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Ajzenberg H, Binhashr MAN, Hewitt MK, Unger M. Critical Care: What You May Have Missed in 2023. Ann Intern Med 2024. [PMID: 38621243 DOI: 10.7326/m24-0565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Critical care medicine is a specialty that brings together a truly wide spectrum of patient populations, disease states, and treatment methods. This article highlights 10 important pieces of research from 2023 (and 1 from 2022) in critical care. The literature was screened for new evidence relevant to internal medicine physicians and hospitalists whose focus of practice is not critical care but who may be taking care of seriously ill patients. The articles highlight the diverse spectrum of pathology and interplay of various specialties that go into critical care. Topics include transfusion medicine, fluid resuscitation, safe intubation practices and respiratory failure, and the management of acute ischemic stroke. Several trials are groundbreaking, forcing clinicians to reconsider preexisting dogma and likely adopt new treatment strategies.
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Affiliation(s)
- Henry Ajzenberg
- McMaster University, Hamilton, Ontario, Canada (H.A., M.A.N.B., M.K.H.)
| | | | - Mark Keith Hewitt
- McMaster University, Hamilton, Ontario, Canada (H.A., M.A.N.B., M.K.H.)
| | - Michael Unger
- Thomas Jefferson University, Korman Respiratory Institute, Philadelphia, Pennsylvania (M.U.)
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Rahman MO, Charbonney E, Vaisler R, Khalifa A, Alhazzani W, Gossack-Keenan K, Garland A, Karachi T, Duan E, Bagshaw SM, Meade MO, Hillis C, Kavsak P, Born K, Mbuagbaw L, Siegal D, Millen T, Scales D, Amaral A, English S, McCredie VA, Dodek P, Cook DJ, Rochwerg B. A Canadian survey of perceptions and practices related to ordering of blood tests in the intensive care unit. Can J Anaesth 2024:10.1007/s12630-024-02745-x. [PMID: 38504038 DOI: 10.1007/s12630-024-02745-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 03/21/2024] Open
Abstract
PURPOSE The ordering of routine blood test panels in advance is common in intensive care units (ICUs), with limited consideration of the pretest probability of finding abnormalities. This practice contributes to anemia, false positive results, and health care costs. We sought to understand practices and attitudes of Canadian adult intensivists regarding ordering of blood tests in critically ill patients. METHODS We conducted a nationwide Canadian cross-sectional survey consisting of 15 questions assessing three domains (global perceptions, test ordering, daily practice), plus 11 demographic questions. The target sample was one intensivist per adult ICU in Canada. We summarized responses using descriptive statistics and present data as mean with standard deviation (SD) or count with percentage as appropriate. RESULTS Over seven months, 80/131 (61%) physicians responded from 77 ICUs, 50% of which were from Ontario. Respondents had a mean (SD) clinical experience of 12 (9) years, and 61% worked in academic centres. When asked about their perceptions of how frequently unnecessary blood tests are ordered, 61% responded "sometimes" and 23% responded "almost always." Fifty-seven percent favoured ordering complete blood counts one day in advance. Only 24% of respondents believed that advanced blood test ordering frequently led to changes in management. The most common factors perceived to influence blood test ordering in the ICU were physician preferences, institutional patterns, and order sets. CONCLUSION Most respondents to this survey perceived that unnecessary blood testing occurs in the ICU. The survey identified possible strategies to decrease the number of blood tests.
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Affiliation(s)
- M Omair Rahman
- McMaster University, Hamilton, ON, Canada.
- Juravinski Hospital, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada.
| | - Emannuel Charbonney
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | | | | | | | | | | | - Erick Duan
- McMaster University, Hamilton, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Maureen O Meade
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | | | - Karen Born
- Institute of Health Policy, Management & Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Deborah Siegal
- Department of Medicine, Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Damon Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Andre Amaral
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Shane English
- Institute of Health Policy, Management & Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Dodek
- Centre for Advancing Health Outcomes and Division of Critical Care Medicine, St. Paul's Hospital and The University of British Columbia, Vancouver, BC, Canada
| | - Deborah J Cook
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Mazzeffi M, Miller D, Wang A, Kothandaraman V, Money D, Clouse B, Zaaqoq AM, Teman N. Iatrogenic blood loss from phlebotomy during adult extracorporeal membrane oxygenation: A retrospective cohort study. Transfusion 2024; 64:475-482. [PMID: 38385665 DOI: 10.1111/trf.17729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. DISCUSSION 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.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - David Miller
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Angela Wang
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | - Dustin Money
- University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Brian Clouse
- University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Akram M Zaaqoq
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Nicholas Teman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
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