dL -1] and [-2.74, 3.19 g dL -1] for the two smartphone models. Conversely, when using a conventional color chart for general photography (Macbeth ColorChecker) (Figure 2b), the computed blood Hgb levels exhibit a low accuracy for both Samsung Galaxy S21 (correlation coefficient of 0.69, 95% LOA = [-5.05, 2.60 g dL -1]) and Apple iPhone 12 Pro (correlation coefficient of 0.57, 95% LOA = [-5.14, 5.87 g dL -1]). Conclusion: This study supports the feasibility of noninvasive blood Hgb assessments as colorimetric diagnostics for SCD patients in telemedical settings. The results correlate significantly with conventional laboratory tests based on venous blood draws and are highly comparable to capillary blood sampling (finger prick) tests (Respiratory Care 2019;64:1343). This study lays the foundation for realizing color accuracy in biological tissue for digital diagnostic colorimetric applications of blood Hgb.The proposed color accuracy-based digital health technology can potentially offer accessible, affordable, and reliable blood Hgb readings via smartphones in at-home or telemedicine settings.

Changes to Blood-Sampling Protocol to Reduce the Sampling Amount in Neonatal Intensive Care Units: A Quality Improvement Project.

(1) Background: This study aimed to evaluate whether the implementation of a modified blood-sampling protocol, which focused on need-based laboratory testing and minimized venous sampling by replacing it with point-of-care testing (POCT) via capillary puncture, successfully reduced iatrogenic blood loss, incidence of anemia, and the frequency of blood transfusion among extremely low-birth-weight infants (ELBWIs) without negatively affecting neonatal outcomes. (2) Methods: A retrospective analysis was conducted on 313 ELBWIs with a gestational age (GA) of between 23 and 28 weeks and born between 2013 and 2019. The infants were divided into two groups corresponding to the periods before (period I) and after (period II) the implementation of the modified blood-sampling protocol in January 2016. Propensity score matching was conducted to minimize selection bias. Clinical data, including the frequency and amount of blood sampling, the frequency and volume of blood transfusion, and clinical characteristics, such as gestational age, birth weight, and neonatal outcome data, were collected and compared between the two groups. (3) Results: No significant differences in GA or birth weight between the two periods were observed. The total sampling volume a month after birth (16.7 ± 4.1 mL vs. 15.6 ± 4.4 mL, p = 0.03) and the total sampling volume during hospitalization days (51.4 ± 29.7 mL vs. 44.3 ± 27.5 mL, p = 0.04) in period II were significantly lower than those in period I. There were no differences in terms of anemia (hemoglobin 10.8 ± 2.2 vs. 11.0 ± 1.9, p = 0.43) and mortality or morbidity, such as intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, and sepsis, between the two periods. Although the transfusion frequency and amount did not present significant differences between the periods, we observed a positive correlation between the transfusion frequency and sampling volume (coefficient: 0.09, 95% CI: 0.08-0.11). (4) Conclusions: The modified blood-sampling protocol effectively reduced the level of iatrogenic blood loss without negatively affecting the neonatal outcomes.

Effect of blood sampling management on reducing blood transfusions in very preterm infants.

Effect of blood sampling management on reducing blood transfusions in very preterm infants.

Patient Blood Management in Liver Transplant—A Concise Review

Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.

Non-invasive hemoglobin estimation for preoperative anemia screening.

Preoperative anemia is common and associated with adverse postoperative outcomes. Assessment of hemoglobin concentrations may facilitate optimization prior to surgery. However, phlebotomy-based hemoglobin measurement may contribute to patient discomfort and iatrogenic blood loss, which makes non-invasive hemoglobin estimation attractive in this setting. This is a prospective study of adult patients presenting for preoperative evaluation before elective surgery at a tertiary care medical center. The Masimo Pronto Pulse CO-Oximeter was utilized to estimate blood hemoglobin concentrations (SpHb), which were then compared with hemoglobin concentrations obtained via complete blood count. Receiver operating curves were used to identify SpHb values maximizing specificity for anemia detection while meeting a minimum sensitivity of 80%. A total of 122 patients were recruited with a median (interquartile range) age of 66 (58, 72) years. SpHb measurements were obtained in 112 patients (92%). SpHb generally overestimated hemoglobin with a mean (± 1.96 × standard deviation) difference of 0.8 (-2.2, 3.9) g/dL. Preoperative anemia, defined by hemoglobin <12.0g/dL in accordance with institutional protocol, was present in 22 patients (20%). The optimal SpHb cut-point to identify anemia was 13.5g/dL: sensitivity 86%, specificity 81%, negative predictive value 96%, and positive predictive value 53%. Utilizing this cut-point, 60% (73/122) of patients could have avoided phlebotomy-based hemoglobin assessment, while an anemia diagnosis would have been missed in <3% (3/122). The use of SpHb devices for anemia screening in surgical patients is feasible with the potential to reliably rule-out anemia despite limited accuracy.

Hemoglobin Determination Using Pulse Co-Oximetry and Reduced-Volume Blood Gas Analysis in the Critically Ill: A Prospective Cohort Study.

Hospital-acquired anemia is common in patients hospitalized in the intensive care unit (ICU). A major source of iatrogenic blood loss in the ICU is the withdrawal of blood for laboratory testing. The aim of our study was to analyze the feasibility and accuracy of non-invasive spot-check pulse co-oximetry (SpHb), and a reduced-volume blood gas analysis (ABG Hb) for the determination of Hb concentration in critically ill patients. Comparisons between Hb determined with test devices and the gold standard-complete blood count (CBC)-were performed using Bland-Altman analysis and concordance correlation coefficient (CCC). The limits of agreement between SpHb and CBC Hb were -2.0 [95%CI -2.3-(-1.7)] to 3.6 (95%CI 3.3-3.9) g/dL. The limits of agreement between ABG Hb and CBC Hb were -0.6 [95%CI -0.7-(-0.4)] to 2.0 (95%CI 1.9-2.2) g/dL. Spearman's coefficient and CCC between ABG Hb and CBC Hb were 0.96 (95%CI 0.95-0.97, p &lt; 0.001) and 0.91 (95%CI 0.88-0.92), respectively. Non-invasive spot-check Hb co-oximetry is not sufficiently accurate for the monitoring of hemoglobin concentration in critically ill patients. Reduced volume arterial blood gas analysis has acceptable accuracy and could replace complete blood count for the monitoring of Hb concentration in critically ill patients, leading to a significant reduction in blood volume lost for anemia diagnostics.

Association of Noninvasive Peripheral Blood Hemoglobin Assessments with Venous Blood Draws Among Sickle Cell Patients

Introduction: Sickle cell disease (SCD) is the most common genetic blood disorder, affecting an estimated 100,000 people in the US and over 20 million worldwide. SCD costs one and a half billion dollars of economic loss annually in the US, resulting in sustained burden to the families and the healthcare systems (Value in Health 2021;24:1095). Many patients living with SCD require frequent blood draws and may have to have a central line for routine blood draws. A blood hemoglobin (Hgb) level is the central information about the pathophysiology of SCD including anemia. Low blood Hgb levels have shown as a potential indicator of painful vaso-occlusion crises (Blood 2021;137:2010). Blood Hgb levels are checked for evaluation of new symptoms, medication monitoring, and routine follow up. Real-time and noninvasive monitoring of blood Hgb levels would be clinically beneficial, but less feasible through frequent invasive blood draws. Developing a reliable, self-educated, and completely non-invasive mobile health (mHealth) tool for real time blood Hgb assessments can directly benefit many patients living with SCD, minimizing the number of iatrogenic blood loss from frequent blood draws and improving the quality of care. Methods: Our team has recently developed an mHealth algorithm that can reliably estimate a blood Hgb level from a photo of a peripheral tissue site at individual's inner eyelid (palpebral conjunctiva) (Figure 1a). We conducted a pilot study to determine the exact relationship between peripherally detected blood Hgb levels (accessed from the inner eyelid) and blood Hgb tests (venous blood draws) performed at a clinical laboratory. Fifteen patients with SCD aged from 14 to 73 years were recruited at Hematology Clinic at University Hospital of the Indiana University School of Medicine. Acquisitions of the inner eyelid photos in RAW format were conducted by Samsung Galaxy S21 immediately before or after a blood draw. Blood Hgb levels from the inner eyelid's photo were computed using the previously developed statistical learning algorithm (Optica 2020;7:563); the first step was to recovery a spectrum from an RGB image (spectral learning) and the second step was to compute blood Hgb content using a spectral analysis (Figure 1a). Results: The linear correlation between the peripheral mHealth blood Hgb levels and the venous blood Hgb levels in the blood (i.e., the gold standard) shows a value of 0.82 with a p-value of 0.0002 (Figure 1b). A Bland-Altman analysis was also conducted as a non-parametric statistical method. The limits of agreement (LOA) were defined by a 95% prediction interval of the standard deviation of the differences between the mHealth and conventional blood Hgb levels. 95% Bland-Altman LOA was +/-2.3 g/dL (Figure 1b) and within LOA, the data points were uniformly scattered, indicating no significant bias. This level of performance is comparable to point-of-care blood sampling (finger prick) testing and noninvasive medical devices (Respiratory Care 2019;64:1343). Conclusion: This preliminary study supports the feasibility of peripheral and noninvasive mHealth blood Hgb assessments among patients with SCD. Importantly, peripheral mHealth blood Hgb levels are significantly associated with conventional venous blood Hgb tests among SCD patients. Thus, the mHealth technology can lay the groundwork for empowering individual patients by offering an easily accessible tool for quickly estimating blood Hgb levels by a smartphone. This mHealth technology has potential advantages including mobility, simplicity, and affordability for rapid and real-time blood Hgb quantification among patients living with SCD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prevalence and risk factors for hospital-acquired anemia in internal medicine patients: learning from the “less is more” perspective

Hospital-acquired anemia is defined as a new-onset anemia in hospitalized patients who have a normal hemoglobin level at admission. Its prevalence is unknown and most studies published on this topic have been conducted in intensive care unit patients with limited applicability to less acute settings, such as internal medicine wards. We conducted a retrospective study and enrolled 129 patients who were admitted to an Internal Medicine Unit between October 2021 and February 2022. The median value of phlebotomy during hospitalization was 46 ml (IQR 30–72 ml), whereas the median length of hospital stay was 9 days (IQR 5–13 days). The median value of hemoglobin reduction was −0.63 g/dl (p < 0.001) and the maximum value of drop in hemoglobin value was −2.6 g/dl. All patients who experienced a phlebotomy > 85 ml had a hemoglobin reduction > 0.6 g/dl. 20.9% of patients developed anemia during the hospital stay (7% moderate and 13.9% mild). No cases of severe anemia were observed. The volume of blood drawn during the hospital stay and the Hb value on admission were the only two variables statistically associated with the development of anemia, whereas gender, age, and chronic diseases, such as diabetes, history of cancer, or heart failure, were not. Strategies, such as elimination of unnecessary laboratory tests and the use of smaller tubes for blood collection, are needed to reduce the volume of iatrogenic blood loss and avoid blood wastage occurring during hospitalization in internal medicine patients.

A Contemporary Analysis of Phlebotomy and Iatrogenic Anemia Development Throughout Hospitalization in Critically Ill Adults.

Anemia is common in critically ill patients and may be exacerbated through phlebotomy-associated iatrogenic blood loss. Differences in phlebotomy practice across patient demographic characteristics, clinical features, and practice environments are unclear. This investigation provides a comprehensive description of contemporary phlebotomy practices for critically ill adults. This is an observational cohort study of adults ≥18 years of age requiring intensive care unit (ICU) admission between January 1, 2019, and December 31, 2019, at a large academic medical center. Descriptive statistics were utilized to summarize all phlebotomy episodes throughout hospitalization, with each phlebotomy episode defined by unique peripheral venous, central venous, or arterial accesses for laboratory draws, exclusive of finger sticks. Secondarily, financial costs of phlebotomy and the relationships between phlebotomy practices, hemoglobin concentrations, and red blood cell (RBC) transfusions were evaluated. A total of 6194 patients were included: 59% were men with a median (interquartile range) age of 66 (54-76) years and median ICU and hospital durations of 2.1 (1.4-3.9) and 7.1 (4.3-11.8) days, respectively. The median number of unique laboratory draws was 41 (18-88) throughout hospitalization, with a median volume of 232 (121-442) mL, corresponding to 5.2 (2.6-8.8) draws and 29 (19-43) mL per day. Waste (ie, discard) volume was responsible for 10.8% of total phlebotomy volume. Surgical patients had a higher number of phlebotomy episodes and greater total phlebotomy volumes compared to nonsurgical patients. Phlebotomy practices differed across ICU types, with the greatest frequency of laboratory draws in the cardiac surgical ICU and the greatest daily phlebotomy volume in the medical ICU. Across hospitalization, ICU environments had the greatest frequency and volumes of laboratory draws, with the least intensive phlebotomy practice observed in the general hospital wards. Patients in the highest quartile of cumulative blood drawn experienced the longest hospitalizations, lowest nadir hemoglobin concentrations, and greatest RBC transfusion utilization. Differences in phlebotomy practice were limited across patient age, gender, and race. Hemoglobin concentrations declined during hospitalization, congruent with intensity of phlebotomy practice. Each 100 mL of phlebotomy volume during hospitalization was associated with a 1.15 (95% confidence interval [CI], 1.14-1.17; P < .001) multiplicative increase in RBC units transfused in adjusted analyses. Estimated annual phlebotomy costs exceeded $15 million (approximately $2500 per patient admission). Phlebotomy continues to be a major source of blood loss in hospitalized patients with critical illness, and more intensive phlebotomy practices are associated with lower hemoglobin concentrations and greater transfusion utilization.

Iatrogenic blood loss in critical care: A prospective observational study conducted at Universitas Academic Hospital in the Free State Province, South Africa.

Background Prevention of iatrogenic blood loss is an essential component of patient blood management (PBM) in intensive care units (ICUs). The amount of iatrogenic blood loss from diagnostic phlebotomy in the ICUs at Universitas Academic Hospital, Free State Province, South Africa, is unknown. Objectives To quantify diagnostic phlebotomy volumes, and volumes submitted in excess for diagnostic testing in the ICU. Methods We conducted a prospective descriptive observational study on adults who were admitted to ICUs at a single centre over a period of 14 days. The weight of each filled phlebotomy tube was calculated using the specific gravity of blood and averages of empty phlebotomy tubes, establishing the total volume. ResultsData from 59 participants with a median length of stay at the ICU of 3 days were analysed. The median phlebotomy volume was 7.0 mL day and 13.6 mL/ICU admission. The volume of blood required for analysis daily and ICU admission was 0.7 mL and 2.2 mL, respectively. The median phlebotomy volume in excess of the amount required for analysis daily and ICU admission was 5.05 mL and 12.11 mL, respectively. Conclusion While the median excess daily phlebotomy volume in this present study may seem insignificant and underestimating the true excess of phlebotomy volume, interventions to reduce phlebotomy volumes and development of a PBM guideline for appropriate phlebotomy volumes and preventing wastage of patients’ blood in the ICU is required. Contributions of the study We determined blood volume requirements for laboratory instrumentation, which allows phlebotomists to be cognisant of the true requirements for diagnostic tests to be undertaken accurately. We established diagnostic blood loss volumes in critical care units at a tertiary hospital in South Africa and we advocate for the introduction of patient blood management practice guidelines at local institutions.

Hospital-Acquired Anemia in Patients Hospitalized in the Intensive Care Unit: A Retrospective Cohort Study.

Hospital-acquired anemia (HAA) is prevalent in patients hospitalized in the intensive care unit (ICU). Iatrogenic blood loss (IBL) may aggravate existing anemia or lead to a need for red blood cell (RBC) transfusion. The aim of our study was to analyze hemoglobin (Hb) concentration changes in up to 14 days, as well as all potential sources of IBL, in consecutive patients admitted to the intensive care unit (ICU) in the years 2020–2021. Patients admitted due to bleeding were excluded. Anemia on admission was present in 218 (58.8%) patients—47 (48.9%) surgical and 171 (62.2%) non-surgical (p = 0.02). Gradual decrease in Hb was seen in all ICU patients. Eighty-one (21.8%) patients required RBC transfusion. The first unit of RBC was transfused on day 7 (IQR 2–13) and the second on day 11 (IQR 4–15) of ICU hospitalization. The median admission Hb in patients who required RBC transfusion was 10.2 (IQR 8.5–11.8) and, in those who did not require transfusion, it was 12.0 (IQR 10.2–13.6) g/dL (p < 0.01). Anemia on admission was associated with a need for RBC transfusion (p < 0.01). Average decrease in Hb during the first week of ICU hospitalization in patients with and without anemia on admission was 1.2 (IQR 0.2–2.3) and 2.8 (IQR 1.1–3.8) g/dL (p < 0.01), respectively. Percentage of patients who bled at the insertion site of invasive devices was as follows: percutaneous tracheostomy—46.7%, therapeutic plasma exchange (TPE) catheter—23.8%, dialysis catheter—13.3%, gastrostomy—9.5%, central venous catheter—7.8%. Moreover, circuit clotting occurred in 17.7 and 9.5% of patients undergoing dialysis and TPE, respectively. Median blood loss for repeated laboratory testing in our study population was 13.7 (IQR 9.9–19.3) mL per patient daily. Anemia is highly prevalent among medical and surgical patients on admission to ICU and is associated with RBC transfusion. Patients who required RBC transfusion had significantly lower daily Hb concentrations. Severity of disease did not seem to have impact on Hb concentration. IBL associated with invasive devices and extracorporeal therapies is frequent in ICU patients and may lead to a gradual decrease in Hb concentration. Further studies are required to analyze causes of HAA in the ICU.

Dissemination of patient blood management practices in Swiss intensive care units: a cross-sectional survey.

Patient blood management (PBM) promotes the routine detection and treatment of anaemia before surgery, optimising the management of bleeding disorders, thus minimising iatrogenic blood loss and pre-empting allogeneic blood utilisation. PBM programmes have expanded from the elective surgical setting to nonsurgical patients, including those in intensive care units (ICUs), but their dissemination in a whole country is unknown. We performed a cross-sectional, anonymous survey (10 October 2018 to 13 March 2019) of all ordinary medical members of the Swiss Society of Intensive Care Medicine and the registered ICU nurses from the 77 certified adult Swiss ICUs. We analysed PBM-related interventions adopted in Swiss ICUs and related them to the spread of PBM in Swiss hospitals. We explored blood test ordering policies, blood-sparing strategies and red blood cell-related transfusion practices in ICUs. A total of 115 medical doctors and 624 nurses (response rates 27% and 30%, respectively) completed the surveys. Hospitals had implemented a PBM programme according to 42% of physicians, more commonly in Switzerland's German-speaking regions (Odds Ratio [OR] 3.39, 95% confidence interval [CI] 1.23-9.35; p = 0.018) and in hospitals with more than 500 beds (OR 3.91, 95% CI 1.48-10.4; p = 0.006). The PBM programmes targeted the detection and correction of anaemia before surgery (79%), minimising perioperative blood loss (94%) and optimising anaemia tolerance (98%). Laboratory tests were ordered in 70.4% by the intensivist during morning rounds; the nurses performed arterial blood gas analyses autonomously in 48.4%. Blood-sparing techniques were used by only 42.1% of nurses (263 of 624, missing: 6) and 47.0% of physicians (54 of 115). Approximately 60% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin threshold for the nonbleeding ICU population was 70 g/l and, therefore, was at the lower limit of current guidelines. Based on this survey, the estimated proportion of the intensivists working in hospitals with a PBM initiative is 42%, with significant variability between regions and hospitals of various sizes. The risk of iatrogenic anaemia is relevant due to liberal blood sample collection practices and the underuse of blood-sparing techniques. The reported transfusion threshold suggests excellent adherence to current international ICU-specific transfusion guidelines.

Anemia of critical illness: a narrative review

The prevalence of anemia in patients admitted to the intensive care unit (ICU) reaches 66%. Moreover, numerous patients develop anemia during ICU hospitalization. In fact, anemia is the most common hematologic disease in the ICU. The majority of patients hospitalized in the ICU present with acute systemic inflammation, so called systemic inflammatory response syndrome (SIRS). These patients may develop anemia of inflammation (AI). In crtitically ill patients AI may present acutely (acute systemic inflammation) or chronically (comorbidities associated with prolonged systemic inflammation), here we describe both presentations of AI as ‘anemia of critical illness’ (ACI). The second most frequent type of anemia in critically ill patients is iron-deficiency anemia (IDA). A mixed type of anemia (ACI + IDA) may also be present in these patients. The three major pathophysiological mechanisms leading to ACI are: iron restriction, decreased erythropoiesis, and decreased erythrocyte lifespan. Cytokines synthesized during SIRS induce the production of hepcidin that inhibits the only transmembrane iron exporter (ferroportin) present in the duodenum and macrophages. Etiological classification of anemia in critically ill patients poses a significant challenge to clinicians, as there is a multitudeof tests available, and there are various reference ranges for these tests reported in the literature in the patient population in question. Pure ACI or mixed ACI + IDA can be diagnosed using a single laboratory test — complete blood count with analysis of reticulocytes — which provides Hb concentration in erythrocyte and reticulocyte. The management of ACI incorporates discontinuation with erythropoiesis-stimulating agent causing anemia, reduction of iatrogenic blood loss, parenteral iron, and combined therapy of parenteral iron with erythropoiesis-stimulating agents in approved indications.