P126: Are we transfusing wisely? An analysis of transfusion practices among hemodynamically stable patients with anemia in four hospitals

Introduction: To help mitigated risks associated with red blood cell transfusions, CWC guidelines recommend practicing restrictively. Transfusion Medicine recommends using a Hgb threshold of 70 g/L, and ordering a single unit at a time (with reassessment after). The purpose of this study is to investigate Emergency Department (ED) compliance with these more restrictive thresholds among hemodynamically stable patients. Methods: A retrospective analysis was performed on data from all emergency visits to 4 adult urban ED sites from July 1 2014 to July 1 2016. We excluded unstable patients (CTAS1, temperature >38°C, HR >100 bpm, RR >20 rpm, systolic BP <90 mmHg, and O2 sat <85%) and certain others (patients without a Hgb level, patients who left without being seen, and orders cancelled via patient discharge). After applying exclusion factors, we examined transfusions ordered. Appropriateness was assessed using the stratified Choosing Wisely Canada Guidelines for Transfusion. As an adjunct, IV iron therapy data was also analyzed for the same period between July 1 2014 and July 1 2016, excluding patients who did not have a Hgb level. Results: We identified 1329 eligible patients (54% female), with a mean age of 68 and average first hemoglobin of 72 g/L. Across all groups, 16% of patients received only 1 unit of blood. 19% of transfused patients had a hemoglobin less than 60 g/L, 45% had a Hgb <70 g/L, 32% had a Hgb 70-80 g/L, 14% had a Hgb 81-90 g/L, and 8% had a Hgb >90 g/L. Over the same two-year period, 178 patients received IV iron. The average Hgb for those patients was 82 g/L. Conclusion: A retrospective analysis documents a significant likelihood of pRBC over-transfusion among Emergency Department physicians and an underutilization of IV iron therapy for certain hemodynamically stable and anemic patients. The development of audit and feedback methods, and creation of a clinical pathway may help address the rate of over-transfusion.

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Intravenous iron therapy and circulating biomarkers of inflammation in men with heart failure with reduced ejection fraction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1167 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Drozd ◽

M Tkaczyszyn ◽

K Wegrzynowska-Teodorczyk ◽

M Kasztura ◽

M Dziegala ◽

...

Keyword(s):

Heart Failure ◽

Intravenous Iron ◽

Inflammatory Biomarkers ◽

Iron Therapy ◽

Reduced Ejection Fraction ◽

Tnf Α ◽

Inflammatory State ◽

Iv Iron ◽

Hs Crp ◽

Intravenous Iron Therapy

Abstract Background Large randomized clinical trials have demonstrated that intravenous (IV) iron therapy in iron-deficient patients with heart failure with reduced ejection fraction (HFrEF) brings clinical benefits related to symptoms of the disease and exercise capacity. Mechanisms underlying beneficial effects of such repletion are still the subject of interest as this is not solely related to improved haematopoiesis (IV iron works also in non-anaemic subjects). In patients with chronic heart failure iron deficiency (ID) is linked with inflammatory processess but data regarding the impact of IV iron on inflammation is scarce. Purposes We evaluated whether IV iron therapy affects circulating biomarkers of pro-inflammatory state in men with HFrEF and concomitant ID. Methods This is the sub-analysis of the study to investigate the effects of IV ferric carboxymaltose (FCM) on the functioning of skeletal muscles in men with HFrEF. For the purposes of current research we analyzed data of 20 men with HFrEF (median age 68 (62, 75 – in brackets interquartile ranges, respectively) years, LVEF: 30 (25, 35) %, ischaemic HF aetiology: 85%, NYHA class I/II/III: 30%/50%/20%) and ID (definition according to ESC guidelines - ferritin <100 ng/mL, or ferritin 100–299 ng/mL with transferrin saturation [TSAT] <20%) who were randomized in a 1:1 ratio to receive either the 24-week therapy with IV FCM (dosing scheme as in the CONFIRM-HF trial) or saline (controls). The study was double-blinded. We used ELISA to evaluate different circulating pro-inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], tumor necrosis factor alpha [TNF-α], interleukin 6 [IL-6], interleukin 1 beta [IL-1β], interleukin 22 [IL-22]) at baseline and week 24. Results IV FCM therapy repleted iron stores in men with HFrEF as reflected by an increase in serum ferritin and TSAT, which was not seen in a control group. IV FCM therapy (as well as the saline administration) affected neither haemoglobin concentration nor parameters reflecting iron stores in red cells. Baseline serum ferritin was not related to hs-CRP, TNF-α, IL-6, IL-1β, and IL-22 (all p>0.23). Baseline TSAT was related to hs-CRP (r=−0.47, p=0.02) but not other inflammatory biomarkers. Levels of hs-CRP, TNF-α, IL-6, IL-1β, and IL-22 at week 0 were similar in subjects who received IV iron and controls (all p>0.22). Change from week 0 to week 24 adjusted for baseline value (delta W24-W0 as the percentage of W0) regarding IL-22 was lower in an active treatment arm as compared with saline (p=0.049) and there was a trend towards lower delta TNF-α in FCM group compared to saline (p=0.067). These findings were not valid for other measured pro-inflammatory biomarkers. Conclusions In men with HFrEF and concomitant ID intravenous iron therapy with FCM affects biomarkers of pro-inflammatory state. Clinical relevance of this finding requires further translational research. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This research was funded by the National Science Centre (Poland) grant allocated on the basis of the decision number DEC-2012/05/E/NZ5/00590

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Preemptive intravenous iron therapy versus autologous whole blood therapy for early postoperative hemoglobin level in patients undergoing bimaxillary orthognathic surgery: a prospective randomized noninferiority trial

BMC Oral Health ◽

10.1186/s12903-020-01359-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Min Suk Chae ◽

Mihyun Lee ◽

Min Ho Choi ◽

Je Uk Park ◽

Misun Park ◽

...

Keyword(s):

Blood Transfusion ◽

Blood Group ◽

Whole Blood ◽

Orthognathic Surgery ◽

Hemoglobin Level ◽

Iron Therapy ◽

Iron Group ◽

Autologous Whole Blood ◽

Bimaxillary Orthognathic Surgery ◽

Iv Iron

Abstract Background Previous studies have reported the efficacy and safety of intravenous (IV) iron therapy during the perioperative period as an alternative and adjunct to allogeneic blood transfusion. Preemptive IV iron therapy provides noninferior hemoglobin levels on postoperative day (POD) 1 compared to autologous whole blood therapy (AWBT) in healthy patients who had undergone bimaxillary orthognathic surgery. Methods This was a prospective, patient-randomized, noninferiority trial. After excluding 2 patients, 64 patients were divided into two groups: the IV iron therapy group (patients received IV iron infusion 4 weeks before surgery; n = 32) and the AWBT group (2 units of autologous whole blood were collected 4 and 2 weeks before surgery; n = 32). The primary outcome was hemoglobin level on POD 1 and the prespecified noninferiority limit was − 1 g/dL. Results Baseline data were comparable, including hemoglobin and iron levels, between the two groups. Immediately before surgery, the levels of hemoglobin, iron, and ferritin were higher in the IV iron group than in the AWBT group. The mean treatment difference (iron group—whole blood group) in hemoglobin level on POD 1 between the two groups was 0.09 (95% CI = − 0.83 to 1.0). As the lower limit of the 95% CI (− 0.83) was higher than the prespecified noninferiority margin (δ = − 1), noninferiority was established. On POD 2, the hemoglobin level became lower in the iron group, which eventually led to greater requirement of allogeneic blood transfusion compared to the whole blood group. However, the iron group did not require allogeneic blood transfusion during or early after surgery, and the whole blood group showed continuously higher incidence of overt iron deficiency compared to the iron group. Conclusion As collection of autologous whole blood caused overt iron loss and anemia before surgery and intraoperative transfusion of whole blood was not able to prevent the occurrence of persistent iron deficiency after surgery, IV iron therapy was found to have potential benefits for iron homeostasis and subsequent erythropoiesis in healthy patients early after bimaxillary orthognathic surgery. Trial registration: Clinical Research Information Service, Republic of Korea, approval number: KCT0003680 on March 27, 2019. https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=15769&sLeft=2&ltype=my&rtype=my.

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741 Manipulation and Reduction of Paediatric Forearm Fractures in The Emergency Department Using Intranasal Diamorphine and Entonox

British Journal of Surgery ◽

10.1093/bjs/znab134.481 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

S Kapoor ◽

A Valand ◽

J Dartnell

Keyword(s):

Emergency Department ◽

Patient Discharge ◽

General Anaesthetic ◽

Forearm Fractures ◽

Distal Radial Fractures ◽

Access To Treatment ◽

Early Access ◽

The Mean ◽

Salter Harris

Abstract Background Paediatric forearm fractures are commonly encountered in Trauma and Orthopaedics. Currently most forearm fractures are manipulated in theatre the following day, increasing resource burden and delays in management. The aim of this project was to introduce guidelines to reduce fractures in the Emergency Department (ED) using intranasal Diamorphine and Entonox. Method 197 cases were identified over a 6-month period in 2018 and 2019. 74 distal radial fractures and 123 mid shaft forearm fractures were analysed. Fractures with an intact periosteal hinge or a Salter Harris type 2 were reduced in ED. The pre manipulation and post manipulation radiographs were compared with particular attention to the post reduction angles. Results 67% of fractures were reduced in the correct setting. A number of fractures reduced in ED required re-manipulation or internal fixation. Overall, there was a 56% reduction in patients undergoing general anaesthetic. There was a reduction in the mean length of stay from 36 hours to 3.5 hours. Conclusions Intranasal Diamorphine and Entonox offer a safe method for managing paediatric forearm fractures in ED. Implementation of this method facilitates early access to treatment and early patient discharge. Manipulation in ED offers significant financial savings and reduces demands on the Trauma Theatres.

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The Temporal Trend in the Transfer of Older Adults to the Emergency Department for Traumatic Injuries: A Retrospective Analysis According to Their Place of Residence

Journal of the American Medical Directors Association ◽

10.1016/j.jamda.2019.07.013 ◽

2019 ◽

Vol 20 (11) ◽

pp. 1462-1466 ◽

Cited By ~ 1

Author(s):

Xavier Dubucs ◽

Philipe de Souto Barreto ◽

Clarisse Laffon de Mazieres ◽

Dominique Lauque ◽

Olivier Azema ◽

...

Keyword(s):

Older Adults ◽

Emergency Department ◽

Retrospective Analysis ◽

Temporal Trend ◽

Place Of Residence ◽

Traumatic Injuries

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A 12-year retrospective analysis of differences between elderly and oldest old patients referred to the emergency department of a large tertiary hospital

Maturitas ◽

10.1016/j.maturitas.2018.11.011 ◽

2019 ◽

Vol 120 ◽

pp. 7-11 ◽

Cited By ~ 6

Author(s):

Marcello Covino ◽

Carmine Petruzziello ◽

Graziano Onder ◽

Alessio Migneco ◽

Benedetta Simeoni ◽

...

Keyword(s):

Emergency Department ◽

Retrospective Analysis ◽

Oldest Old ◽

Tertiary Hospital ◽

Old Patients

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Preemptive intravenous iron therapy versus autologous whole blood therapy for early postoperative hemoglobin level in patients undergoing bimaxillary orthognathic surgery: A prospective randomized noninferiority trial

10.21203/rs.3.rs-64923/v2 ◽

2020 ◽

Author(s):

Min Suk Chae ◽

Mihyun Lee ◽

Min Ho Choi ◽

Je Uk Park ◽

Misun Park ◽

...

Keyword(s):

Blood Transfusion ◽

Blood Group ◽

Whole Blood ◽

Orthognathic Surgery ◽

Hemoglobin Level ◽

Iron Therapy ◽

Iron Group ◽

Autologous Whole Blood ◽

Bimaxillary Orthognathic Surgery ◽

Iv Iron

Abstract Background: Previous studies have reported the efficacy and safety of intravenous (IV) iron therapy during the perioperative period as an alternative and adjunct to allogeneic blood transfusion. Preemptive IV iron therapy provides noninferior hemoglobin levels on postoperative day (POD) 1 compared to autologous whole blood therapy (AWBT) in healthy patients who had undergone bimaxillary orthognathic surgery.Methods: This was a prospective, patient-randomized, noninferiority trial. After excluding 2 patients, 64 patients were divided into two groups: the IV iron therapy group (patients received IV iron infusion 4 weeks before surgery; n = 32) and the AWBT group (2 units of autologous whole blood were collected 4 and 2 weeks before surgery; n = 32). The primary outcome was hemoglobin level on POD 1 and the prespecified noninferiority limit was –1 g/dL. Results: Baseline data were comparable, including hemoglobin and iron levels, between the two groups. Immediately before surgery, the levels of hemoglobin, iron, and ferritin were higher in the IV iron group than in the AWBT group. The mean treatment difference (iron group – whole blood group) in hemoglobin level on POD 1 between the two groups was 0.09 (95% CI = –0.83 to 1.0). As the lower limit of the 95% CI (–0.83) was higher than the prespecified noninferiority margin (δ = –1), noninferiority was established. On POD 2, the hemoglobin level became lower in the iron group, which eventually led to greater requirement of allogeneic blood transfusion compared to the whole blood group. However, the iron group did not require allogeneic blood transfusion during or early after surgery, and the whole blood group showed continuously higher incidence of overt iron deficiency compared to the iron group. Conclusion: As collection of autologous whole blood caused overt iron loss and anemia before surgery and intraoperative transfusion of whole blood was not able to prevent the occurrence of persistent iron deficiency after surgery, IV iron therapy was found to have potential benefits for iron homeostasis and subsequent erythropoiesis in healthy patients early after bimaxillary orthognathic surgery.Trial registration: Clinical Research Information Service, Republic of Korea, approval number: KCT0003680 on March 27, 2019https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=15769&sLeft=2&ltype=my&rtype=my

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31 Impacting Emergency Department Left Without Being Seen Rates Through Physician Resourcing

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2019.08.034 ◽

2019 ◽

Vol 74 (4) ◽

pp. S13 ◽

Cited By ~ 1

Author(s):

B.J. Theiling ◽

R. Donohoe ◽

C. Gerardo ◽

A. Limkakeng ◽

N. Kapadia

Keyword(s):

Emergency Department ◽

Left Without Being Seen

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Red Blood Cell Transfusion and the Use of Intravenous Iron in Iron Deficient Patients Presenting to the Emergency Department

Blood ◽

10.1182/blood-2020-141154 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 1-2

Author(s):

Arvand Barghi ◽

Robert Balshaw ◽

Emily Rimmer ◽

Murdoch Leeies ◽

Allan Garland ◽

...

Keyword(s):

Emergency Department ◽

Logistic Regression ◽

Iron Deficiency ◽

Blood Cell ◽

Red Blood Cell ◽

Hemoglobin Concentration ◽

Factors Associated ◽

Iv Iron ◽

Iron Parameters ◽

Rbc Transfusion

Background: Red blood cell (RBC) transfusions are often used to treat patients with iron deficiency who present to the emergency department (ED) with symptomatic anemia. Intravenous (IV) iron is the preferred treatment in this setting, as it has been shown to increase hemoglobin concentration rapidly and durably. We aim to determine the incidence of iron deficiency anemia (IDA) and the management of these patients in the ED setting. Objectives: To evaluate the incidence of IDA, the frequency of RBC transfusion and iron supplementation, and factors associated with RBC transfusion. Study Design: Retrospective cohort study of all adult patients presenting to the St Boniface Hospital (Winnipeg, CAN) ED from January 2014 to January 2019. Methods: We used electronic data from the Emergency Department Information System (EDIS) and Laboratory Information Services (LIS) databases to identify patients presenting with IDA, defined as anemia (hemoglobin <120 g/L) with either a transferrin saturation less than 20% or ferritin less than 30 umol/L, or mean corpuscular volume (MCV) of < 75 fL. A ferritin greater than 100 umol was used to exclude IDA, regardless of MCV. We extracted patient demographics, diagnoses, markers of iron storage, RBC transfusion and use of IV iron. Multivariate logistic regression analysis was used to evaluate factors associated with RBC transfusion. Results: Of 39222 patients, 17945 (45%) were anemic. Of the anemic patients, iron parameters were ordered in 1848 (10.3%) patients, and IDA was present in 910 (5.1 %). In the IDA population, 95 patients (10.4 %) received 1 RBC unit, and 197 patients (21.6 %) received 2 or more units. Oral iron and IV iron were prescribed for 64 (7 %) and 14 (1.5 %) patients, respectively. Our logistic regression model demonstrated that hemoglobin concentration was the main determinant of whether patients received RBC transfusion. Other variables including patient age, cardiac symptoms, heart rate, blood pressure, and CTAS score were not associated with increased likelihood of receiving RBC transfusion. Conclusion: Iron parameters were infrequently ordered in the evaluation of anemia in the ED, with limited use of oral and IV iron. The decision to transfuse RBCs was primarily influenced by hemoglobin concentration, but not other surrogates of hemodynamic instability. An interventional study to improve education and access to oral and IV iron is planned to reduce unnecessary RBC transfusions and their associated risks in patients with IDA. Disclosures No relevant conflicts of interest to declare.

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