Transfusion in critical care – a UK regional audit of current practice

Plumb, J et. al. Transfusion in critical care – a UK regional audit of current practice Anaesthesia. 2017 May; 72(5) :633-640

Introduction blood-2169514_1920

Critical care publications have advised that a restrictive transfusion strategy is non-inferior, and possibly superior, to a liberal strategy for stable, non-bleeding critically ill patients. However, translation into clinical practice has been slow. These authors describe the degree of adherence to UK best practice guidelines in a regional network of nine intensive care units in Wessex.

Methods and results

All transfusions given during a 2-month period were included (n = 444). Those given for active bleeding or within 24 hours of major surgery, trauma or gastrointestinal bleeding were excluded (n = 148). The median (interquartile range [range]) haemoglobin concentration before transfusion was 73 (68–77 [53–106]) g/L, with only 34% of transfusion episodes using a transfusion threshold of <70 g/L. In a subgroup analysis that did not study patients with a history of cardiac disease (n = 42), haemoglobin concentration before transfusion was 72 (68–77 [50–98]) g/L, with only 36% of transfusion episodes using a threshold of < 70 g/L. Most blood transfusions given to critically ill patients who were not bleeding in this audit used a haemoglobin threshold >70 g/L.

 Conclusions

The authors conclude that it is unclear why recommendations on transfusion triggers have not translated into clinical practice. With a clear national drive to decrease usage of blood products and clear evidence that a threshold of 70 g/L is non-inferior, the authors find it surprising that a scarce and potentially dangerous resource is still being overused within critical care. They suggest that simple solutions such as electronic patient records that force pause for thought before blood transfusion, or prescriptions that only allow administration of a single unit in non-emergency circumstances, may help to reduce the incidence of unnecessary blood transfusions.

 

Preoperative risk stratification of critically ill patients

Copeland, C.C. et al. (2017) The Journal of Clinical Anesthesia. 39 (June) pp. 122–127

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Highlights:

  • Preoperative assessment of critically ill patients is challenging and understudied.
  • ASA class, RCRI, and SOFA score were studied to predict survival to discharge.
  • One in four ICU patients did not survive to discharge after an intervention.
  • Available scores inadequately discriminated between survivors and non-survivors.
  • SOFA score (AUC = 0.68) outperformed ASA class (AUC = 0.59).

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Pain Assessment in INTensive care (PAINT)

Kemp, H.I. et al. Anaesthesia. Published online: 19 February 2017

Pain is a common and distressing symptom experienced by intensive care patients. Assessing pain in this environment is challenging, and published guidelines have been inconsistently implemented. The Pain Assessment in INTensive care (PAINT) study aimed to evaluate the frequency and type of physician pain assessments with respect to published guidelines.

The likelihood of receiving a physician pain assessment was affected by the following factors: the number of nursing assessments performed; whether the patient was admitted as a surgical patient; the presence of tracheal tube or tracheostomy; and the length of stay in ICU. Physician-documented pain assessments in the majority of participating ICUs were infrequent and did not utilise recommended behavioural pain assessment tools. Further research to identify factors influencing physician pain assessment behaviour in ICU, such as human factors or cultural attitudes, is urgently needed.

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Antibiotic therapy in critically ill patients

Martin-Loeches, I. et al. European Journal of Anaesthesiology. Published online: 30  January 2017

Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.

At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.

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The management of pulmonary embolism

Lewis, J.E. & Pilcher, D.V. Anaesthesia & Intensive Care Medicine. Published online: 19 January 2017

Pulmonary embolism (PE) is a significant cause of hospitalization, morbidity and mortality and frequently triggers referral to critical care services. Critically ill patients are also at increased risk of developing venous thrombo-embolism (VTE) and acute PE.

Critical care clinicians should be confident in their approach to the patient with suspected and diagnosed PE. Furthermore, the co-morbid conditions in this patient group may present additional challenges both in diagnosis (e.g. safe access to radiology) and management (e.g. absolute and relative contraindications to anticoagulation/thrombolysis in critically ill patients).

This brief review summarizes the contemporary evidence base regarding both diagnosis and treatment strategies and draws upon this to suggest a simple algorithm for investigation, risk stratification and management, particularly tailored to patients within a critical care setting.

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Care of the eye during anaesthesia and intensive care

 O’Driscoll, A. & White, E. Anaesthesia and Intensive Care Medicine. Published online: November 26 2016

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Image source: Dianne Harris – Wellcome Images // CC BY-NC-ND 4.0

 

Perioperative eye injuries and blindness are rare but important complications of anaesthesia. The three causes of postoperative blindness are ischaemic optic neuropathy, central retinal artery thrombosis (these can exist in tandem and have been described as ischaemic oculopathies) and cortical blindness.

This review aims to improve anaesthetists’ knowledge of orbital anatomy, ocular physiology and the mechanisms of perioperative eye injuries to help reduce their occurrence.

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Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial

Kelly, S.J. et al. (2016) Anaesthesia. 71. pp. 1153-62

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Introduction: Reports in the literature have suggested that paracetamol is associated with significant hypotension, a potentially important interaction for labile critically ill patients. These authors carried out a single-centre, prospective, open-label, randomised, parallel-arm, active-control trial, designed to determine the incidence of hypotension following the administration of paracetamol to critically ill patients.

Methods: A total of 50 adult patients receiving paracetamol for analgesia or pyrexia were randomly assigned to receive either the parenteral or enteral formulation of the drug. Paracetamol concentrations were measured at baseline and at multiple time points over 24 hours.

Results: The maximal plasma paracetamol concentration was significantly different between routes; 156 versus 73 µmol/L (p=0.0005) following the first dose of parenteral or enteral paracetamol, respectively. Sixteen hypotensive events occurred in 12 patients: parenteral n=12; enteral n=4. The incident rate ratio for parenteral versus enteral paracetamol was 2.94 (95% confidence interval 0.97 to 8.92; p=0.06).

Conclusions: The authors conclude that the incidence of hypotension associated with paracetamol administration is higher than previously reported and tends to be more frequent with parenteral paracetamol.

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