Hemoglobin levels and transfusions in neurocritically ill patients: a systematic review of comparative studies.

Abstract Introduction Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients. Methods We conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes. Results Among 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean, -11.4 days (95% confidence interval, -16.1 to -6.7)), and one, a shorter hospital stay (mean, -5.7 days (-10.3 to -1.1)) in the lower-Hb groups, whereas the other two found no significant association. Conclusions We found insufficient evidence to confirm or refute a difference in effect between lower- and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients.Peer Reviewe

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Adjudicating Bleeding Outcomes in a Large Thromboprophylaxis Trial in Critical Illness.

Abstract Abstract 2471 Poster Board II-448 Background: Adjudication in clinical trials can confirm or refute eligibility, describe cointerventions, judge appropriateness of care, or assess the severity of morbidity outcomes. Objective: To refine the adjudication process, calibrate 4 adjudicators, and measure agreement on bleeding severity in an international trial of heparin thromboprophylaxis (PROTECT). Methods: Independently and blinded to each others' ratings and study drug, 4 adjudicators used web-based methods to examine 40 charts of patients assessed by local research coordinators to have either major (20 patients) or minor (20 patients) bleeding. We discussed reasons for disagreement after the first 20 charts to remediate and recalibrate. We calculated crude agreement, chance-corrected agreement (kappa), and chance-independent agreement (phi). Results: For 45 events in 40 patients, pair-wise crude agreement ranged from 86.7-93.3% (average 82.2%). Overall kappa was 0.81. Phi (which can only analyze pair-wise values) ranged from 0.75-0.87. We resolved all disagreements. During adjudication discussions, we 1) addressed methodological issues (e.g., handling recurrent bleeds), 2) added a category (e.g., no bleed), 3) expanded a category (e.g., a major bleed did not have to be overt if other criteria were fulfilled), and 4) divorced procedure-grounded definitions (such as the need for transfusion or therapeutic interventions) from bleeding severity criteria (e.g., the patient could still be classified as having no bleed or a minor bleed if 2 units of PRBCs were transfused for anemia). Conclusions: After independent quadruplicate review of 45 bleeding events, we documented satisfactory agreement for bleeding outcomes, refined the adjudication process, and calibrated adjudicators for the remainder of the trial. Henceforth, charts will be randomly allocated to pairs of adjudicators for blinded review. Disclosures: No relevant conflicts of interest to declare. </jats:sec