Point-of-care versus central testing of hemoglobin during large volume blood transfusion.

BACKGROUND: Point-of-care (POC) hemoglobin testing has the potential to revolutionize massive transfusion strategies. No prior studies have compared POC and central laboratory testing of hemoglobin in patients undergoing massive transfusions. METHODS: We retrospectively compared the results of our point-of-care hemoglobin test (EPOC®) to our core laboratory complete blood count (CBC) hemoglobin test (Sysmex XE-5000™) in patients undergoing massive transfusion protocols (MTP) for hemorrhage. One hundred seventy paired samples from 90 patients for whom MTP was activated were collected at a single, tertiary care hospital between 10/2011 and 10/2017. Patients had both an EPOC® and CBC hemoglobin performed within 30 min of each other during the MTP. We assessed the accuracy of EPOC® hemoglobin testing using two variables: interchangeability and clinically significant differences from the CBC. The Clinical Laboratory Improvement Amendments (CLIA) proficiency testing criteria defined interchangeability for measurements. Clinically significant differences between the tests were defined by an expert panel. We examined whether these relationships changed as a function of the hemoglobin measured by the EPOC® and specific patient characteristics. RESULTS: Fifty one percent (86 of 170) of paired samples\u27 hemoglobin results had an absolute difference of ≤7 and 73% (124 of 170) fell within ±1 g/dL of each other. The mean difference between EPOC® and CBC hemoglobin had a bias of - 0.268 g/dL (p = 0.002). When the EPOC® hemoglobin was \u3c 7 g/dL, 30% of the hemoglobin values were within ±7, and 57% were within ±1 g/dL. When the measured EPOC® hemoglobin was ≥7 g/dL, 55% of the EPOC® and CBC hemoglobin values were within ±7, and 76% were within ±1 g/dL. EPOC® and CBC hemoglobin values that were within ±1 g/dL varied by patient population: 77% for cardiac surgery, 58% for general surgery, and 72% for non-surgical patients. CONCLUSIONS: The EPOC® device had minor negative bias, was not interchangeable with the CBC hemoglobin, and was less reliable when the EPOC® value was \u3c 7 g/dL. Clinicians must consider speed versus accuracy, and should check a CBC within 30 min as confirmation when the EPOC® hemoglobin is \u3c 7 g/dL until further prospective trials are performed in this population

We came, we saw, we cannulated?

Introduction: Despite advances in management of patients with severe acute respiratory distress syndrome (ARDS), mortality due to ARDS still remains high. In patients with refractory gas-exchange abnormalities, extracorporeal membrane oxygenation (ECMO) is considered as salvage therapy that aims to decrease ventilator induced lung injury and provide lung rest. injury and provide lung rest. Methods: We conducted a retrospective study of patients diagnosed with ARDS from October 2010 to September 2012. The aim of the study was to describe the population of patients placed on ECMO for ARDS in our institution. All patients placed on ARDSnet protocol were identified in the electronic patient record. Demographic, laboratory and ventilator data was extracted. Specifically mode of ventilation, use of rescue modalities (which included inhaled epoprostenol, skeletal muscle paralytics and/or use of airway pressure release ventilation (APRV)), Murray score, Oxygenation Index (OI), Alveolar-arterial gradient (A-a) and PaO2/FiO2 ratio (P/F) were tabulated. Survival to hospital discharge was recorded. Results: We identified a total of 149 patients. Of these 87 were managed per ARDSnet protocol, 48 received rescue modalities, and 14 patients were placed on ECMO in addition to rescue therapy after a mean interval of 72 hours. Six of 14 patients were placed on veno-arterial ECMO and the rest on veno-venous ECMO. Table 1 shows the baseline characteristics of these patients. Table 2 depicts the etiology of ARDS among our patient population. Mortality was higher in the ARDS group treated with rescue modalities (other than ECMO) compared to the group placed on ECMO as additional rescue therapy (77% vs. 50%; p = 0.3243). The ECMO group had a survival advantage despite higher A-a gradient, PaO2/Fio2 ratio, Oxygenation Index and Murray Score in the ECMO group (Table 1). Conclusion: Patients with ARDS placed on ECMO had an absolute reduction in mortality of 27% when compared to other rescue modalities. However this did not reach statistical significance due to the small sample size. We believe that ECMO is an important rescue modality in the right clinical setting. Treating physicians should consider ECMO as a treatment modality for severe ARDS patients

Surgical Pulmonary Embolectomy Outcomes for Acute Pulmonary Embolism

Introduction: Acute pulmonary embolism (PE) is associated with significant mortality. Surgical embolectomy is a viable treatment option; however, it remains controversial due to variable outcomes. This review investigates patient outcomes following surgical embolectomy for acute PE. Methods: Electronic search was performed to identify articles reporting surgical embolectomy for treatment of PE. 32 studies were included comprising 936 patients. Demographic, perioperative, and outcome data were extracted and pooled for systematic review. Results: Mean patient age was 56.3 [95% CI 52.5; 60.1] years and 50% [46; 55] were male. 82% had right ventricular dysfunction [62; 93], 80% [67; 89] had unstable hemodynamics, and 9% [5; 16] experienced cardiac arrest. Massive PE and submassive PE were present in 83% of patients [43; 97] and 13% [2; 56], respectively. Before embolectomy, 33% of patients [14; 60] underwent systemic thrombolysis and 14% [8; 24] catheter embolectomy. Preoperatively, 47% of patients were ventilated [26; 70] and 36% had percutaneous cardiopulmonary support [11; 71]. Mean operative time and mean cardiopulmonary bypass time were 170 [101; 239] and 56 [42; 70] minutes, respectively. Intraoperative mortality was 4% [2; 8]. Mean hospital and ICU stay were 10 [6; 14] and 2 [1; 3] days, respectively. Mean postoperative systolic pulmonary artery pressure (sPAP) was significantly decreased from preoperative (sPAP 57.8 mmHg [53; 62.7]) to postoperative period (sPAP 31.3 mmHg [24.9; 37.8]), p \u3c0.01). In-hospital mortality was 16% [12; 21]. Overall survival at five years was 73% [64; 81]. Discussion: Surgical embolectomy is an acceptable treatment option with favorable outcomes

Back to the Future: Open Lung Concept of Mechanical Ventilation in ARDS

Dr. Bharat Awsare is an Assistant Professor of Medicine in the Department of Medicine/Division of Pulmonary and Critical Care Medicine at Thomas Jefferson University Hospital. He has been a two time teacher of the year from the Department of Medicine. He won the Dean\u27s Award for Teaching Excellence. His clinical interests include mechanical ventilation, ventilator associated pneumonia, hepatic pulmonary syndromes, and chronic thromboembolic disease

Ventilator Associated Pneumonia: A Review and Update for the Intensivist

Overall Goals and Objectives: 1. Understand the clinical and economic consequences of VAP. 2. Review areas of uncertainty in VAP including diagnostic options and therapy. 3. Review newer paradigms for VAP including novel biomarkers. Presentation: 55 minute

Using a SWIFT Score Guided Time Out to Reduce Medical ICU Readmission Rates

AIM: For patients admitted to the medical ICU over an additional period of 17 months, our goal is to reduce the rate of ICU readmissions within 72 hours of transfer out of the ICU to less than 2%. This will as a result reduce the costs of care, length of stay, and in-hospital mortality rates for these patients.http://jdc.jefferson.edu/patientsafetyposters/1012/thumbnail.jp

Outcomes of extracorporeal life support for the treatment of acute massive pulmonary embolism: a systematic review

Background: Massive pulmonary embolism (PE) can cause hemodynamic instability leading to high mortality. Extracorporeal life support (ECLS) has been increasingly used as a bridge to definitive therapy. This systematic review investigates the outcomes of ECLS for the treatment of massive PE. Methods: Electronic search was performed to identify all relevant studies published on ECLS use in patients with PE. 50 case series or reports were selected comprising 128 patients with acute massive PE who required ECLS. Patient-level data were extracted for statistical analysis. Results: Median patient age was 50 [36, 63] years and 41.3% (50/121) were male. 67.2% (86/128) of patients presented with cardiac arrest. Median heart rate was 126 [118, 135] and median systolic pulmonary artery pressure (sPAP) was 55 [48, 69] mmHg. The majority of ECLS included veno-arterial ECLS [97.1% (99/102)]. Median ECLS time was 3 [2, 6] days. 43.0 0 0 (55/128) patients received systemic thrombolysis, 22.7% (29/128), received catheter-guided thrombolysis, and 37.5% (48/128) underwent surgical embolectomy. 85.1% (97/114) were weaned off ECLS. Post-ECLS complications included bleeding in 23.4% (30/128), acute renal failure in 8.6% (11/128), dialysis in 6.3% (8/128), heparin-induced thrombocytopenia in 3.1 (4/128), and extremity hypoperfusion in 2.3% (3/128). The most common cause of death was shock at 30.3% (10/33). The median length of hospital stay was 22 [11, 39] days including 8 [5, 13] intensive care unit (ICU) days. The 30-day mortality rate was 22% (20/91). Conclusions: ECLS is safe and effective therapy in unstable patients with acute massive pulmonary embolism and offers acceptable outcomes