Minimum Hemoglobin Research Articles

Blood transfusion might not be recommended for gastric cancer patients with pretransfusion minimum hemoglobin values higher than 90g/l: a real-world study covering 20 years of 13470 patients.

There was no consistent evidence of whether perioperative blood transfusion (PBT) affects the long-term survival of gastric cancer (GC) patients after undergoing gastrectomy. This study aimed to investigate the effects of PBT on the long-term survival of GC patients, as well as to determine the threshold of PBT and provide evidence for future surgical practice. We performed this real-world study of GC patients undergoing gastrectomy at China National Cancer Center from January 1, 2000 to December 30, 2019. Overall survival (OS) curves were plotted using the Kaplan-Meier method and compared statistically using the log-rank test. Univariate and multivariate Cox proportional hazard models were used to determine the risk factors for OS. In total, 13470 GC patients undergoing gastrectomy from 2000 to 2019 were included, of whom 3465 (34.6%) GC patients received PBT. PBT ratios declined from 29.1% (114/392) in 2000 to 11.2% in 2019 (149/1178), with the highest blood transfusion ratio in 2005 at 43.7% (220/504). For patients transfused with red blood cells, the median value of hemoglobin (Hb) before transfusion in the PBT group decreased from 110g/l in 2000 to 87g/l in 2019. Compared with patients who not receiving PBT, PBT group are more likely to be older (≥65, 39.1% vs. 30.1%, P <0.001), open operation (89.7% vs. 78.1%, P <0.001), higher American Society of Anesthesiologists score (>2, 25.3% vs. 14.9%, P <0.001) and in the later pTNM stage (pTNM stage III, 68.5% vs. 51.5%, P <0.001). Results of multivariable Cox regression analysis showed that PBT was an independent prognostic factor for worse OS in GC patients undergoing gastrectomy [HR=1.106, 95% confidence interval (CI): 1.01-1.211, P =0.03). After stratified according to tumor stage, we found that PBT group had a worse prognosis only in pTNM stage III (HR=1.197, 95% CI: 1.119-1.281, P <0.001). OS was obviously poor in the PBT group when Hb levels were higher than 90g/l (90g/l<Hb≤120g/l: HR=1.196, 95% CI: 1.090-1.313, P <0.001; Hb>120g/l: HR=1.207, 95% CI: 1.098-1.327, P <0.001), while there was no difference between the two groups when Hb levels were lower than or equal to 90g/l (Hb≤90g/l: HR=1.162, 95% CI: 0.985-1.370, P =0.075). In conclusion, PBT was an independent prognostic factor for worse OS. Blood transfusion might not be recommended for GC patients with perioperative minimum Hb values higher than 90g/l.

Association of Hemoglobin Decrement During Hospitalization with Prognosis of Aneurysmal Subarachnoid Hemorrhage and Mediation Effects of Cerebral Infarction and Pneumonia.

Hemoglobin decrement is a common complication after aneurysmal subarachnoid hemorrhage (aSAH) and is associated with poor outcome. However, the mediating variables on the causal pathway between hemoglobin decrement and poor outcome in aSAH are not clear. This is a single-center retrospective observational study containing all consecutive patients with aSAH admitted to our hospital between January 1, 2019, and June 30, 2022. Hemoglobin decrement was defined as the hemoglobin at admission minus the minimum hemoglobin during hospitalization. Calculation of cutoff value using ROC curve Youden index. The main exposure of interest was a hemoglobin decrement greater than the cutoff value. The primary outcome was poor outcome at 3 months (mRS 4-6). A total of 480 patients with aSAH were included in the study, 414 (71.1%) had a favorable and 66 (28.9%) had a poor outcome at 3 months. The cut-off value for calculating the degree of hemoglobin decrease using the ROC curve was 12.5 g/l. Hemoglobin decrement greater than the cutoff value was significantly associated with pneumonia (OR 3.12; 95% CI 1.78-5.57; p < 0.001), cerebral infarction (OR 3.06; 95% CI 1.80-5.30; p < 0.001), and poor prognosis (OR 2.88; 95% CI 1.44-5.92; p = 0.003) at 3 months. The mediation effect was significant for both pneumonia and cerebral infarction, with the average causal mediation effect (ACME) were 0.04 (95% CI 0.02-0.08; p < 0.05) and 0.05 (95% CI 0.02-0.08; p < 0.001), respectively. Hemoglobin decrement during hospitalization was significantly associated with poor prognosis after aSAH, and the increased risk of cerebral infarction and pneumonia might mediate this effect. Avoiding hemoglobin decrement greater than 12.5g/l may improve the prognosis of patients with aSAH.

Predisposing and precipitating factors of post-operative delirium after transfemoral TAVI

Abstract Background Transcatheter aortic valve implantation (TAVI) represents the treatment of choice for aortic stenosis (AS) patients at higher age (&amp;gt; 75y) or with relevant comorbidities. Post-operative delirium (POD) is a frequent complication which has been associated with worse outcome. Thus, preventive options are highly needed. The aim of our single-center study was to investigate predisposing and precipitating factors of POD after transfemoral TAVI, with a focus on the influence of anaesthesia. Methods Risk factors for POD after TAVI were analysed in 2 merged cohorts of 480 study patients (43% women; mean age 80 years), enrolled in 2017-2022 (n=375, TAVI in 95% in general anaesthesia) and in 2022-2024 (n=105, TAVI in 91% in local anaesthesia). Incidence of POD was evaluated retrospectively by nursing documentation, medical records, and DRG coding. The association of demographics, comorbidities, echo parameters, procedural parameters, anaesthesia, and peri-procedural complications with POD incidence was investigated. Results In total, 29 patients (6%) developed POD, with a tendency towards a lower incidence in the later cohort (6.7% vs. 3.8%; p=0.28). Regarding baseline characteristics, patients experiencing POD were more likely to be male (p=0.03), frail (Katz Index &amp;lt;6, p=0.049), and to suffer from low-gradient AS (p=0.005 for paradoxical, p=0.02 for classical low-flow, low-gradient AS; see also fig. 1A). Total procedure time was significantly longer in patients with POD (median, 86 vs. 62 min, p=0.004; fig 1B), and a tendency towards a more frequent implantation of other than ballon-expandable valves could be observed (p=0.07). Concerning the role of anaesthesia, POD did not differ significantly after general anaesthesia (n=24/360, 6.7%), conscious sedation (n=1/19, 5.3%), and local anaesthesia (n=4/100, 4%) (p=0.38). Regarding procedural complications, POD patients were characterized by lower minimum hemoglobin post-TAVI (9.3 vs. 10.1 g/dl, p=0.05; fig. 1C) and higher incidences of intra-procedural resuscitation (11% vs. 2%, p=0.03), cerebrovascular accidents (10% vs. 2%, p=0.04) and new permanent pacemaker implantations (25% vs. 10%, p=0.02). In POD patients, long-term survival after TAVI was significantly reduced, with a median survival of only 2 years (Kaplan-Meier curves in fig. 2; p=0.001). Conclusions POD after TAVI stays common and unfavourable. The role of anaesthesia seems less pronounced than expected. Total procedure time and relevant anaemia after TAVI emerged as most important modifiable risk factors. Future research is warranted, since strategies to reduce precipitating factors for POD may have a significant impact on post-TAVI outcomes.Selected risk factors for PODConsequence of POD: Reduced Survival

Gastric adenocarcinoma due to H. Pylori infection on patient with chronic kidney disease on hemodialysis

A 53-year-old Male was admitted to our emergency department presenting with severe anemia (Hb 6.9 gr/dl) with a history of chronic kidney disease on routine hemodialysis twice a week and insulin-dependent type 2 diabetes. He was diagnosed with gastric adenocarcinoma after biopsy sample acquired from endoscopy confirmed by pathologist. The patient also has a positive HPSA test result. He was given rapid insulin 3 times daily and long-acting insulin once daily, continued routine hemodialysis and planned to do partial gastrectomy after recommended serum-creatinine level and minimum hemoglobin level are reached. We will take into consideration the routine use of anti-platelets and anti-coagulants during hemodialysis and how it will affect our decision to do surgery. Currently the patient still discusses the option of surgery even though it has been suggested by the digestive surgeon. In conclusion, we are discussing the difficulties of managing patient with gastric adenocarcinoma caused by H. pylori infection with chronic kidney disease and diabetes as the aggravating factors, including the use of routine medication and managing the blood sugar.

Beyond the Valve: Incidence, Outcomes, and Modifiable Factors of Acute Kidney Injury in Patients with Infective Endocarditis Undergoing Valve Surgery-A Retrospective, Single-Center Study.

Background/Objectives: Infective endocarditis (IE) often requires surgical intervention, with postoperative acute kidney injury (AKI), posing a significant concern. This retrospective study aimed to investigate AKI incidence, its impact on short-term mortality, and identify modifiable factors in patients with IE scheduled for valve surgery. Methods: This single-center study enrolled 130 consecutive IE patients from 2013 to 2021 undergoing valve surgery. The creatinine levels were monitored pre- and postoperatively, and AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patient demographics, comorbidities, procedural details, and complications were recorded. Primary outcomes included AKI incidence; the relevance of creatinine levels for AKI detection; and the association of AKI with 30-, 60-, and 180-day mortality. Modifiable factors contributing to AKI were explored as secondary outcomes. Results: Postoperatively, 35.4% developed AKI. The highest creatinine elevation occurred on the second postoperative day. Best predictive value for AKI was a creatinine level of 1.35 mg/dL on the second day (AUC: 0.901; sensitivity: 0.89, specificity: 0.79). Elevated creatinine levels on the second day were robust predictors for short-term mortality at 30, 60, and 180 days postoperatively (AUC ranging from 0.708 to 0.789). CK-MB levels at 24 h postoperatively and minimum hemoglobin during surgery were identified as independent predictors for AKI in logistic regression. Conclusions: This study highlights the crucial role of creatinine levels in predicting short-term mortality in surgical IE patients. A specific threshold (1.35 mg/dL) provides a practical marker for risk stratification, offering insights for refining perioperative strategies and optimizing outcomes in this challenging patient population.

BURDEN OF ANEMIA AND ASSOCIATED FACTORS AMONG PREGNANT WOMEN AT KAUSAR HOSPITAL MOTHER AND CHILD HEALTH CARE CENTRE KHAIRPUR MIR’S, PAKISTAN

Anemia is the condition in which hemoglobin level may become lower than normal &lt;11.0g/dl. According to an estimate, about one-third of the world's population (over 2 billion) are anemic. The study aimed to determine the Prevalence of anemia and associated factors among pregnant women at Kausar Hospital Mother and Child Health Care Centre Khairpur Mir’s, Sindh, Pakistan. The cross-sectional study was conducted from August to December 2019. A total number of 100 pregnant women were randomly included in this study. A predesigned questionnaire was filled out by face-to-face interviews consisting of socio-demographic characteristics, including Name, Age, gestational age, educational level, occupation, and monthly income. Anemia was classified as per World Health Organisation (WHO) criteria. The prevalence rate of Anemia in the present study was 69%. Minimum Haemoglobin levels were observed at 5.6 g/dL, and maximum Haemoglobin levels were observed at 12.4 g/dL with an average Haemoglobin of 10.05 g/dL ±1.44. Among them, 49% had mild anemia, 17% moderate anemia, and 3% severe anemia. At the same time, the patients were divided into age groups of 15-20 years, 21 to 25 years, 26 to 30 years, and 31-35 years to compare Anemia or Haemoglobin levels. Results showed a higher prevalence of anemia between the ages of 26 and 30. The minimum age was observed to be 20 years and a maximum of 35 years, with an average age of 28.12 years ±2.5 years. It was observed that the prevalence of Anemia was higher in 7-9 gestational months; socio-economic factors (Age, Gestational month, Number of children, and income source) showed significant association with Anemia. The present study concludes that the Prevalence of Anemia and Associated Factors among Pregnant Women at Kausar Hospital was 69%. Among them, 49% had mild anemia, 17% moderate anemia, and 3% severe anemia.

Safety and efficacy of peripheral blood stem cells collection in healthy children and pediatric patients with thalassemia major weighing 20 kg or less.

Peripheral blood stem cell (PBSC) collection in children poses challenges due to their small size, low body weight (BW), and unique pediatric physiology, especially among children weighing 20 kg (kg) or less. PBSC collection data of both healthy children and patients with thalassemia major (TM) weighing 20 kg or less between January 2013 and December 2020 were reviewed. Moreover, PBSCs characteristics along with various aspects of efficiency and safety between healthy donors and patients with TM were compared. A total of 262 PBSC procedures were performed on 255 children. Of these, 91 procedures were carried out on 85 allogeneic healthy donors, and 171 auto-backup collections were performed on 170 patients with TM to ensure PBSC availability and prevent transplantation failure. A minimum pre-apheresis hemoglobin (HGB) level of 60 g/L was discovered to be safe and feasible in patients with TM. The median CD34+ cell dose in the PBSC product during the initial apheresis procedure was higher in healthy donors compared to patients with TM (7.29 ± 5.28 × 106 cells/kg vs5.88 ± 4.23 × 106 cells/kg, P = .043). The total CD34+ cells/kg recipient weight exhibited a positive correlation with pre-apheresis monocyte counts, but a negative correlation with donor weight. Apheresis significantly reduced hematocrit and platelet counts in the allogeneic group compared to the autologous group. Patients with TM experienced a higher occurrence of bone pain related to granulocyte colony-stimulating factor treatment. Notably, no serious complications related to PBSCs mobilization, central venous catheter placement, or the apheresis procedure were observed in either group. PBSCs collection was both safe and effective in healthy children and pediatric patients with TM weighing 20 kg or less.

Hemoglobin levels and clinical outcomes after extracorporeal circulation auxiliary to open heart surgery: a retrospective cohort study

BackgroundExtracorporeal circulation auxiliary to open heart surgery is a common procedure used to treat heart diseases. However, the optimal transfusion strategy for patients undergoing this surgery remains a subject of debate. This study aims to investigate the association between hemoglobin levels and clinical outcomes in patients undergoing extracorporeal circulation auxiliary to open heart surgery, with the ultimate goal of improving surgical success rates and enhancing patients' quality of life.MethodsA retrospective analysis was conducted on data from the Medical Information Mart for Intensive Care IV 2.2 (MIMIC-IV 2.2) database, including 4144 patients. The patients were categorized into five groups based on their minimum hemoglobin levels during hospitalization. Baseline characteristics, clinical scores, laboratory results, and clinical outcome data were collected. Statistical analyses utilized descriptive statistics, ANOVA or Kruskal-Wallis tests, Kaplan-Meier method, and Log-rank test.ResultsThe results revealed a significant correlation between hemoglobin levels and in-hospital mortality, as well as mortality rates at 30 days, 60 days, and 180 days (p < 0.001). Patients with lower hemoglobin levels exhibited higher mortality rates. However, once hemoglobin levels exceeded 7g/dL, no significant difference in mortality rates was observed (p = 0.557). Additionally, lower hemoglobin levels were associated with prolonged hospital stay, ICU admission time, and mechanical ventilation time (p < 0.001). Furthermore, hemoglobin levels were significantly correlated with complication risk, norepinephrine dosage, and red blood cell transfusion volume (p < 0.001). However, there was no significant difference among the groups in terms of major complications, specifically sepsis (p > 0.05).ConclusionThe study highlights the importance of managing hemoglobin levels in patients undergoing heart surgery with extracorporeal circulation. Hemoglobin levels can serve as valuable indicators for predicting clinical outcomes and guiding treatment decisions. Physicians should carefully consider hemoglobin levels to optimize transfusion strategies and improve postoperative patient outcomes. Further research and intervention studies are warranted to validate and implement these findings in clinical practice.

Acute Chest Syndrome at the Emory University Georgia Comprehensive Sickle Cell Center at Grady Health System

Background: Individuals who have sickle cell disease (SCD) are susceptible to several severe consequences, such as vasoocclusive crisis (VOC), which may further develop into acute chest syndrome (ACS), a specific type of acute lung injury. Although VOC can result in substantial morbidity, it is important to note that ACS is the primary cause of mortality among individuals with SCD. Despite the devastating consequences of ACS, no interventions exist that directly treat this complication. Consequently, when patients present with ACS, their treatment options are frequently limited to supportive care. The absence of ideal therapeutic interventions for individuals with SCD who are experiencing ACS is a significant factor in their increased rates of illness and death. A cohort of adult patients diagnosed with ACS was examined with the objective to evaluate indicators of disease severity and identify risk factors associated with recurrent ACS. Methods: The Emory University Georgia Comprehensive Sickle Cell Center, located at Grady Health System, offers a dedicated acute care unit (ACU) that operates around the clock. This unit is specifically designed to assess and manage SCD patients who present with sickle cell crises. A pilot retrospective study was undertaken to analyze 25 patients with ACS. The evaluation included the examination of admission laboratory results, demographic information, past medical history, co-morbidity, interventions for each ACS admission for each patient (refer to Table 1). Descriptive statistics were used to report frequencies or median and range (Table 2). Patient characteristics of patients with 1 ACS event versus those with recurrent ACS (&amp;gt;=2) were compared using fishers exact test or the Wilcoxon-rank-sum test. Statistical significance was set at 0.05. Analysis was completed using SAS 9.4 (Cary, NC). Results: A total of 47 ACS episodes were detected in a cohort of 25 individuals, resulting in a median of 1 ACS event per patient (range of 1 to 6). A total of 85% of the patients included in this study had homozygosity for SCD, whereas 36% of the patients were receiving hydroxyurea treatment. Chronic pain was reported in three-fourth of the cohort. Out of all the ACS events observed, only 40% necessitated red cell exchange transfusion. A correlation between a minimum hemoglobin (Hb) level of 3.3 g/dL and lactate dehydrogenase (LDH) levels over 4000 U/L was noted during ACS admission. These findings indicate the presence of intravascular hemolysis. Three individuals died to ACS. Next, we conducted a comparison between a group of 10 patients who experienced recurring ACS events, with a minimum of 2 to a maximum of 6 occurrences, and another group of 15 patients who only had a single ACS episode. The group of patients with recurrent ACS exhibits a median of 5.5 episodes of VOC that necessitate visits to the acute care unit within the year prior. In contrast, the group with a single ACS episode has a median of 1 event. There was a notable disparity in the frequency of transfusions received by patients with recurrent ACS compared to those who experienced only a single episode over the past year. Although no other variable demonstrated statistical significance, the recurrent ACS group exhibited lower levels of hemoglobin and higher levels of LDH in comparison to the group with a single ACS episode. Further examination of our patients with SCD could provide valuable insights into the potential factors that may predict ACS episodes. These factors include a patient's genetic background, the frequency of VOC, the use of hydroxyurea, evidence of hemolysis, and previous blood transfusions. Furthermore, the utilization of acute care unit by patients with SCD has had a positive effect in our cohort, on the reduction of red cell exchange transfusions and mortality rates from ACS, possibly from early identification and episodic transfusion, in comparison to similar cohorts with ACS.

Validation of the impact of post discharge change in hemoglobin by renal function on the prognosis of HFpEF patients after acute decompensated heart failure from the PURSUIT-HFpEF registry

Abstract Background Anemia has been reported as poor prognostic factor on heart failure with preserved ejection fraction (HFpEF). However, it is not clear at what minimum level hemoglobin (Hb) by renal function should be managed to prevent worsening the prognosis of HFpEF. Aim The aim of this study is to evaluate the impact of the change in Hb by renal function from discharge of congestive heart failure to one year after discharge on the prognosis of HFpEF and verify at what minimum level hemoglobin (Hb) should be managed to prevent worsening the prognosis of HFpEF. Method 809 HFpEF cases enrolled from 2016 to 2021 in PURSUIT-HFpEF registry were divided into two groups according to estimated glomerular filtration rate (eGFR) at discharge, group with eGFR &amp;lt; 45 (n = 438) and group with eGFR ≥ 45 (n = 371). Two groups were further divided according to whether Hb was above or below 11 &amp;lt; g/dl at discharge: the group with Hb &amp;lt; 11 g/dl was divided into two groups, one with progression anemia (G1) and preserved anemia (G2) after one year, and the group with Hb ≥ 11 g/dl was divided into three groups, Hb &amp;lt; 11 g/dl (G3), 11 g/dl ≤ Hb &amp;lt; 13 g/dl (G4a), Hb ≥ 13 g/dl (G4b). We examined Hazard ratio (HR) and incidence rate of Major Adverse Cardiovascular Events (MACE), all-cause death and heart failure readmission between each two groups, G1 and G2, G3 and G4a, G4a and G4b, and examined predictor for MACE in each two groups with Hb &amp;lt; 11g/dl and ≥ 11 g/dl at discharge by Cox regression model, in two groups with eGFR &amp;lt;45 and ≥ 45 at discharge. Result All-cause death was significantly lower in G2 than in G1 (HR : 0.33, [95%Confidence Interval (CI), 0.14 - 0.80], p = 0.011) in the group with eGFR ≥ 45. MACE was significantly higher in G3 than in G4a by log-rank test (HR : 1.61, [95%CI, 1.02 - 3.45], p = 0.038) in the group with eGFR &amp;lt; 45, however, MACE, all-cause death and heart failure readmission were significantly higher in G3 than in G4a in the group with eGFR ≥ 45 (MACE ; HR : 1.99, [95%CI, 1.15 - 3.45], p = 0.013, All-cause death ; HR : 2.09, [95%CI, 1.02 - 4.29], p = 0.042, heart failure readmissio ; HR : 2.43, [95%CI, 1.22 - 4.82], p = 0.009). Only all-cause death was significantly lower in G4b than in G4a by log-rank test regardless of renal function (eGFR &amp;lt; 45 ; HR : 0.08, [95%CI, 0.01 - 0.60], p = 0.002, eGFR ≥ 45 ; HR : 0.38, [95%CI, 0.18 - 0.83], p = 0.012). In multivariate Cox regression model, worsening anemia to Hb &amp;lt; 11 g/dl one year later was independent predictor for MACE in patients with eGFR ≥ 45 and Hb ≥ 11 g/dl at discharge (HR : 2.45, [95%CI, 1.22 – 4.91], p = 0.012). Conclusion Hb levels of at least 11 g/dl should be maintained to prevent the prognosis of HFpEF worse after discharge of acute decompensated heart failure regardless of renal function, however it might be necessary to maintain higher hemoglobin level in HFpEF patients with moderate to severe renal dysfunction than those with mild renal dysfunction.study flow by eGFR and outcomekaplan-meier curves of outcomes

Construction of a prediction model for predicting rebleeding in patients with obscure gastrointestinal bleeding after capsule endoscopy

Objective: To explore the risk factors of rebleeding in patients with obscure gastrointestinal bleeding (OGIB) after capsule endoscopy (CE), and construct a model to predict rebleeding. Methods: The data of patients with OGIB who underwent CE in Zhongda Hospital Affiliated to Southeast University from July 2018 to September 2021 were retrospectively analyzed. Follow-up data were obtained via electronic medical records or telephone interviews. Univariate and multivariate Cox regression models were performed to figure out the risk factors of rebleeding in OGIB patients. Then the optimal prediction model was determined and presented as a nomogram. The model was evaluated by C statistic, calibration curve and decision curve analysis. Results: One hundred and thirty patients with OGIB were included, including 64 females and 66 males, aged (55.8±17.2) years (18-87 years), and 39 (30.0%) cases developed rebleeding during follow-up. Univariate and multivariate Cox regression model analysis showed the duration of more than 2 weeks OGIB (HR=3.70, 95%CI: 1.85-7.42, P<0.001), a history of previous gastrointestinal bleeding (HR=5.25, 95%CI: 2.00-13.81, P<0.001), positive CE findings (HR=3.72, 95%CI: 1.66-8.33, P=0.001), and the lowest hemoglobin level before CE<80 g/L (HR=2.00, 95%CI: 1.02-3.84, P=0.044) were risk factors for rebleeding, while specific treatment (HR=0.25, 95%CI: 0.11-0.54, P<0.001) was a protective factor. The corresponding scores of the above five predictive factors were: OGIB duration>2 weeks: 79 points; Previous history of gastrointestinal bleeding: 100 points; The result of CE was positive: 79 points; Specific treatment:-85 points; Minimum hemoglobin before CE<80 g/L: 41 points. The prediction model constructed from the above five variables had good discriminative capability (concordance index=0.798, 95%CI: 0.732-0.865). The calibration curves showed high consistency between nomogram-predicted probabilities and actual observations. The decision curves showed that when the threshold probability was above 0.04, the use of the nomogram to predict rebleeding provided a greater net benefit than the assumption of "all patients rebleeding or no patients rebleeding". Conclusion: The prediction model established in this study has a good ability to predic rebleeding in patients with OGIB after CE examination.

Intravascular Hemolysis and AKI in Children Undergoing Extracorporeal Membrane Oxygenation.

AKI is common in ECMO patients, with a variety of proposed mechanisms. We sought to describe the impact of laboratory evidence of ECMO-associated intravascular hemolysis on AKI and renal replacement therapy (RRT). This retrospective cohort study included patients treated with ECMO at a single center over ten years. The primary outcome was a composite of time to RRT or AKI (by creatinine based KDIGO criteria) after ECMO start. Serum creatinine closest to ECMO start time was considered the pre-ECMO baseline and used to determine abnormal kidney function at ECMO start. The patient's subsequent creatinine values were used to identify AKI on ECMO. Multivariable cause-specific cox proportional hazards models were used to assess the impact of separate markers of intravascular hemolysis on the time to the composite outcome after controlling for confounders. 501 children were evaluated with a median age 1.2 years, 56% male. Four separate multivariable models, each with a different marker of hemolysis (plasma free hemoglobin, LDH, minimum platelet count, minimum daily hemoglobin) were used to examine the impact on the composite outcome of AKI/RRT. An elevated plasma free hemoglobin, the most specific of these hemolysis markers, demonstrated an almost three-fold higher adjusted hazard for the composite outcome (HR 2.9, p-value <0.01, 95% CI 1.4-5.6). Elevated LDH was associated with an adjusted hazard ratio of 3.1 (p-value <0.01, 95% CI 1.7-5.5). Effect estimates were also pronounced in a composite outcome of only more severe AKI, stage 2+ AKI/RRT: HR 6.6 (p-value <0.01, 95% CI 3.3-13.2) for plasma free hemoglobin and 2.8 (p-value <0.01, 95% CI 1.5-5.6) for LDH. Laboratory findings consistent with intravascular hemolysis on ECMO were independently associated with a higher hazard of a composite outcome of AKI/RRT in children undergoing ECMO.

Approach to red blood cell transfusions in post-operative congenital heart disease surgery patients: when to stop?

The best transfusion approach for CHD surgery is controversial. Studies suggest two strategies: liberal (haemoglobin ≤ 9.5 g/dL) and restrictive (waiting for transfusion until haemoglobin ≤ 7.0 g/dL if the patient is stable). Here we compare liberal and restrictive transfusion in post-operative CHD patients in a cardiac intensive care unit. Retrospective analysis was conducted on CHD patients who received liberal transfusion (2019-2021, n=53) and restrictive transfusion (2021-2022, n=43). The two groups were similar in terms of age, gender, Paediatric Risk of Mortality-3 score, Paediatric Logistic Organ Dysfunction-2 score, Risk Adjustment for Congenital Heart Surgery-1 score, cardiopulmonary bypass time, vasoactive inotropic score, total fluid balance, mechanical ventilation duration, length of cardiac intensive care unit stay, and mortality. The liberal transfusion group had a higher pre-operative haemoglobin level than the restrictive group (p < 0.05), with no differences in pre-operative anaemia. Regarding the minimum and maximum post-operative haemoglobin levels during a cardiac intensive care unit stay, the liberal group had higher haemoglobin levels in both cases (p<0.01 and p=0.019, respectively). The number of red blood cell transfusions received by the liberal group was higher than that of the restrictive group (p < 0.001). There were no differences between the two groups regarding lactate levels at the time of and after red blood cell transfusion. The incidence of bleeding, re-operation, acute kidney injury, dialysis, sepsis, and systemic inflammatory response syndrome was similar. Restrictive transfusion may be preferable over liberal transfusion. Achieving similar outcomes with restrictive transfusions may provide promising evidence for future studies.

Analysis of donor hemoglobin levels at the blood transfusion service of Dr. Sardjito Hospital, Yogyakarta

Introduction: Blood service is a health service that utilizes human blood as a basic ingredient for humanitarian and non-commercial purposes. Donors in Indonesia are required to have a minimum Hemoglobin (Hb) level of 12.5 g/dL in accordance with National Regulations. It aims to ensure that the donor can tolerate the loss of blood without the appearance of anemia symptoms. This study aims to analyze the Hb levels of donors at the Blood Transfusion Service of Dr. Sardjito Hospital, Yogyakarta, Indonesia. Method: This analytic observational study applied a retrospective design. The data of 62,221 donors were taken from the donor database of the Blood Transfusion Service of Dr. Sardjito Hospital. The inclusion criteria were donors aged ≥ 17 years and met other donor selection criteria. Donors with incomplete data were excluded. The chi-Square test was performed using the SPSS version 22. The p &lt; 0.05 was considered significant. Results: The subjects were dominated by male donors, i.e., 48,348 (77.7%), and the most Hb level were 14.1-15.5 g/dL. This range of Hb levels was identified as the highest proportion in all age groups. The Hb levels of 14.1-15.5 g/dL were determined in 5,874 (39.6%) blood group A, 7,332 (39%) blood group B; 1,830 (39.6%) blood group AB and 9,486 (39.5%) blood group O donors. Conclusions: There was a significant difference in the proportion of donors based on Hb levels, sexes, ABO groups, Rhesus D groups, donation types, and donor statuses (p &lt; 0.001).

Are Patients Requiring Hartmann's Procedure Being Adequately Optimised for Surgery: An Audit Cycle.

Introduction Hartmann's procedures are common surgical operations indicated in a wide variety of presentations including colon malignancy, diverticular disease, volvulus, and colovesical and colovaginal fistulas. The procedure is a major undertaking for the patient and those presenting in the emergency setting are often clinically unwell with deranged laboratory investigations. Numerous studies have demonstrated that pre-operative anaemia contributes to increased morbidity and mortality. Applying the conclusions of one study recommending a minimum haemoglobin >12 g/dL level pre-operatively, this audit assessed patient optimisation prior to Hartmann's procedure. Materials and methods Patients undergoing Hartmann's procedures between May 2016 and February 2020 were identified. Data was collected retrospectively to analyse American Society of Anesthesiology (ASA) grade and pre-operative haemoglobin level. Pre-operative haemoglobin and group and save blood test values were identified pre-and post-intervention. Results Pre-intervention, 15 (21%) of 70 patients had a haemoglobin level <12 g/dL and 63 patients (90%) had a group and save blood test completed on admission. Post-intervention data was collected from 45 patients, with figures improving to five (11%) and 44 (97%) patients, respectively. Conclusion Our flowchart poster distribution and addition to the surgical proforma led to increased patient optimisation prior to Hartmann's procedure.

Correlation between blood pressure indexes and prognosis in sepsis patients: a cohort study based on MIMIC-III database

To investigate the correlation between early-stage blood pressure indexes and prognosis in sepsis patients. A retrospective cohort study was conducted on the medical records of patients diagnosed with sepsis from 2001 to 2012 in the Medical Information Mart for Intensive Care-III (MIMIC-III) database. Patients were divided into survival group and death group according to the 28-day prognosis. General data of patients and heart rate (HR) and blood pressure at admission to ICU and within 24 hours after admission were collected. The blood pressure indexes including the maximum, median and mean value of systolic index, diastolic index and mean arterial pressure (MAP) index were calculated. The data were randomly divided into training set and validation set (4 : 1). Univariate Logistic regression analysis was used to screen covariates, and multivariate Logistic stepwise regression models were further developed. Model 1 (including HR, blood pressure, and blood pressure index related variables with P < 0.1 and other variables with P < 0.05) and Model 2 (including HR, blood pressure, and blood pressure index related variables with P < 0.1) were developed respectively. The receiver operator characteristic curve (ROC curve), precision recall curve (PRC) and decision curve analysis (DCA) curve were used to evaluate the quality of the two models, and the influencing factors of the prognosis of sepsis patients were analyzed. Finally, nomogram model was developed according to the better model and effectiveness of it was evaluated. A total of 11 559 sepsis patients were included in the study, with 10 012 patients in the survival group and 1 547 patients in the death group. There were significant differences in age, survival time, Elixhauser comorbidity score and other 46 variables between the two groups (all P < 0.05). Thirty-seven variables were preliminarily screened by univariate Logistic regression analysis. After multivariate Logistic stepwise regression model screening, among the indicators related to HR, blood pressure and blood pressure index, the HR at admission to ICU [odds ratio (OR) = 0.992, 95% confidence interval (95%CI) was 0.988-0.997] and the maximum HR (OR = 1.006, 95%CI was 1.001-1.011), maximum MAP index (OR = 1.620, 95%CI was 1.244-2.126), mean diastolic index (OR = 0.283, 95%CI was 0.091-0.856), median systolic index (OR = 2.149, 95%CI was 0.805-4.461), median diastolic index (OR = 3.986, 95%CI was 1.376-11.758) were selected (all P < 0.1). There were 14 other variables with P < 0.05, including age, Elixhauser comorbidity score, continuous renal replacement therapy (CRRT), use of ventilator, sedation and analgesia, norepinephrine, norepinephrine, highest serum creatinine (SCr), maximum blood urea nitrogen (BUN), highest prothrombin time (PT), highest activated partial thromboplastin time (APTT), lowest platelet count (PLT), highest white blood cell count (WBC), minimum hemoglobin (Hb). The ROC curve showed that the area under the curve (AUC) of Model 1 and Model 2 were 0.769 and 0.637, respectively, indicating that model 1 had higher prediction accuracy. The PRC curve showed that the AUC of Model 1 and Model 2 were 0.381 and 0.240, respectively, indicating that Model 1 had a better effect. The DCA curve showed that when the threshold was 0-0.8 (the probability of death was 0-80%), the net benefit rate of Model 1 was higher than that of Model 2. The calibration curve showed that the prediction effect of the nomogram model developed according to Model 1 was in good agreement with the actual outcome. The Bootstrap verification results showed that the nomogram model was consistent with the above results and had good prediction effects. The nomogram model constructed has good prediction effects on the 28-day prognosis in sepsis patients, and the blood pressure indexes are important predictors in the model.

Hematological effects of Levosimendan therapy in patients with heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Levosimendan is an inotropic drug, acting as calcium sensitizer, used in the management of acute heart failure. Despite its hemodynamic benefits, Levosimendan is associated with several adverse reactions, including hematological effects, with a hemoglobin value decrease, causing anemia. Acute coronary syndromes (ACS) might be a precipitant of acute heart failure, in a substantial proportion of cases. These situations may require the use of inotropic drugs, such as Levosimendan. Antithrombotic therapy is the cornerstone therapy for management of acute coronary syndromes, and the decision of which strategy is determined by the balance of ischemic and hemorrhagic risks. Therefore, in the management of acute heart failure, associated with ACS, the use of Levosimendan might be associated with the increase of hemorrhagic risk, due to hemoglobin decrease, influencing the antithrombotic therapy strategy choice. Purpose This study aims to evaluate the effect of the use of Levosimendan on the hemoglobin value, comparing with Dobutamine, in patients hospitalized for ACS. Methods We analyzed a retrospective, multicenter, observational cohort of 317 patients, admitted for ACS, requiring inotropic therapy. The population was divided into two groups: a group that used Levosimendan and a group that used Dobutamine. The mean decrease in hemoglobin value, and the minimum hemoglobin value, during hospitalization, was compared between both groups. Results Levosimendan sample included 39 patients, of which 40,1% (n=15) were women, with a mean age of 83±12,1 year old, while Dobutamine sample had 278 elements, of which 38% (n=105) were women with a mean age of 82±12,1. There was no statistically significant difference between both samples on age and sex distribution. Levosimendan group had a mean minimum hemoglobin value of 10,7±2,2 g/dL and a mean decrease in hemoglobin value, during hospitalization, of 2,7±1,9 g/dL, while Dobutamine group had a mean minimum hemoglobin value of 10,7±2,2 g/dL and a decrease in hemoglobin value, during hospitalization, 2,1±1,9g/dL. There was no statically significant difference on mean minimum hemoglobin value on both samples (p&amp;gt;0,05), however, there was a statistically significant difference, with a higher decrease in mean hemoglobin value, during hospitalization in patients using Levosimendan, comparing with patients using Dobutamine (2,7±1,9g/dL vs 2,1±1,9g/dL, p=0,04). Conclusion Levosimendan is associated with a higher decrease in hemoglobin value. As heart failure might complicate ACS episode, and might require inotropic therapy, we should be aware that the choice of using Levosimendan in these situations may confer a greater risk of bleeding, associated with the higher decrease in hemoglobin value, in patients who need intense antithrombotic therapy.

Sickle cell disease and the need for blood: Barriers to donation for African, Caribbean, and Black young adults in Canada.

Many blood operators around the world face the challenge of increasing the number of donors of African ancestry to meet the transfusion needs of people living with sickle cell disease. This article reports results of the barriers to blood donation for young adults (aged 19-35) in Canada who identify as African, Caribbean, or Black. A community-based qualitative study was conducted by researchers from community organizations, blood operator, and universities. In-depth focus groups and interviews (n = 23) were conducted from Dec 2021 to Apr 2022 and thematic analysis was completed. Applying a socio-ecological model, multiple levels of interacting barriers to blood donation were identified. These included macro-level barriers (e.g., systemic racism, mistrust of the healthcare system, sociocultural beliefs and views about blood and sickle cell disease), mezzo-level barriers (e.g., deferral criteria, minimum hemoglobin levels, donor questionnaire, access, parental concerns), and microlevel barriers (e.g., limited knowledge of blood needs for people with sickle cell disease, lacking information about blood donation process, fear of needles, personal health concerns). This study is the first to focus on barriers to donation for African, Caribbean, and Black young adults across Canada. Parental concerns, informed by parents' experiences of inequitable healthcare and mistrust, emerged as a novel finding in our study population. Results suggest that higher order (macro-level) barriers influence and may reinforce lower order (mezzo- and microlevel) barriers. As such, interventions aimed at addressing barriers to donation should keep in view all levels with particular attention paid to higher order barriers.

Long-term use of somatostatin analogs for chronic gastrointestinal bleeding in hereditary hemorrhagic telangiectasia.

Chronic bleeding due to gastrointestinal (GI) involvement in patients with hemorrhagic hereditary telangiectasia (HHT) can provoke severe anemia with high red blood cells (RBC) transfusion requirements. However, the evidence about how to deal with these patients is scarce. We aimed to assess the long-term efficacy and safety of somatostatin analogs (SA) for anemia management in HHT patients with GI involvement. This is a prospective observational study including patients with HHT and GI involvement attended at a referral center. SA were considered for those patients with chronic anemia. Anemia-related variables were compared in patients receiving SA before and during treatment. Patients receiving SA were divided into responders (patients with minimal hemoglobin levels improvement >10 g/L and maintaining hemoglobin levels ≥80 g/L during treatment), and non-responders. Adverse effects during follow-up were collected. Among 119 HHT patients with GI involvement, 67 (56.3%) received SA. These patients showed lower minimal hemoglobin levels (73 [60-87] vs. 99 [70.2-122.5], p < 0.001), and more RBC transfusion requirements (61.2% vs. 38.5%, p = 0.014) than patients without SA therapy. Median treatment period was 20.9 ± 15.2 months. During treatment, there was a statistically significant improvement in minimum hemoglobin levels (94.7 ± 29.8 g/L vs. 74.7 ± 19.7, p < 0.001) and a reduction of patients with minimal hemoglobin levels <80 g/L (39 vs. 61%, p = 0.007) and RBC transfusions requirement (33.9% vs. 59.3%, p < 0.001). Sixteen (23.9%) patients showed mild adverse effects, mostly diarrhea or abdominal pain, leading to treatment discontinuation in 12 (17.9%) patients. Fifty-nine patients were eligible for efficacy assessment and 32 (54.2%) of them were considered responders. Age was associated with non-responder patients, OR 95% CI; 1.070 (1.014-1.130), p = 0.015. SA can be considered a long-term effective and safe option for anemia management in HHT patients with GI bleeding. Older age is associated with poorer response.

Prognostic impact of in-hospital hemoglobin decline in non-overt bleeding ICU patients with acute myocardial infarction

BackgroundThe prognostic value of in-hospital hemoglobin drop in non-overt bleeding patients with acute myocardial infarction (AMI) admitted to the intensive care unit (ICU) remains insufficiently investigated.MethodsA retrospective analysis was performed based on the Medical Information Mart for Intensive Care (MIMIC)-IV database. 2,334 ICU-admitted non-overt bleeders diagnosed with AMI were included. In-hospital hemoglobin values (baseline value on admission and nadir value during hospitalization) were available. Hemoglobin drop was defined as a positive difference between admission and in-hospital nadir hemoglobin. The primary endpoint was 180-day all-cause mortality. The time-dependent Cox proportional hazard models were structured to analyze the connection between hemoglobin drop and mortality.Results2,063 patients (88.39%) experienced hemoglobin drop during hospitalization. We categorized patients based on the degree of hemoglobin drop: no hemoglobin drop (n = 271), minimal hemoglobin drop (< 3 g/dl; n = 1661), minor hemoglobin drop (≥ 3 g/dl & < 5 g/dl, n = 284) and major hemoglobin drop (≥ 5 g/dl; n = 118). Minor (adjusted hazard ratio [HR] = 12.68; 95% confidence interval [CI]: 5.13–31.33; P < 0.001) and major (adjusted HR = 13.87; 95% CI: 4.50-42.76; P < 0.001) hemoglobin drops were independently associated with increased 180-day mortality. After adjusting the baseline hemoglobin level, a robust nonlinear relationship was observed in the association between hemoglobin drop and 180-day mortality, with 1.34 g/dl as the lowest value (HR = 1.04; 95% CI: 1.00-1.08).ConclusionIn non-overt bleeding ICU-admitted patients with AMI, in-hospital hemoglobin drop is independently associated with higher 180-day all-cause mortality.