Early Post-Hospitalization Hemoglobin Recovery and Clinical Outcomes in Survivors of Critical Illness: A Population-Based Cohort Study

Prevalence and factors influencing anemia recovery after intensive care

BACKGROUND

Anemia is associated with adverse outcomes and prolonged hospitalizations in critically ill patients. Regarding the recent adoption of restrictive transfusion protocols in intensive care unit (ICU) management, anemia remains highly prevalent even after ICU discharge. This study aimed to investigate the prevalence of anemia following ICU discharge and factors affecting recovery from anemia.

METHODS

In this retrospective cohort study involving 3969 adult ICU survivors, we assessed anemia severity using the National Cancer Institute criteria at six time points: ICU admission, ICU discharge, hospital discharge, and at 3-, 6-, and 12-month post-hospital discharge. In addition, baseline characteristics, including age, sex, comorbidities, and recent iron supplementation or erythropoietin administration, were evaluated.

RESULTS

Our findings revealed an in-hospital mortality rate of 28.6%. The median hospital and ICU stays were 20 and 5 days, respectively, with common comorbidities including hypertension, and diabetes mellitus (DM). Among the patients, the hemoglobin levels of 3967 patients were confirmed at the time of discharge from the ICU, representing 99.95% of the total. The prevalence of anemia persisted post- ICU discharge; less than 30% of patients recovered, whereas 13.6% of them experienced worsening of anemia post-ICU discharge. Factors contributing to anemia severity were female sex, DM, chronic renal failure, malignant solid tumors, and administration of iron supplements.

CONCLUSIONS

This study highlighted the need for targeted interventions to manage anemia post-ICU discharge and suggested potential factors that influence recovery from anemia.

Iron and erythropoietin to heal and recover after intensive care (ITHRIVE): A pilot randomised clinical trial

Objective

To determine the feasibility of a pivotal randomised clinical trial of intravenous (IV) iron and erythropoietin in adult survivors of critical illness with anaemia requiring treatment in the intensive care unit.

Design

An investigator-initiated, parallel group, placebo-controlled, randomised feasibility trial.

Setting

A tertiary intensive care unit (ICU) in Perth, Western Australia.

Participants

Adults with anaemia (haemoglobin <100 g/L), requiring ICU-level care for more than 48 h, and likely to be ready for ICU discharge within 24 h.

Interventions

A single dose of IV ferric carboxymaltose and Epoetin alfa (active group) or an equal volume of 0.9% saline (placebo group).

Main outcome measures

Study feasibility was considered met if the pilot achieved a recruitment rate of ≥2 participants per site per month, ≥90% of participants received their allocated study treatment, and≥ 90% of participants were followed up for the proposed pivotal trial primary outcome - days alive and at home to day 90 (DAH90).

Results

The 40-participant planned sample size included twenty in each group and was enrolled between 1/9/2021 and 2/3/2022. Participants spent a median of 3.4 days (interquartile range 2.8-5.1) in the ICU prior to enrolment and had a mean baseline haemoglobin of 83.7 g/L (standard deviation 6.7). The recruitment rate was 6.7 participants per month [95% confidence interval (CI) 4.8-9.0], DAH90 follow-up was 100% (95% CI 91.2%-100%), and 39 (97.5%, 95% CI 86.8%-99.9%) participants received the allocated study intervention. No serious adverse events were reported.

Conclusion

The iron and erythropoietin to heal and recover after intensive care (ITHRIVE) pilot demonstrated feasibility based on predefined participant recruitment, study drug administration, and follow-up thresholds.

Patient Blood Management, Anemia, and Transfusion Optimization Across Surgical Specialties

Patient blood management (PBM) is a systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood and minimizing allogenic transfusion need and risk. According to the PBM approach, the goals of perioperative anemia management include early diagnosis, targeted treatment, blood conservation, restrictive transfusion except in cases of acute and massive hemorrhage, and ongoing quality assurance and research efforts to advance overall blood health.

Blood count derangements after sepsis and association with post-hospital outcomes

Rationale

Predicting long-term outcomes in sepsis survivors remains a difficult task. Persistent inflammation post-sepsis is associated with increased risk for rehospitalization and death. As surrogate markers of inflammation, complete blood count parameters measured at hospital discharge may have prognostic value for sepsis survivors.

Objective

To determine the incremental value of complete blood count parameters over clinical characteristics for predicting 90-day outcomes in sepsis survivors.

Methods

Electronic health record data was used to identify sepsis hospitalizations at United States Veterans Affairs hospitals with live discharge and relevant laboratory data (2013 to 2018). We measured the association of eight complete blood count parameters with 90-day outcomes (mortality, rehospitalization, cause-specific rehospitalizations) using multivariable logistic regression models.

Measurements and main results

We identified 155,988 eligible hospitalizations for sepsis. Anemia (93.6%, N=142,162) and lymphopenia (28.1%, N=29,365) were the most common blood count abnormalities at discharge. In multivariable models, all parameters were associated with the primary outcome of 90-day mortality or rehospitalization and improved model discrimination above clinical characteristics alone (likelihood ratio test, p<0.02 for all). A model including all eight parameters significantly improved discrimination (AUROC, 0.6929 v. 0.6756) and reduced calibration error for the primary outcome. Hemoglobin had the greatest prognostic separation with a 1.5 fold increased incidence of the primary outcome in the lowest quintile (7.2-8.9 g/dL) versus highest quintile (12.70-15.80 g/dL). Hemoglobin and neutrophil lymphocyte ratio provided the most added value in predicting the primary outcome and 90-day mortality alone, respectively. Absolute lymphocyte count added little value in predicting 90-day outcomes.

Conclusions

The incorporation of discharge complete blood count parameters into prognostic scoring systems could improve prediction of 90-day outcomes. Hemoglobin had the greatest prognostic value for the primary composite outcome of 90-day rehospitalization or mortality. Absolute lymphocyte count provided little added value in multivariable model comparisons, including for infection- or sepsis-related rehospitalization.

Association between anaemia and hospital readmissions in patients undergoing major surgery requiring postoperative intensive care

Anaemia is a common sequela of surgery, although its relationship with patient recovery is unclear. The goal of this investigation was to assess the associations between haemoglobin concentrations at the time of hospital discharge following major surgery and early post-hospitalisation outcomes, with a primary outcome of 30 day unanticipated hospital readmissions. This investigation includes data from two independent population-based observational cohorts of adult surgical patients (aged ≥ 18 years) requiring postoperative intensive care unit admission between 1 January 2010 and 31 December 2019 in hospitals in Olmsted County, Minnesota, and between 1 July 2010 and 30 June 2017 in the Kaiser Permanente Northern California integrated healthcare system, California. Cox proportional hazards models assessed the associations between discharge haemoglobin concentrations (per 10 g.l-1 ) and outcomes, with prespecified multivariable adjustment. A total of 3260 patients were included from Olmsted County hospitals and 29,452 from Kaiser Permanente Northern California. In adjusted analyses, each 10 g.l-1 decrease in haemoglobin at hospital discharge was associated with a 9% (hazard ratio 1.09, 95%CI 1.02-1.18; p = 0.014) and 8% increase (hazard ratio 1.08, 95%CI 1.06-1.11; p < 0.001) in the hazard for readmission within 30 days in Olmsted County and Kaiser Permanente Northern California, respectively. In a sensitivity analysis exploring relationships across varying levels of pre-operative anaemia severity, these associations remained consistent, with lower discharge haemoglobin concentrations associated with higher readmissions irrespective of pre-operative anaemia severity. Anaemia at hospital discharge in surgical patients requiring postoperative intensive care is associated with increased rates of hospital readmission in two large independent cohorts. Future studies are necessary to evaluate strategies to prevent and/or treat anaemia in these patients for the improvement of post-hospitalisation outcomes.

Practical Anemia Bundle for Sustained Blood Recovery (PABST-BR) in critical illness: a protocol for a randomised controlled trial

INTRODUCTION

Anaemia is highly prevalent in critical illness and is associated with impaired outcomes during and after hospitalisation. However, the impact of interventions designed to attenuate or treat anaemia during critical illness on post-hospitalisation haemoglobin recovery and functional outcomes is unclear.

METHODS AND ANALYSIS

The Practical Anemia Bundle for Sustained Blood Recovery (PABST-BR) clinical trial is a pragmatic, open-label, parallel group, single-centre, randomised clinical trial assessing the impact of a multifaceted anaemia prevention and treatment strategy versus standard care for improvement of haemoglobin concentrations and functional outcomes after critical illness. The intervention, which will be delivered early in critical illness for those with moderate-to-severe anaemia (ie, haemoglobin <100 g/L), includes three components: (1) optimised phlebotomy, (2) clinical decision support and (3) pharmacological anaemia treatment directed at the underlying aetiology of anaemia. In-person assessments will occur at 1 and 3 months post-hospitalisation for laboratory evaluations and multidimensional functional outcome assessments. The primary outcome is differences in haemoglobin concentrations between groups, with secondary endpoints of anaemia-related fatigue, physical function, cognition, mental health, quality of life, phlebotomy volumes and frequency, transfusions, readmissions and mortality through 1-year post-hospitalisation.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Board of the Mayo Clinic in Minnesota, USA. A Data Safety Monitoring Plan has been created in accordance with the policies of the Institutional Review Board and the study funder, the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH). The study will comply with NIH data sharing and dissemination policies. Results will be presented at national and international meetings and published in peer-reviewed journals. Designing and testing strategies to optimise haemoglobin recovery and improve functional outcomes after critical illness remain important research gaps. The PABST-BR trial will inform the development of a larger multicentre clinical trial.

TRIAL REGISTRATION NUMBER

NCT05167734.