Rimki Rana

Transfusion‐related acute lung injury and pulmonary edema in critically ill patients: a retrospective study

BACKGROUND: Using the recent Consensus Panel recommendations, we sought to describe the incidence of transfusion‐related acute lung injury (TRALI) and transfusion‐associated circulatory overload (TACO) in critically ill patients.

Fresh frozen plasma transfusion in critically ill medical patients with coagulopathy

Objective:Although restrictive red cell transfusion practice has become a standard of care in the critically ill, data on the use of fresh frozen plasma (FFP) are limited. We hypothesized that the practice of FFP transfusion in the medical intensive care unit is variable and that liberal use may not be associated with improved outcome. Design:Retrospective cohort study. Setting:A 24-bed medical intensive care unit in a tertiary referral center. Patients:All patients admitted to a medical intensive care unit during a 5-month period who had abnormal coagulation defined as international normalized ratio (INR) of ≥1.5-times normal. Interventions:None. Measurements and Main Results:We collected data on demographics, severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE) III scores, INR, bleeding episodes, and transfusion complications. We identified 115 patients with coagulopathy (INR of ≥1.5) but without active bleeding. A total of 44 patients (38.3%) received FFP transfusion. INR was corrected in 16 of 44 patients (36%) who received transfusion. Median dose of FFP was 17 mL/kg in patients who had INR corrected vs. 10 mL/kg in those who did not (p = .018). There was no difference in age, sex, APACHE III scores, liver disease, Coumadin treatment, or INR level between those who did and did not receive FFP. Invasive procedures (68.2% vs. 40.8%, p = .004) and history of recent gastrointestinal bleeding (41% vs. 7%, p < .001) were more frequent in the group with transfusion. Although there was no difference in new bleeding episodes (6.8% in transfused vs. 2.8% in nontransfused group, p = .369), new onset acute lung injury was more frequent in the transfused group (18% vs. 4%, p = .021). Adjusted for severity of illness, hospital mortality and intensive care unit length of stay among survivors were not different between the two groups. Conclusion:The risk–benefit ratio of FFP transfusion in critically ill medical patients with coagulopathy may not be favorable. Randomized controlled trials evaluating restrictive vs. liberal FFP transfusion strategies are warranted.

Acute lung injury after blood transfusion in mechanically ventilated patients.

BACKGROUND:  Liberal transfusion strategy increases the risk of acute lung injury (ALI), but specific transfusion‐related factors have not been characterized. We tested the hypotheses that storage age and specific type of blood products are associated with increased risk of ALI in mechanically ventilated patients.

Evidence-based red cell transfusion in the critically ill: Quality improvement using computerized physician order entry

Objective:The implementation of evidence-based practice poses a significant challenge in the intensive care unit. In this quality improvement intervention we assessed the effect of an institutional protocol and computerized decision support for red cell transfusion in the critically ill. Design:We compared processes of care and outcomes during the two 3-month periods before and after the introduction of a multidisciplinary quality improvement intervention. Setting:Multidisciplinary intensive care units—medical, surgical, and mixed—in a tertiary academic center. Patients:Consecutive critically ill patients with anemia (hemoglobin of <10 g/dL). Intervention:Using the computerized provider order entry, we developed an evidence-based decision algorithm for red cell transfusion in adult intensive care units. Measurements and Main Results:We collected information on demographics, diagnosis, severity of illness, transfusion complications, and laboratory values. The main outcome measures were number of transfusions, proportion of patients who were transfused outside evidence-based indications, transfusion complications, and adjusted hospital mortality. The mean number of red cell transfusions per intensive care unit admission decreased from 1.08 ± 2.3 units before to 0.86 ± 2.3 units after the protocol (p<.001). We observed a marked decrease in the percentage of patients receiving inappropriate transfusions (17.7% vs. 4.5%, p< .001). The rate of transfusion complications was also lower in the period after the protocol (6.1% vs. 2.7%, p = .015). In the multivariate analysis, protocol introduction was associated with decreased likelihood of red cell transfusion (odds ratio, 0.43; 95% confidence interval, 0.30 to 0.62). Adjusted hospital mortality did not differ before and after protocol implementation (odds ratio, 1.12; 95% confidence interval, 0.69 to 1.8). Conclusions:The implementation of an institutional protocol and decision support through a computerized provider order entry effectively decreased inappropriate red cell transfusions.

B-type natriuretic peptide in the assessment of acute lung injury and cardiogenic pulmonary edema

Objective:The role of plasma B-type natriuretic peptide (BNP) in critically ill patients with acute pulmonary edema is controversial. We postulated that a low BNP level would exclude cardiac dysfunction as the principal cause of pulmonary edema and therefore help in the diagnosis of acute lung injury. Design:A retrospective derivation cohort was followed by a prospective validation cohort of consecutive patients with acute pulmonary edema admitted to three intensive care units. BNP was measured within 24 hrs from onset. Critical care experts blinded to BNP results integrated clinical data with the course of disease and response to therapy and served as the reference standard. Setting:Three intensive care units at the tertiary center. Patients:Consecutive critically ill patients with acute pulmonary edema. Interventions:None. Measurements and Main Results:In a derivation cohort of 84 patients, a BNP threshold of ≤250 pg/mL had a specificity of 87% and sensitivity of 48% for the diagnosis of acute lung injury. High specificity of BNP (90%, likelihood ratio of 3.9) was confirmed in a validation cohort of 120 consecutive patients, 52 (43%) of whom had acute lung injury. Notably, 32% of patients with acute lung injury had concomitant cardiac dysfunction. The median time from the onset of pulmonary edema to BNP testing was 3 hrs. The accuracy of BNP (area under receiver operator curve, 0.71) was comparable with pulmonary artery occlusion pressure (area under receiver operator curve, 0.66) and superior to ejection fraction (area under receiver operator curve, 0.60) in subgroups of patients in whom these tests were performed. The accuracy of BNP improved when patients with renal insufficiency were excluded (area under receiver operator curve, 0.82). Conclusion:When measured early after the onset of acute pulmonary edema, a BNP level of <250 pg/mL supports the diagnosis of acute lung injury. The high rate of cardiac and renal dysfunction in critically ill patients limits the discriminative role of BNP. No level of BNP could completely exclude cardiac dysfunction.

Long-Haul Air Travel Before Major Surgery: A Prescription for Thromboembolism?

OBJECTIVE To investigate the Incidence of postoperative venous thromboembolism (VTE) in patients who had flown long distances before major surgery. PATIENTS AND METHODS Using the Mayo Clinic computerized patient database, we Identified patients who had flown more than 5000 km before major surgery (travelers) and had experienced an episode of clinically significant VTE within 28 days after surgery. Individual medical records were reviewed for the diagnosis of VTE, pertinent risk factors, and outcome. We compared the Incidence of VTE in travelers to the incidence of VTE in patients from North America (nontravelers) undergoing similar surgical procedures. RESULTS Eleven patients met our criteria for long-haul air travel and clinically significant VTE within 28 days after surgery. Compared with nontravelers undergoing similar surgical procedures, long-haul travelers had a higher Incidence of VTE (4.9% vs 0.15%; P < .001). Compared with nontravelers who developed VTE, travelers were younger (P = .006), developed VTE earlier in the postoperative course (P = .01), had higher American Society of Anesthesiologists physical status classification (P = .02), and had higher prevalence of smoking (P = .007). Of the 11 travelers with VTE, 10 were of Middle Eastern origin. CONCLUSION Prolonged air travel before major surgery significantly increases the risk of perioperative VTE. Such patients should receive more Intensive VTE prophylactic measures during the flight and throughout the perioperative period.