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Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
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Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Yu Y, Fu Y, Li W, Sun T, Cheng C, Chong Y, Han R, Cui W. Red blood cell transfusion in neurocritical patients: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:106. [PMID: 38504153 PMCID: PMC10949741 DOI: 10.1186/s12871-024-02487-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Anemia can lead to secondary brain damage by reducing arterial oxygen content and brain oxygen supply. Patients with acute brain injury have impaired self-regulation. Brain hypoxia may also occur even in mild anemia. Red blood cell (RBC) transfusion is associated with increased postoperative complications, poor neurological recovery, and mortality in critically ill neurologic patients. Balancing the risks of anemia and red blood cell transfusion-associated adverse effects is challenging in neurocritical settings. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE (PubMed) from inception to January 31, 2024. We included all randomized controlled trials (RCTs) assessing liberal versus restrictive RBC transfusion strategies in neurocritical patients. We included all relevant studies published in English. The primary outcome was mortality at intensive care unit (ICU), discharge, and six months. RESULTS Of 5195 records retrieved, 84 full-text articles were reviewed, and five eligible studies were included. There was no significant difference between the restrictive and liberal transfusion groups in ICU mortality (RR: 2.53, 95% CI: 0.53 to 12.13), in-hospital mortality (RR: 2.34, 95% CI: 0.50 to 11.00), mortality at six months (RR: 1.42, 95% CI: 0.42 to 4.78) and long-term mortality (RR: 1.22, 95% CI: 0.64 to 2.33). The occurrence of neurological adverse events and most major non-neurological complications was similar in the two groups. The incidence of deep venous thrombosis was lower in the restrictive strategy group (RR: 0.41, 95% CI: 0.18 to 0.91). CONCLUSIONS Due to the small sample size of current studies, the evidence is insufficiently robust to confirm definitive conclusions for neurocritical patients. Therefore, further investigation is encouraged to define appropriate RBC transfusion thresholds in the neurocritical setting.
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Affiliation(s)
- Yun Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Yuxuan Fu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Wenying Li
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, 5 Shijingshan Rd, Shijingshan District, Beijing, PR China
| | - Tiantian Sun
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, PR China
| | - Chan Cheng
- Department of Anesthesiology, Beijing Stomatological Hospital Affiliated to Capital Medical University, No.4 Tiantan Xili, Dongcheng District, Beijing, 100050, PR China
| | - Yingzi Chong
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China
| | - Weihua Cui
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, PR China.
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Quintana-Diaz M, Anania P, Juárez-Vela R, Echaniz-Serrano E, Tejada-Garrido CI, Sanchez-Conde P, Nanwani-Nanwani K, Serrano-Lázaro A, Marcos-Neira P, Gero-Escapa M, García-Criado J, Godoy DA. "COAGULATION": a mnemonic device for treating coagulation disorders following traumatic brain injury-a narrative-based method in the intensive care unit. Front Public Health 2023; 11:1309094. [PMID: 38125841 PMCID: PMC10730733 DOI: 10.3389/fpubh.2023.1309094] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Coagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication. Methods A narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device. Results and conclusion Eleven factors were identified: cerebral computed tomography, oral anticoagulant & antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid-base status, forming the acronym "Coagulation." This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis.
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Affiliation(s)
- Manuel Quintana-Diaz
- Department of Medicine, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
| | - Pasquale Anania
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero eCura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Raúl Juárez-Vela
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
- Department of Nursing, University of La Rioja, Logroño, Spain
- Health and Healthcare Research Group (GRUPAC), Faculty of Health Sciences, University of La Rioja, Logroño, Spain
| | - Emmanuel Echaniz-Serrano
- Department of Nursing and Physiatry, Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain
- Aragon Healthcare Service, Aragon, Zaragoza, Spain
| | - Clara Isabel Tejada-Garrido
- Department of Nursing, University of La Rioja, Logroño, Spain
- Health and Healthcare Research Group (GRUPAC), Faculty of Health Sciences, University of La Rioja, Logroño, Spain
| | | | - Kapil Nanwani-Nanwani
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
| | - Ainhoa Serrano-Lázaro
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
- Intensive Care Unit, Valencia University Clinical Hospital, Valencia, Spain
| | - Pilar Marcos-Neira
- Intensive Care Unit, Germans Trias i Pujol University Hospital, Badalona, Spain
| | | | | | - Daniel Agustín Godoy
- Critical Care Department, Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina
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Chegondi M, Hernandez Rivera JF, Alkhoury F, Totapally BR. The need for blood transfusion therapy is associated with increased mortality in children with traumatic brain injury. PLoS One 2023; 18:e0279709. [PMID: 36607845 DOI: 10.1371/journal.pone.0279709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Blood transfusion therapy (BTT) is widely used in trauma patients. However, the adverse effects of BTT in pediatric trauma patients with traumatic brain injury (TBI) were poorly studied. The objective of this study is to evaluate the effect of BTT on mortality in children with severe TBI. METHODS In this retrospective cohort analysis, we analyzed 2012 and 2016 Kids' Inpatient Databases and used a weighted sample to obtain national outcome estimates. We included children aged 1 month to 21 years with TBI who were mechanically ventilated, considered severe TBI; we then compared the demographics, comorbidities, and mortality rates of those patients who had undergone BTT to those who did not. Statistical analysis was performed using the chi-squared test and regression models. In addition, in a correlative propensity score matched analysis, cases (BTT) were matched 1:1 with controls (non-BTT) based on age, gender, hospital region, income quartiles, race, and All Patients Refined Diagnosis Related Groups (APRDRG) severity of illness scores to minimize the effect of confounding variables between the groups. RESULTS Out of 87,980 children with a diagnosis of TBI, 17,199 (19.5%) with severe TBI were included in the analysis. BTT was documented in 3184 (18.5%) children. Among BTT group, the mortality was higher compared to non-BTT group [31.6% (29.7-33.5%) vs. 14.4 (13.7-15.1%), (OR 2.2, 95% CI 1.9-2.6; p<0.05)]. In the BTT group, infants and adolescents, white race, APRDRG severity of illness, cardiac arrest, platelet, and coagulation factor transfusions were associated with higher mortality. In a propensity-matched analysis, BTT associated with a higher risk of mortality (32.1% [30.1-34.2] vs. 17.4% [15.8-19.1], p<0.05; OR: 2.2, 95% CI: 1.9-2.6). CONCLUSION In children with severe TBI, blood transfusion therapy is associated with higher mortality.
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Turgeon AF, Fergusson DA, Clayton L, Patton MP, Zarychanski R, English S, Docherty A, Walsh T, Griesdale D, Kramer AH, Scales D, Burns KEA, Boyd JG, Marshall JC, Kutsogiannis DJ, Ball I, Hébert PC, Lamontagne F, Costerousse O, St-Onge M, Lessard Bonaventure P, Moore L, Neveu X, Rigamonti A, Khwaja K, Green RS, Laroche V, Fox-Robichaud A, Lauzier F. Haemoglobin transfusion threshold in traumatic brain injury optimisation (HEMOTION): a multicentre, randomised, clinical trial protocol. BMJ Open 2022; 12:e067117. [PMID: 36216432 PMCID: PMC9557781 DOI: 10.1136/bmjopen-2022-067117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the leading cause of mortality and long-term disability in young adults. Despite the high prevalence of anaemia and red blood cell transfusion in patients with TBI, the optimal haemoglobin (Hb) transfusion threshold is unknown. We undertook a randomised trial to evaluate whether a liberal transfusion strategy improves clinical outcomes compared with a restrictive strategy. METHODS AND ANALYSIS HEMOglobin Transfusion Threshold in Traumatic Brain Injury OptimizatiON is an international pragmatic randomised open label blinded-endpoint clinical trial. We will include 742 adult patients admitted to an intensive care unit (ICU) with an acute moderate or severe blunt TBI (Glasgow Coma Scale ≤12) and a Hb level ≤100 g/L. Patients are randomly allocated using a 1:1 ratio, stratified by site, to a liberal (triggered by Hb ≤100 g/L) or a restrictive (triggered by Hb ≤70 g/L) transfusion strategy applied from the time of randomisation to the decision to withdraw life-sustaining therapies, ICU discharge or death. Primary and secondary outcomes are assessed centrally by trained research personnel blinded to the intervention. The primary outcome is the Glasgow Outcome Scale extended at 6 months. Secondary outcomes include overall functional independence measure, overall quality of life (EuroQoL 5-Dimension 5-Level; EQ-5D-5L), TBI-specific quality of life (Quality of Life after Brain Injury; QOLIBRI), depression (Patient Health Questionnaire; PHQ-9) and mortality. ETHICS AND DISSEMINATION This trial is approved by the CHU de Québec-Université Laval research ethics board (MP-20-2018-3706) and ethic boards at all participating sites. Our results will be published and shared with relevant organisations and healthcare professionals. TRIAL REGISTRATION NUMBER NCT03260478.
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Affiliation(s)
- Alexis F Turgeon
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Dean A Fergusson
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lucy Clayton
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Centre de Recherche du CHU Sainte-Justine, Montréal, Québec, Canada
| | - Marie-Pier Patton
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Hematology/Oncology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Shane English
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Annemarie Docherty
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Timothy Walsh
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Center for Clinical Epidemiology & Evaluation, Vancouver General Hospital, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Andreas H Kramer
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Damon Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Gordon Boyd
- Department of Medicine, Division of Neurology, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, Division of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Ian Ball
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Paul C Hébert
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Centre de Recherche du CHU de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Olivier Costerousse
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Maude St-Onge
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - Paule Lessard Bonaventure
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec City, Québec, Canada
| | - Xavier Neveu
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Andrea Rigamonti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kosar Khwaja
- Department of Critical Care Medicine, McGill University, Montréal, Québec, Canada
| | - Robert S Green
- Departments of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vincent Laroche
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Medicine, Université Laval, Québec City, Québec, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Francois Lauzier
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- Department of Medicine, Université Laval, Québec City, Québec, Canada
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Kapoor I, Prabhakar H, Mahajan C. Letter to the Editor: Incidence and Associated Factors of Anemia in Patients with Acute Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2022; 37:810. [PMID: 36085343 DOI: 10.1007/s12028-022-01591-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Vanhala H, Junttila E, Kataja A, Huhtala H, Luostarinen T, Luoto T. Incidence and Associated Factors of Anemia in Patients with Acute Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2022; 37:629-637. [PMID: 35915348 PMCID: PMC9671999 DOI: 10.1007/s12028-022-01561-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/17/2022] [Indexed: 12/05/2022]
Abstract
Background Anemia might contribute to the development of secondary injury in patients with acute traumatic brain injury (TBI). Potential determinants of anemia are still poorly acknowledged, and reported incidence of declined hemoglobin concentration varies widely between different studies. The aim of this study was to investigate the incidence of severe anemia among patients with moderate to severe TBI and to evaluate patient- and trauma-related factors that might be associated with the development of anemia. Methods This retrospective cohort study involved all adult patients admitted to Tampere University Hospital’s emergency department for moderate to severe TBI (August 2010 to July 2012). Detailed information on patient demographics and trauma characteristics were obtained, including data on posttraumatic care, data on neurosurgical procedures, and all measured in-hospital hemoglobin values. Severe anemia was defined as a hemoglobin level less than 100 g/L. Both univariate and multivariable analyses were performed, and hemoglobin trajectories were created. Results The study included 145 patients with moderate to severe TBI (male 83.4%, mean age 55.0 years). Severe anemia, with a hemoglobin level less than 100 g/L, was detected in 66 patients (45.5%) and developed during the first 48 h after the trauma. In the univariate analysis, anemia was more common among women (odds ratio [OR] 2.84; 95% confidence interval [CI] 1.13–7.15), patients with antithrombotic medication prior to trauma (OR 3.33; 95% CI 1.34–8.27), patients with cardiovascular comorbidities (OR 3.12; 95% CI 1.56–6.25), patients with diabetes (OR 4.56; 95% CI 1.69–12.32), patients with extracranial injuries (OR 3.14; 95% CI 1.69–12.32), and patients with midline shift on primary head computed tomography (OR 2.03; 95% CI 1.03–4.01). In the multivariable analysis, midline shift and extracranial traumas were associated with the development of severe anemia (OR 2.26 [95% CI 1.05–4.48] and OR 4.71 [95% CI 1.74–12.73], respectively). Conclusions Severe anemia is common after acute moderate to severe TBI, developing during the first 48 h after the trauma. Possible anemia-associated factors include extracranial traumas and midline shift on initial head computed tomography.
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Affiliation(s)
- Heidi Vanhala
- Department of Anesthesia and Intensive Care, Tampere University Hospital, Tampere, Finland.
| | - Eija Junttila
- Department of Anesthesia and Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Anneli Kataja
- Medical Imaging Center, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Biostatistics Group, Tampere University, Tampere, Finland
| | - Teemu Luostarinen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Teemu Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
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Juárez-Vela R, Andrés-Esteban EM, Santolalla-Arnedo I, Ruiz de Viñaspre-Hernández R, Benito-Puncel C, Serrano-Lázaro A, Marcos-Neira P, López-Fernández A, Tejada-Garrido CI, Sánchez-González JL, Quintana-Díaz M, García-Erce JA. Epidemiology and Associated Factors in Transfusion Management in Intensive Care Unit. J Clin Med 2022; 11:jcm11123532. [PMID: 35743602 PMCID: PMC9225042 DOI: 10.3390/jcm11123532] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Severe traumatic injury is one of the main global health issues which annually causes more than 5.8 million worldwide deaths. Uncontrolled haemorrhage is the main avoidable cause of death among severely injured individuals. Management of trauma patients is the greatest challenge in trauma emergency care, and its proper diagnosis and early management of bleeding trauma patients, including blood transfusion, are critical for patient outcomes. Aim: We aimed to describe the epidemiology of transfusion practices in severe trauma patients admitted into Spanish Intensive Care Units. Material and Methods: We performed a multicenter cross-sectional study in 111 Intensive Care Units across Spain. Adult patients with moderate or severe trauma were eligible. Distribution of frequencies was used for qualitative variables and the mean, with its 95% CI, for quantitative variables. Transfusion programmes, the number of transfusions performed, and the blood component transfused were recorded. Demographic variables, mortality rate, hospital stay, SOFA-score and haemoglobin levels were also gathered. Results: We obtained results from 109 patients. The most transfused blood component was packet red blood cells with 93.8% of total transfusions versus 43.8% of platelets and 37.5% of fresh plasma. The main criteria for transfusion were analytical criteria (43.75%), and acute anaemia with shock (18.75%) and without haemodynamic impact (18.75%). Conclusion: Clinical practice shows a ratio of red blood cells, platelets, and Fresh Frozen Plasma (FFP) of 2:1:1. It is necessary to implement Massive Transfusion Protocols as they appear to improve outcomes. Our study suggests that transfusion of RBC, platelets and FFP in a 2:1:1 ratio could be beneficial for trauma patients.
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Affiliation(s)
- Raúl Juárez-Vela
- Doctoral Programme in Medicine and Surgery, Faculty of Medicine, Autonomous University of Madrid, 28049 Madrid, Spain;
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
- Research Institute IdiPaz, 28029 Madrid, Spain;
| | - Eva María Andrés-Esteban
- Research Institute IdiPaz, 28029 Madrid, Spain;
- Department of Business Economics and Applied Economy, Faculty of Legal and Economic Sciences, Rey Juan Carlos University, 28933 Madrid, Spain
| | - Ivan Santolalla-Arnedo
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
| | | | | | | | - Pilar Marcos-Neira
- Intensive Care Unit, Hospital Germans Trias i Pujol, 08916 Badalona, Spain;
| | | | - Clara Isabel Tejada-Garrido
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
- Correspondence: (C.I.T.-G.); (M.Q.-D.)
| | | | - Manuel Quintana-Díaz
- Research Institute IdiPaz, 28029 Madrid, Spain;
- Intensive Care Unit, University Hospital of La Paz, 28046 Madrid, Spain;
- Correspondence: (C.I.T.-G.); (M.Q.-D.)
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Yang X, Chen L, Pu J, Li Y, Cai J, Chen L, Feng S, He J, Wang Y, Zhang S, Cheng S, Huang H. Guideline of clinical neurorestorative treatment for brain trauma (2022 China version). Journal of Neurorestoratology 2022; 10:100005. [DOI: 10.1016/j.jnrt.2022.100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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10
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Gouvêa Bogossian E, Rass V, Lindner A, Iaquaniello C, Miroz JP, Cavalcante Dos Santos E, Njimi H, Creteur J, Oddo M, Helbok R, Taccone FS. Factors Associated With Brain Tissue Oxygenation Changes After RBC Transfusion in Acute Brain Injury Patients. Crit Care Med 2022. [PMID: 35132018 DOI: 10.1097/CCM.0000000000005460] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Anemia is common after acute brain injury and can be associated with brain tissue hypoxia. RBC transfusion (RBCT) can improve brain oxygenation; however, predictors of such improvement remain unknown. We aimed to identify the factors associated with PbtO2 increase (greater than 20% from baseline value) after RBCT, using a generalized mixed model. DESIGN This is a multicentric retrospective cohort study (2012-2020). SETTING This study was conducted in three European ICUs of University Hospitals located in Belgium, Switzerland, and Austria. PATIENTS All patients with acute brain injury who were monitored with brain tissue oxygenation (PbtO2) catheters and received at least one RBCT. INTERVENTION Patients received at least one RBCT. PbtO2 was recorded before, 1 hour, and 2 hours after RBCT. MEASUREMENTS AND MAIN RESULTS We included 69 patients receiving a total of 109 RBCTs after a median of 9 days (5-13 d) after injury. Baseline hemoglobin (Hb) and PbtO2 were 7.9 g/dL [7.3-8.7 g/dL] and 21 mm Hg (16-26 mm Hg), respectively; 2 hours after RBCT, the median absolute Hb and PbtO2 increases from baseline were 1.2 g/dL [0.8-1.8 g/dL] (p = 0.001) and 3 mm Hg (0-6 mm Hg) (p = 0.001). A 20% increase in PbtO2 after RBCT was observed in 45 transfusions (41%). High heart rate (HR) and low PbtO2 at baseline were independently associated with a 20% increase in PbtO2 after RBCT. Baseline PbtO2 had an area under receiver operator characteristic of 0.73 (95% CI, 0.64-0.83) to predict PbtO2 increase; a PbtO2 of 20 mm Hg had a sensitivity of 58% and a specificity of 73% to predict PbtO2 increase after RBCT. CONCLUSIONS Lower PbtO2 values and high HR at baseline could predict a significant increase in brain oxygenation after RBCT.
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Montgomery EY, Barrie U, Kenfack YJ, Edukugho D, Caruso JP, Rail B, Hicks WH, Oduguwa E, Pernik MN, Tao J, Mofor P, Adeyemo E, Ahmadieh TYE, Tamimi MA, Bagley CA, Bedros N, Aoun SG. Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence. Neurotrauma Rep 2022; 3:554-568. [PMID: 36636743 PMCID: PMC9811955 DOI: 10.1089/neur.2022.0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.
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Affiliation(s)
- Eric Y. Montgomery
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Address correspondence to: Eric Y. Montgomery, BA, Department of Neurosurgery, The University of Texas Southwestern, 5151 Harry Hines Boulevard, Dallas, TX 75235, USA.
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yves J. Kenfack
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Derrek Edukugho
- Department of Neurological Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA
| | - James P. Caruso
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin Rail
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William H. Hicks
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuella Oduguwa
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan Tao
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paula Mofor
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuel Adeyemo
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tarek Y. El Ahmadieh
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mazin Al Tamimi
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bedros
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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12
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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13
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Mollayeva T, Mollayeva S, Pacheco N, Colantonio A. Systematic Review of Sex and Gender Effects in Traumatic Brain Injury: Equity in Clinical and Functional Outcomes. Front Neurol 2021; 12:678971. [PMID: 34566834 PMCID: PMC8461184 DOI: 10.3389/fneur.2021.678971] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/09/2021] [Indexed: 01/12/2023] Open
Abstract
Background: Although traumatic brain injury (TBI) is a leading cause of death and disability in male and female patients worldwide, little is known about the effect of sex and gender on TBI outcomes. Objectives: This systematic review summarizes the evidence on the effect of sex and gender on core TBI outcomes. Methods: All English-language studies from six literature databases that addressed core outcomes in adults with TBI and included sex or gender, TBI severity, and age in their analyses were considered eligible. Two reviewers extracted data, and two reviewers assessed study quality using tools recommended by the National Institutes of Health. The results were sorted according to time post-injury, injury severity, gender equity ranking of the study's country of origin, and outcomes studied. The results from the included studies were grouped based on the approach taken in reporting their respective findings. Results and Limitations: Of 172 articles assessed, 58 studies were selected, comprising 1, 265, 955 participants with TBI (67% male across all studies) of all injury severities. All studies were conducted in countries with a very high or high human development index, while the Gender Inequality Index (GII) varied. While the heterogeneity across studies limited any meaningful conclusions with respect to the role of sex and gender, we did observe that as gender equality ranking improved, differences between male and female participants in outcomes would diminish. Inclusion of social equity parameters in the studies was limited. Conclusions and Implications: The non-uniform findings observed bring forth the need to develop and use a comprehensive and consistent methodology in the study of sex and gender post-TBI, incorporating social equity parameters to uncover the potential social underpinnings of gender effects on health and functional outcomes. Systematic Review Registration: CRD42018098697.
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Affiliation(s)
- Tatyana Mollayeva
- KITE Toronto Rehabilitation Institute University Health Network, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,School of Occupational Therapy, Western University, London, ON, Canada
| | - Shirin Mollayeva
- Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada
| | - Nicole Pacheco
- Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,School of Occupational Therapy, Western University, London, ON, Canada
| | - Angela Colantonio
- KITE Toronto Rehabilitation Institute University Health Network, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,Department of Epidemiology, Dalla Lana School of Public Health University of Toronto, Toronto, ON, Canada
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14
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KIYOHIRA M, SUEHIRO E, SHINOYAMA M, FUJIYAMA Y, HAJI K, SUZUKI M. Combined Strategy of Burr Hole Surgery and Elective Craniotomy under Intracranial Pressure Monitoring for Severe Acute Subdural Hematoma. Neurol Med Chir (Tokyo) 2021; 61:253-259. [PMID: 33597319 PMCID: PMC8048118 DOI: 10.2176/nmc.oa.2020-0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/25/2020] [Indexed: 11/24/2022] Open
Abstract
Burr hole surgery in the emergency room can be lifesaving for patients with acute subdural hematoma (ASDH). In the first part of this study, a strategy of combined burr hole surgery, a period of intracranial pressure (ICP) monitoring, and then craniotomy was examined for safe and effective treatment of ASDH. Since 2012, 16 patients with severe ASDH with indications for burr hole surgery were admitted to Kenwakai Otemachi Hospital. From 2012 to 2016, craniotomy was performed immediately after burr hole surgery (emergency [EM] group, n = 10). From 2017, an ICP sensor was placed before burr hole surgery. After a period for correction of traumatic coagulopathy, craniotomy was performed when ICP increased (elective [EL] group, n = 6). Patient background, bleeding tendency, intraoperative blood transfusion, and outcomes were compared between the groups. In the second part of the study, ICP was measured before and after burr hole surgery in seven patients (including two of the six in the EL group) to assess the effect of this surgery. Activated partial thromboplastin time (APTT) and prothrombin time-international normalized ratio (PT-INR) were significantly prolonged after craniotomy in the EM group, but not in the EL group, and the EM group tended to require a higher intraoperative transfusion volume. The rate of good outcomes was significantly higher in the EL group, and ICP was significantly decreased after burr hole surgery. These results suggest the value of burr hole surgery followed by ICP monitoring in patients with severe ASDH. Craniotomy can be performed safely using this method, and this may contribute to improved outcomes.
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Affiliation(s)
- Miwa KIYOHIRA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Eiichi SUEHIRO
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Chiba, Japan
| | - Mizuya SHINOYAMA
- Department of Neurosurgery, Kenwakai Otemachi Hospital, Kitakyushu, Fukuoka, Japan
| | - Yuichi FUJIYAMA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
- Department of Neurosurgery, Shinyurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kohei HAJI
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Michiyasu SUZUKI
- Department of Neurosurgery, Shinyurigaoka General Hospital, Kawasaki, Kanagawa, Japan
- Department of Advanced ThermoNeuroBiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
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15
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Abujaber A, Fadlalla A, Gammoh D, Abdelrahman H, Mollazehi M, El-Menyar A. Prediction of in-hospital mortality in patients on mechanical ventilation post traumatic brain injury: machine learning approach. BMC Med Inform Decis Mak 2020; 20:336. [PMID: 33317528 PMCID: PMC7737377 DOI: 10.1186/s12911-020-01363-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 12/03/2020] [Indexed: 12/17/2022] Open
Abstract
Background The study aimed to introduce a machine learning model that predicts in-hospital mortality in patients on mechanical ventilation (MV) following moderate to severe traumatic brain injury (TBI).
Methods A retrospective analysis was conducted for all adult patients who sustained TBI and were hospitalized at the trauma center from January 2014 to February 2019 with an abbreviated injury severity score for head region (HAIS) ≥ 3. We used the demographic characteristics, injuries and CT findings as predictors. Logistic regression (LR) and Artificial neural networks (ANN) were used to predict the in-hospital mortality. Accuracy, area under the receiver operating characteristics curve (AUROC), precision, negative predictive value (NPV), sensitivity, specificity and F-score were used to compare the models` performance. Results Across the study duration; 785 patients met the inclusion criteria (581 survived and 204 deceased). The two models (LR and ANN) achieved good performance with an accuracy over 80% and AUROC over 87%. However, when taking the other performance measures into account, LR achieved higher overall performance than the ANN with an accuracy and AUROC of 87% and 90.5%, respectively compared to 80.9% and 87.5%, respectively. Venous thromboembolism prophylaxis, severity of TBI as measured by abbreviated injury score, TBI diagnosis, the need for blood transfusion, heart rate upon admission to the emergency room and patient age were found to be the significant predictors of in-hospital mortality for TBI patients on MV. Conclusions Machine learning based LR achieved good predictive performance for the prognosis in mechanically ventilated TBI patients. This study presents an opportunity to integrate machine learning methods in the trauma registry to provide instant clinical decision-making support.
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Affiliation(s)
- Ahmad Abujaber
- Assistant Executive Director of Nursing, Hamad Medical Corporation, Doha, Qatar
| | - Adam Fadlalla
- Management Information Systems, Business, and Economics Faculty, Qatar University, Doha, Qatar
| | - Diala Gammoh
- Industrial Engineering, University of Central Florida, Orlando, USA
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Monira Mollazehi
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar. .,Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
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16
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Liu C, Huang C, Xie J, Li H, Hong M, Chen X, Wang J, Wang J, Li Z, Wang J, Wang W. Potential Efficacy of Erythropoietin on Reducing the Risk of Mortality in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Biomed Res Int 2020; 2020:7563868. [PMID: 33178833 DOI: 10.1155/2020/7563868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 01/28/2023]
Abstract
Objective The objective of this study is to assess the effectiveness of erythropoietin (EPO) on mortality, neurological outcomes, and adverse event in the treatment of traumatic brain injury (TBI). Methods We searched databases including PubMed, OVID, and the Cochrane Library from inception until October 18, 2019 for randomized controlled trials (RCTs) to compare EPO treatment group and placebo in patients with TBI. Two authors independently processed the data and evaluated the quality of inclusion studies. Statistical analysis was performed with heterogeneity test with I 2 and chi-square tests. We summarized the mortality, prognosis of neurological function, and deep vein thrombosis (DVT) outcomes and presented as risk ratio (RR) or risk difference (RD) with a 95% CI. Results Seven RCTs accounting for 1180 patients were included after meeting the inclusion criteria. Compared with placebo, the overall mortality of EPO-treated patients was significantly reduced (RR 0.68 [95% CI 0.50-0.93]; p = 0.02). EPO therapy did not improve neurological prognosis (RR 1.21 [95% CI 0.93-1.15]; p = 0.16) or increase the occurrence of DVT (RR 0.83 [95% CI 0.61-1.13]; p = 0.242), which showed no significant difference. Conclusions The results showed that the administration of EPO may reduce the risk of mortality without enhancing the occurrence of DVT in TBI patients. However, the effect of EPO on neurological outcome remains indistinct. Through subgroup analysis, we demonstrated that the dose of EPO may be a potential factor affecting the heterogeneity in neurological function and that the follow-up duration may influence the stability of the result.
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17
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Wise RD, de Vasconcellos K, Gopalan D, Ahmed N, Alli A, Joubert I, Kabambi KF, Mathiva LR, Mdladla N, Mer M, Miller M, Mrara B, Omar S, Paruk F, Richards GA, Skinner D, von Rahden R. Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018. South Afr J Crit Care 2020; 36:10.7196/SAJCC.2020.v36i1b.440. [PMID: 37415775 PMCID: PMC10321416 DOI: 10.7196/sajcc.2020.v36i1b.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 07/08/2023] Open
Abstract
The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.
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Affiliation(s)
- R D Wise
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - K de Vasconcellos
- Department of Critical Care, King Edward VIII Hospital, Durban; Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - D Gopalan
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - N Ahmed
- Surgical ICU, Tygerberg Academic Hospital; Department of Surgical Sciences and Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa
| | - A Alli
- Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - I Joubert
- Division of Critical Care, Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - K F Kabambi
- Department of Anaesthesia and Critical Care, Nelson Mandela Academic Hospital, Mthatha; Department of Surgery, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - L R Mathiva
- Intensive Care Unit, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - N Mdladla
- Dr George Mukhari Academic Hospital; Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - M Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Miller
- Department of Anaesthesia and Peri-operative Medicine, Division of Critical Care, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - B Mrara
- Anaesthesia Department, Walter Sisulu University, Mthatha, South Africa
| | - S Omar
- Department of Critical Care, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - F Paruk
- Department of Critical Care, Steve Biko Academic Hospital and Critical Care, School of Medicine, University of Pretoria, South Africa
| | - G A Richards
- Department of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - D Skinner
- Department of Critical Care, King Edward VIII Hospital, Durban; Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R von Rahden
- Private practice (Critical Care), Rodseth and Partners, Pietermaritzburg, South Africa
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Sims CA, Holena D, Kim P, Pascual J, Smith B, Martin N, Seamon M, Shiroff A, Raza S, Kaplan L, Grill E, Zimmerman N, Mason C, Abella B, Reilly P. Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg 2020; 154:994-1003. [PMID: 31461138 DOI: 10.1001/jamasurg.2019.2884] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Current therapies for traumatic blood loss focus on hemorrhage control and blood volume replacement. Severe hemorrhagic shock, however, is associated with a state of arginine vasopressin (AVP) deficiency, and supplementation of this hormone may decrease the need for blood products in resuscitation. Objective To determine whether low-dose supplementation of AVP in patients with trauma (hereinafter referred to as trauma patients) and with hemorrhagic shock decreases their need for transfused blood products during resuscitation. Design, Setting, and Participants This randomized, double-blind placebo-controlled clinical trial included adult trauma patients (aged 18-65 years) who received at least 6 U of any blood product within 12 hours of injury at a single urban level 1 trauma center from May 1, 2013, through May 31, 2017. Exclusion criteria consisted of prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment. Data were analyzed from May 1, 2013, through May 31, 2017, using intention to treat and per protocol. Interventions After administration of an AVP bolus (4 U) or placebo, participants received AVP (≤0.04 U/min) or placebo for 48 hours to maintain a mean arterial blood pressure of at least 65 mm Hg. Main Outcomes The primary outcome was total volume of blood product transfused. Secondary end points included total volume of crystalloid transfused, vasopressor requirements, secondary complications, and 30-day mortality. Results One hundred patients underwent randomization (49 to the AVP group and 51 to the placebo group). Patients were primarily young (median age, 27 years [interquartile range {IQR}, 22-25 years]) and male (n = 93) with penetrating trauma (n = 79). Cohort characteristics before randomization were well balanced. At 48 hours, patients who received AVP required significantly less blood products (median, 1.4 [IQR, 0.5-2.6] vs 2.9 [IQR, 1.1-4.8] L; P = .01) but did not differ in requirements for crystalloids (median, 9.9 [IQR, 7.9-13.0] vs 11.0 [8.9-15.0] L; P = .22) or vasopressors (median, 400 [IQR, 0-5900] vs 1400 [IQR, 200-7600] equivalent units; P = .22). Although the groups had similar rates of mortality (6 of 49 [12%] vs 6 of 51 [12%]; P = .94) and total complications (24 of 44 [55%] vs 30 of 47 [64%]; P = .37), the AVP group had less deep venous thrombosis (5 of 44 [11%] vs 16 of 47 [34%]; P = .02). Conclusions and Relevance Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements. Additional research is necessary to determine whether including AVP improves morbidity or mortality. Trial Registration ClinicalTrials.gov identifier: NCT01611935.
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Affiliation(s)
- Carrie A Sims
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Penn Acute Research Collaboration (PARC), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Patrick Kim
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jose Pascual
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Brian Smith
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Neils Martin
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Adam Shiroff
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Shariq Raza
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Lewis Kaplan
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Elena Grill
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Nicole Zimmerman
- Department of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christopher Mason
- Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Benjamin Abella
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Patrick Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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Abujaber A, Fadlalla A, Gammoh D, Abdelrahman H, Mollazehi M, El-Menyar A. Prediction of in-hospital mortality in patients with post traumatic brain injury using National Trauma Registry and Machine Learning Approach. Scand J Trauma Resusc Emerg Med 2020; 28:44. [PMID: 32460867 PMCID: PMC7251921 DOI: 10.1186/s13049-020-00738-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of machine learning techniques to predict diseases outcomes has grown significantly in the last decade. Several studies prove that the machine learning predictive techniques outperform the classical multivariate techniques. We aimed to build a machine learning predictive model to predict the in-hospital mortality for patients who sustained Traumatic Brain Injury (TBI). METHODS Adult patients with TBI who were hospitalized in the level 1 trauma center in the period from January 2014 to February 2019 were included in this study. Patients' demographics, injury characteristics and CT findings were used as predictors. The predictive performance of Artificial Neural Networks (ANN) and Support Vector Machines (SVM) was evaluated in terms of accuracy, Area Under the Curve (AUC), sensitivity, precision, Negative Predictive Value (NPV), specificity and F-score. RESULTS A total of 1620 eligible patients were included in the study (1417 survival and 203 non-survivals). Both models achieved accuracy over 91% and AUC over 93%. SVM achieved the optimal performance with accuracy 95.6% and AUC 96%. CONCLUSIONS for prediction of mortality in patients with TBI, SVM outperformed the well-known classical models that utilized the conventional multivariate analytical techniques.
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Affiliation(s)
- Ahmad Abujaber
- Assistant Executive Director of Nursing, Hamad Medical Corporation, Doha, Qatar
| | - Adam Fadlalla
- College of Business and Economics, Management Information Systems, Qatar University, Doha, Qatar
| | - Diala Gammoh
- Industrial Engineering, University of Central Florida, Orlando, USA
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Monira Mollazehi
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar. .,Department of Clinical Medicine, Weill Cornell Medical College Hamad General Hospital, Doha, Qatar.
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Merck LH, Yeatts SD, Silbergleit R, Manley GT, Pauls Q, Palesch Y, Conwit R, Le Roux P, Miller J, Frankel M, Wright DW. The Effect of Goal-Directed Therapy on Patient Morbidity and Mortality After Traumatic Brain Injury: Results From the Progesterone for the Treatment of Traumatic Brain Injury III Clinical Trial. Crit Care Med 2019; 47:623-31. [PMID: 30730438 DOI: 10.1097/CCM.0000000000003680] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate the impact of goal-directed therapy on outcome after traumatic brain injury, our team applied goal-directed therapy to standardize care in patients with moderate to severe traumatic brain injury, who were enrolled in a large multicenter clinical trial. DESIGN Planned secondary analysis of data from Progesterone for the Treatment of Traumatic Brain Injury III, a large, prospective, multicenter clinical trial. SETTING Forty-two trauma centers within the Neurologic Emergencies Treatment Trials network. PATIENTS Eight-hundred eighty-two patients were enrolled within 4 hours of injury after nonpenetrating traumatic brain injury characterized by Glasgow Coma Scale score of 4-12. MEASUREMENTS AND MAIN RESULTS Physiologic goals were defined a priori in order to standardize care across 42 sites participating in Progesterone for the Treatment of Traumatic Brain Injury III. Physiologic data collection occurred hourly; laboratory data were collected according to local ICU protocols and at a minimum of once per day. Physiologic transgressions were predefined as substantial deviations from the normal range of goal-directed therapy. Each hour where goal-directed therapy was not achieved was classified as a "transgression." Data were adjudicated electronically and via expert review. Six-month outcomes included mortality and the stratified dichotomy of the Glasgow Outcome Scale-Extended. For each variable, the association between outcome and either: 1) the occurrence of a transgression or 2) the proportion of time spent in transgression was estimated via logistic regression model. RESULTS For the 882 patients enrolled in Progesterone for the Treatment of Traumatic Brain Injury III, mortality was 12.5%. Prolonged time spent in transgression was associated with increased mortality in the full cohort for hemoglobin less than 8 gm/dL (p = 0.0006), international normalized ratio greater than 1.4 (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0003), and systolic blood pressure less than 90 mm Hg (p < 0.0001). In the patient subgroup with intracranial pressure monitoring, prolonged time spent in transgression was associated with increased mortality for intracranial pressure greater than or equal to 20 mm Hg (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0293), hemoglobin less than 8 gm/dL (p = 0.0220), or systolic blood pressure less than 90 mm Hg (p = 0.0114). Covariates inversely related to mortality included: a single occurrence of mean arterial pressure less than 65 mm Hg (p = 0.0051) or systolic blood pressure greater than 180 mm Hg (p = 0.0002). CONCLUSIONS The Progesterone for the Treatment of Traumatic Brain Injury III clinical trial rigorously monitored compliance with goal-directed therapy after traumatic brain injury. Multiple significant associations between physiologic transgressions, morbidity, and mortality were observed. These data suggest that effective goal-directed therapy in traumatic brain injury may provide an opportunity to improve patient outcomes.
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Roux PL. Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lessard Bonaventure P, Lauzier F, Zarychanski R, Boutin A, Shemilt M, Saxena M, Zolfagari P, Griesdale D, Menon DK, Stanworth S, English S, Chassé M, Fergusson DA, Moore L, Kramer A, Robitaille A, Myburgh J, Cooper J, Hutchinson P, Turgeon AF. Red blood cell transfusion in critically ill patients with traumatic brain injury: an international survey of physicians' attitudes. Can J Anaesth 2019; 66:1038-1048. [PMID: 31012052 DOI: 10.1007/s12630-019-01369-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Restrictive transfusion strategies have been advocated in critically ill patients. Nevertheless, considerable uncertainty exists regarding optimal transfusion thresholds in traumatic brain injury (TBI) patients because the injured brain is susceptible to hypoxemic damage. We aimed to identify the determinants of red blood cell (RBC) transfusion and the perceived optimal transfusion thresholds in adult patients with moderate-to-severe TBI. METHODS We conducted an electronic, self-administered survey targeting critical care specialists and neurosurgeons from Canada, Australia, and the United Kingdom caring for TBI patients. The questionnaire was initially developed by a panel of experts using a structured process (domains/items generation and reduction). The questionnaire was validated for clinical sensibility, reliability, and content. RESULTS The response rate was 28.7% (218/760). When presented with the hypothetical scenario of a young adult TBI patient, a wide range of transfusion practices was observed, with 47 (95% confidence interval [CI], 41 to 54)% favouring RBC transfusion at a hemoglobin level of ≤ 70 g·L-1 in the acute phase of care, while 73 (95% CI, 67 to 79)% would use this trigger in the plateau phase of care. Multiple trauma, neuro-monitoring data, hemorrhagic shock, and planned surgery were the main factors that influenced the need for transfusion. The lack of clinical evidence and guidelines was responsible for uncertainty regarding RBC transfusion strategies in this patient population. CONCLUSION In our survey about critically ill TBI patients, transfusion practice was found to be mainly influenced by the acuity of care, patient characteristics, and neuro-monitoring. Clinical equipoise regarding optimal transfusion strategy is believed to be mainly attributed to the lack of clear clinical evidence and guidelines. Appropriate randomized-controlled trials are required to determine the optimal transfusion strategies in TBI patients.
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Affiliation(s)
- Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, QC, Canada
| | - Francois Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Department of Medicine, Université Laval, Québec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, of Haematology and of Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Amélie Boutin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - Michèle Shemilt
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - Manoj Saxena
- The George Institute for Global Health, Sydney, Australia
| | - Parjam Zolfagari
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Donald Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David K Menon
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Simon Stanworth
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford University Hospitals and the University of Oxford, Oxford, UK
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Michaël Chassé
- CHUM Research Center, Université de Montréal, Montréal, QC, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Department of Preventive and Social Medicine, Université Laval, Québec City, QC, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Foothills Medical Center, Calgary, AB, Canada
| | - Amélie Robitaille
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - John Myburgh
- The George Institute for Global Health, Sydney, Australia
| | - Jamie Cooper
- The George Institute for Global Health, Sydney, Australia.,The Alfred Hospital, Melbourne, Australia
| | - Peter Hutchinson
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada. .,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.
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Ruel-Laliberté J, Lessard Bonaventure P, Fergusson D, Lacroix J, Zarychanski R, Lauzier F, Tinmouth A, Hébert PC, Green R, Griesdale D, Fowler R, Kramer A, McIntyre LA, Zygun D, Walsh T, Stanworth S, Capellier G, Pili-Floury S, Samain E, Clayton L, Marshall J, Pagliarello G, Sabri E, Neveu X, Léger C, Turgeon AF; Canadian Critical Care Trials Group. Effect of age of transfused red blood cells on neurologic outcome following traumatic brain injury (ABLE-tbi Study): a nested study of the Age of Blood Evaluation (ABLE) trial. Can J Anaesth 2019; 66:696-705. [PMID: 30809776 DOI: 10.1007/s12630-019-01326-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/06/2019] [Accepted: 01/10/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Anemia is common in critically ill patients with traumatic brain injury, and often requires red blood cell transfusion. Studies suggest that prolonged storage causes lesions of the red blood cells, including a decreased ability to carry oxygen. Considering the susceptibility of the brain to hypoxemia, victims of traumatic brain injury may thus be more vulnerable to exposure to older red blood cells. METHODS Our study aimed to ascertain whether the administration of fresh red blood cells (seven days or less) results in a better neurologic outcome compared with standard red blood cells in critically ill patients with traumatic brain injury requiring transfusion. The Age of Blood Evaluation in traumatic brain injury (ABLE-tbi) study was a nested study within the ABLE study (ISRCTN44878718). Our primary outcome was the extended Glasgow Outcome Scale (GOSe) at six months. RESULTS In the ABLE study, 217 subjects suffered a traumatic brain injury: 110 in the fresh group, and 107 in the standard group. In the fresh group, 68 (73.1%) of the patients had an unfavourable neurologic outcome (GOSe ≤ 4) compared with 60 (64.5%) in the standard group (P = 0.21). Using a sliding dichotomy approach, we observed no overall effect of fresh red blood cells on neurologic outcome (odds ratio [OR], 1.34; 95% confidence interval [CI], 0.72 to 2.50; P = 0.35) but observed differences across prognostic bands with a decreased odds of unfavourable outcome in patients with the best prognosis at baseline (OR, 0.33; 95% CI, 0.11 to 0.96; P = 0.04) but an increased odds in those with intermediate and worst baseline prognosis (OR, 5.88; 95% CI,1.66 to 20.81; P = 0.006; and OR, 1.67; 95% CI, 0.53 to 5.30; P = 0.38, respectively). CONCLUSION Overall, transfusion of fresh red blood cells was not associated with a better neurologic outcome at six months in critically ill patients with traumatic brain injury. Nevertheless, we cannot exclude a differential effect according to the patient baseline prognosis. TRIAL REGISTRATION ABLE study (ISRCTN44878718); registered 22 August, 2008.
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Abstract
Purpose of review The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. Recent findings Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. Summary Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion.
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Spotlight on Neurotrauma Research in Canada's Leading Academic Centers. J Neurotrauma 2018; 35:1986-2004. [PMID: 30074875 DOI: 10.1089/neu.2018.29017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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