Effect of fluid resuscitation with balanced solutions on platelets: In vitro simulation of 20% volume substitution

   Background: Fluid resuscitation in massive bleeding may cause coagulation disorders by dilution of platelets and clotting factors or by the impact on their function. The aim of this study was to investigate the effects of balanced crystalloid and colloid solutions on platelets in vitro using complex assessment of coagulation. Methods: The study group was comprised of 32 American Society of Anesthesiologists physical status class I male volunteers, aged 21–35 (29 ± 4) years, weighting 59–103 (81.2 ± 9.8) kg. Whole blood samples were diluted at a 4:1 ratio with the following fluids: balanced crystalloid (Plasmalyte®), 6% hydroxyethyl starch 130/0.4 (Volulyte®) and succinylated gelatin (Geloplasma®). Coagulation was as­sessed using standard morphology, rotational thromboelastometry and aggregometry. Results: Dilution with all fluids caused statistically significant drop in the number of platelets (p < 0.01) but the effect did not differ between solutions (p > 0.05 for all). Other platelet parameters, such as platelet distribution width, mean platelet volume and platelet-large cell ratio were not affected by the solutions. Hemodilution had no effect on platelet function (p = 0.1). Decreased platelet component of clot strength was found for all three fluids (p < 0.05), although the effect for colloids was more pronounced. Conclusions: The effect of balanced crystalloids and colloids on platelet aggregation was insignificant, even after 20% volume substitution with the resuscitation fluids.

Ferritin and transferrin saturation cannot be used to diagnose iron-deficiency anemia in critically ill patients

Abstract Introduction: Iron-deficiency anaemia (IDA) is the most common anaemia globally. The frequency of IDA among critically ill patients is not known. The aim of our study was to analyse performance of standard iron metabolism parameters in diagnosis of IDA in the critically ill. Material and methods: We performed a retrospective analysis of consecutive anaemic patients admitted to the intensive care unit. Based on various cut-off values for ferritin and/or transferrin saturation (TfS), we determined the incidence of IDA. Results: The population consisted of 27 (53%) men and 24 (47%) women. The median haemoglobin concentration was well 96 [interquartile range (IQR 87–109)] g/L. The studied population had markedly increased concentration of C-reactive protein [119 (IQR 44–196) mg/L], ferritin [686 (385–1114) µg/L], whereas iron concentration and TfS were below reference value. Depending on cut-off value chosen, IDA could be diagnosed in between 7.8 (ferritin < 100 µg/L +TfS < 20%) and 56.9 % (TfS < 20%) of patients. Conclusions: Ferritin and transferrin saturation cannot be used for precise diagnosis of IDA caused by absolute or functional iron deficiency in the critically ill

The Impact of Red Blood Cell Transfusion on Blood Lactate in Non-Bleeding Critically Ill Patients—A Retrospective Cohort Study

Anemia should preferably be managed without red blood cell transfusion (RBCT); instead, therapy should be focused on causes of anemia along with efforts to minimize blood loss. Lactate could potentially be used as a physiologic RBCT trigger, although there are some limitations to its interpretation. The aim of our study was to analyze the impact of RBCT on blood lactate with consideration of factors known to increase its concentration and to assess the usefulness of blood lactate as a potential physiologic RBCT trigger. We performed a retrospective analysis of all RBCT episodes in non-bleeding critically ill patients. We retrieved demographic data, data on RBCT itself (duration, type of RBC, volume of RBC, age of RBC), laboratory parameters (lactate, hemoglobin, glucose, total bilirubin), and factors potentially increasing lactate. We analyzed 77 RBCTs with elevated pre-RBCT lactate. The median age of patients was 66 (IQR 57–73) years and the distribution of sexes was even. The named factors potentially influencing lactate had no impact on its concentration. The median pre-post RBCT lactate was 2.44 (IQR 2.08–3.27) and 2.13 (IQR 1.75–2.88) mmol/L, respectively (p < 0.01); the median decrease was 0.41 (IQR 0.07–0.92) mmol/L. We conclude that RBCT did not normalize mildly elevated lactate. Common causes of elevated lactate probably had no impact on its concentration. Therefore lactate may have a limited role as a physiologic RBCT trigger in non-bleeding severely anemic critically ill patients

Management Strategies in Septic Coagulopathy: A Review of the Current Literature

One of the ‘organs’ that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized

Iron deficiency in sepsis patients managed with divided doses of iron dextran: a prospective cohort study

Abstract Iron deficiency (ID) impairs hemoglobin (Hb) synthesis and immune function, both crucial for sepsis patients. We assessed the impact of iron dextran on reticulocyte (Ret) Hb equivalent (Ret-He) and Ret subpopulations in iron-deficient sepsis patients. In this prospective clinical study we enrolled patients with sepsis or septic shock with procalcitonin concentration > 0.5 ng/mL, diagnosed with ID based on Ret-He. Study subjects received divided doses of iron dextran until normalization of Ret-He. The study population included 35 subjects. The median Ret-He increase after 2 doses of iron dextran was 3.0 (IQR 1.9–6.1) pg (p < 0.01) with median time to normalization 4 (IQR 3–5) days. Although no change in Ret percentage [Me 1.5 (IQR 1.1–2.1) vs. Me 1.4 (IQR 1.1–2.4) %, p = 0.39] and number [Me 0.05 (IQR 0.04–0.07) vs. Me 0.05 (IQR 0.03–0.06) 106/µL, p = 0.88] was noted, Ret subpopulations changed significantly (p for all < 0.01). Divided doses of iron dextran relatively quickly normalize Ret-He in iron-deficient sepsis patients. Changes in Ret subpopulations suggest increased erythropoietic activity. Further research is needed to explore the role of intravenous iron in this clinical setting

Anemia of critical illness: a narrative review

The prevalence of anemia in patients admitted to the intensive care unit (ICU) reaches 66%. Moreover, numerous patients develop anemia during ICU hospitalization. In fact, anemia is the most common hematologic disease in the ICU. The majority of patients hospitalized in the ICU present with acute systemic inflammation, so called systemic inflammatory response syndrome (SIRS). These patients may develop anemia of inflammation (AI). In crtitically ill patients AI may present acutely (acute systemic inflammation) or chronically (comorbidities associated with prolonged systemic inflammation), here we describe both presentations of AI as ‘anemia of critical illness’ (ACI). The second most frequent type of anemia in critically ill patients is iron-deficiency anemia (IDA). A mixed type of anemia (ACI + IDA) may also be present in these patients. The three major pathophysiological mechanisms leading to ACI are: iron restriction, decreased erythropoiesis, anddecreased erythrocyte lifespan. Cytokines synthesized during SIRS induce the production of hepcidin that inhibits theonly transmembrane iron exporter (ferroportin) present in the duodenum and macrophages. Etiological classification of anemia in critically ill patients poses a significant challenge to clinicians, as there is a multitudeof tests available, and there are various reference ranges for these tests reported in the literature in the patient population in question. Pure ACI or mixed ACI + IDA can be diagnosed using a single laboratory test — complete blood count with analysis of reticulocytes — which provides Hb concentration in erythrocyte and reticulocyte. The management of ACI incorporates discontinuation with erythropoiesis-stimulating agent causing anemia, reductionof iatrogenic blood loss, parenteral iron, and combined therapy of parenteral iron with erythropoiesis-stimulatingagents in approved indications

Management Strategies in Septic Coagulopathy: A Review of the Current Literature

One of the ‘organs’ that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized

Czy resuscytacja płynowa z wykorzystaniem roztworów zbilansowanych wywołuje zaburzenia elektrolitowe i metaboliczne? Badanie in vitro

Background: Popular intravenous fluids in clinical use may have an impact on electrolyte concentration and metabolic balance and should be considered as powerful pharmacological agents. There is a growing body of evidence that fluid therapy should be more individualised and preferably based on balanced solutions. Aim: We sought to investigate the impact of three commonly used balanced fluids on electrolytes and metabolic equilibrium in an in vitro setting. Methods: Study group comprised 32 healthy male volunteers (without history of any acute/chronic disorder or known metabolic abnormality), aged 21–35 (29 ± 4) years, weight 59–103 (81.2 ± 9.8) kg, from whom blood samples were withdrawn. The whole blood was diluted in 4:1 ratio with the study solutions to make an end-concentration of 20 vol.% of each solution. The test solutions included balanced crystalloid (Plasmalyte®, Baxter, Poland [PL]), succinylated gelatin (Geloplasma®, Fresenius Kabi, Poland [GEL]) and 6% HES 130/0.4 (Volulyte®, Fresenius Kabi, Poland [HES]). Results: All fluids caused comparable degree of haemodilution. PL and GEL decreased (104 mmol/L, interquartile range [IQR] 103–105; and 106 mmol/L, IQR 105–107.5, respectively), whereas HES increased the concentration of Cl– to 109 (IQR 108–110) mmol/L. PL and HES decreased (136, IQR 136–137 mmol/L; and 138 mmol/L, IQR 137–139, respectively), whereas GEL increased the Na+ level to 140.5 (IQR 140–141) mmol/L. PL and HES decreased osmolality (277.2 mOsm/kg, IQR 275.7–278.4; and 280.9 mOsm/kg, IQR 279.3–282.0, respectively). GEL increased it to 285.7 (IQR 283.7–286.8) mOsm/kg. All test solutions caused a similar statistically significant (p &lt; 0.05) drop in base excess and bicarbonate concentration, and these fell outside the reference values. Due to its composition, GEL caused a significant increase in lactate concentration. HES and GEL caused a statistically significant drop in strong ion difference value. Due to high lactate level, the effect of GEL was most pronounced. Conclusions: Balanced intravenous solutions should be safe in terms of their impact on human plasma electrolyte and meta­bolic equilibrium when administered to replace up to 20% of blood volume. In metabolic acidosis, balanced succinylated gelatin should be used with caution. Therefore, arterial blood gas analysis should be performed in patients in whom significant amounts of fluid are administrated, preferably with assessment of Cl–, Na+, lactate concentrations as well as pH, osmolality, and strong ion difference.Wstęp: Powszechnie dostępne w praktyce klinicznej roztwory infuzyjne wpływają m.in. na stężenie elektrolitów i parametry metaboliczne osocza, tym samym powinny być postrzegane jako środki farmakologiczne o określonym wpływie na homeostazę ustrojową. Istnieje coraz więcej danych, że taki rodzaj terapii powinien być dobierany indywidualnie do pacjenta, z uwzględnieniem wskazań oraz przeciwskazań klinicznych, i oparty na roztworach zbilansowanych, czyli zbliżonych swym składem do osocza. Cel: Celem niniejszej pracy była ocena wpływu trzech najczęściej stosowanych roztworów zbilansowanych płynów (krystaloidu i dwóch koloidów) na równowagę elektrolitową i metaboliczną w warunkach eksperymentalnych in vitro. Metody: Badaną grupę stanowiło 32 zdrowych mężczyzn (ujemny wywiad w kierunku chorób ostrych i przewlekłych, farmakoterapii oraz zaburzeń metabolicznych), w wieku 21–35 (29 ± 4) lat, o masie ciała 59–103 (81,2 ± 9,8) kg, od któ­rych pobrano próbki krwi z zachowaniem należnych standardów laboratoryjnych. Krew pełna była następnie rozcieńczana w stosunku 4:1 z roztworami testowymi, aby uzyskać 20-procentowe stężenie końcowe każdego roztworu. Roztwory testowe stanowiły: zbilansowany krystaloid (Plasmalyte®, Baxter, Polska [PL]), sukcynylowana żelatyna (Geloplasma®, Fresenius Kabi, Polska [GEL]) oraz 6% HES 130/0,4 (Volulyte®, Fresenius Kabi, Polska [HES]). Wyniki: PL i GEL zmniejszyły (odpowiednio do 104 mmol/l, przedział międzykwartylowy [IQR] 103–105 oraz 106 mmol/l, IQR 105–107,5) stężenie chlorków, podczas gdy HES zwiększył stężenie jonów Cl– do 109 (IQR 108–110) mmol/l. PL i HES zredukowały (odpowiednio do 136 mmol/l, IQR 136–137 oraz 138 mmol/l, IQR 137–139) stężenie Na+, podczas gdy roztwór GEL zwiększył stężenie sodu do 140,5 (IQR 140–141) mmol/l. PL i HES zmniejszyły osmolalność osocza (odpowiednio do 277,2 mOsm/kg, IQR 275,7–278,4 oraz 280,9 mOsm/kg, IQR 279,3–282,0). GEL zwiększyła osmolalność do 285,7 (IQR 283,7–286,8) mOsm/kg. Wszystkie roztwory testowe spowodowały podobne, istotne statystycznie (p &lt; 0,05), zmniejszenie niedoboru zasad (BE) oraz stężenia wodorowęglanów poniżej wartości normatywnych. Z powodu swojego składu GEL spowodowała istotny wzrost stężenia mleczanów w próbkach. HES i GEL wywołały istotny statystycznie spadek wartości różnicy silnych jonów, jednak z powodu dużej zawartości mleczanów efekt GEL był najbardziej zaznaczony. Wnioski: Roztwory zbilansowane są bezpieczne w kontekście ich wpływu na równowagę elektrolitową i metaboliczną, gdy są stosowane do zastąpienia utraty krwi w ilości do 20% jej objętości. Przy współistniejącej kwasicy metabolicznej zbilansowany roztwór sukcynylowanej żelatyny powinien być stosowany z ostrożnością

Let Us Know Transfusion Triggers for Prophylactic Use of Platelet Concentrate—Analysis of Compliance with Recent Transfusion Guidelines in a Large Academic Medical Center

Platelet concentrate (PC) is a blood component that is used to prevent or manage bleeding associated with thrombocytopenia or impaired platelet function. The aim of our study was to assess the compliance of ordering physicians with the most recent PC transfusion guidelines in our academic medical center. All PC transfusions performed between January 2019 and December 2022 were analyzed. The appropriateness of PC transfusions was assessed based on the most recent PC transfusion guidelines. During 2019–2022, there were 362 (0.2%) PC recipients out of 161,762 hospitalized patients. There were 971 PCs transfused during the analyzed period. Inappropriate transfusions accounted for 53.3% of cases, and most of them were given prophylactically (80.2%). Compliance with platelet transfusion guidelines varied among departments. The overall percentage of inappropriately transfused PC ranged from 50.7% to 60.8% in successive years. Educational activities should target clinicians performing procedures associated with high rates of inappropriate PC transfusions. Implementing clinical decision support systems can help reduce unnecessary PC transfusions and associated costs. The majority of inappropriate PC transfusions in our medical center were given as prophylaxis against bleeding. Prescribers should be educated about evidence-based transfusion triggers for the prophylactic use of PC in various clinical scenarios