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Aggressive blood pressure reduction is not associated with decreased perfusion in leukoaraiosis regions in acute intracerebral hemorrhage patients
Kate M, Gioia L, Jeerakathil T, Hill MD, Gould B, McCourt R, Dowlatshahi D, Coutts S, Kosior J, Demchuk A, et al
PloS one. 2019;14(3):e0213645
Abstract
Leukoaraiosis regions may be more vulnerable to decreases in cerebral perfusion. We aimed to assess perfusion in leukoaraiosis regions in acute intracerebral hemorrhage (ICH) patients. We tested the hypothesis that aggressive acute BP reduction in ICH patients is associated with hypoperfusion in areas of leukoaraiosis. In the ICH Acutely Decreasing Arterial Pressure Trial (ICH ADAPT), patients with ICH <24 hours duration were randomized to two systolic BP (SBP) target groups (<150 mmHg vs. <180 mmHg). Computed tomography perfusion (CTP) imaging was performed 2h post-randomization. Leukoaraiosis tissue volumes were planimetrically measured using semi-automated threshold techniques on the acute non-contrast CT. CTP source leukoaraiosis region-of-interest object maps were co-registered with CTP post-processed maps to assess cerebral perfusion in these areas. Seventy-one patients were included with a mean age of 69+/-11.4 years, 52 of whom had leukoaraiosis. The mean relative Tmax (rTmax) of leukoaraiotic tissue (2.3+/-2s) was prolonged compared to that of normal appearing white matter in patients without leukoaraiosis (1.1+/-1.2s, p = 0.04). In the 52 patients with leukoaraiosis, SBP in the aggressive treatment group (145+/-20.4 mmHg, n = 27) was significantly lower than that in the conservative group (159.9+/-13.1 mmHg, n = 25, p = 0.001) at the time of CTP. Despite this SBP difference, mean leukoaraiosis rTmax was similar in the two treatment groups (2.6+/-2.3 vs. 1.8+/-1.6 seconds, p = 0.3). Cerebral perfusion in tissue affected by leukoaraiosis is hypoperfused in acute ICH patients. Aggressive BP reduction does not appear to acutely aggravate cerebral hypoperfusion.
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Longitudinal Changes in Disability Rating Scale Scores: A Secondary Analysis Among Patients With Severe TBI Enrolled in the Epo Clinical Trial
Benoit JS, Hannay HJ, Yamal JM, Francis DJ, Aisiku I, Robertson C
Journal of the International Neuropsychological Society : JINS. 2019;25(3):293-301
Abstract
OBJECTIVES Long-term neurological response to treatment after a severe traumatic brain injury (sTBI) is a dynamic process. Failure to capture individual heterogeneity in recovery may impact findings from single endpoint sTBI randomized controlled trials (RCT). The present study re-examined the efficacy of erythropoietin (Epo) and transfusion thresholds through longitudinal modeling of sTBI recovery as measured by the Disability Rating Scale (DRS). This study complements the report of primary outcomes in the Epo sTBI RCT, which failed to detect significant effects of acute treatment at 6 months post-injury. METHODS We implemented mixed effects models to characterize the recovery time-course and to examine treatment efficacy as a function of time post-injury and injury severity. RESULTS The inter-quartile range (25th-75th percentile) of DRS scores was 20-28 at week1; 8-24 at week 4; and 3-17 at 6 months. TBI severity group was found to significantly interact with Epo randomization group on mean DRS recovery curves. No significant differences in DRS recovery were found in transfusion threshold groups. CONCLUSIONS This study demonstrated the value of taking a comprehensive view of recovery from sTBI in the Epo RCT as a temporally dynamic process that is shaped by both treatment and injury severity, and highlights the importance of the timing of primary outcome measurement. Effects of Epo treatment varied as a function of injury severity and time. Future studies are warranted to understand the possible moderating influence of injury severity on treatment effects pertaining to sTBI recovery. (JINS, 2019, 25, 293-301).
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Transfusion requirements after head trauma: a randomized feasibility controlled trial
Gobatto ALN, Link MA, Solla DJ, Bassi E, Tierno PF, Paiva W, Taccone FS, Malbouisson LM
Critical care (London, England). 2019;23(1):89
Abstract
BACKGROUND Anemia is frequent among patients with traumatic brain injury (TBI) and is associated with an increased risk of poor outcome. The optimal hemoglobin concentration to trigger red blood cell (RBC) transfusion in patients with TBI is not clearly defined. METHODS All eligible consecutive adult patients admitted to the intensive care unit (ICU) with moderate or severe TBI were randomized to a "restrictive" (hemoglobin transfusion threshold of 7 g/dL), or a "liberal" (threshold 9 g/dL) transfusion strategy. The transfusion strategy was continued for up to 14 days or until ICU discharge. The primary outcome was the mean difference in hemoglobin between groups. Secondary outcomes included transfusion requirements, intracranial pressure management, cerebral hemodynamics, length of stay, mortality and 6-month neurological outcome. RESULTS A total of 44 patients were randomized, 21 patients to the liberal group and 23 to the restrictive group. There were no baseline differences between the groups. The mean hemoglobin concentrations during the 14-day period were 8.4 +/- 1.0 and 9.3 +/- 1.3 (p < 0.01) in the restrictive and liberal groups, respectively. Fewer RBC units were administered in the restrictive than in the liberal group (35 vs. 66, p = 0.02). There was negative correlation (r = - 0.265, p < 0.01) between hemoglobin concentration and middle cerebral artery flow velocity as evaluated by transcranial Doppler ultrasound and the incidence of post-traumatic vasospasm was significantly lower in the liberal strategy group (4/21, 3% vs. 15/23, 65%; p < 0.01). Hospital mortality was higher in the restrictive than in the liberal group (7/23 vs. 1/21; p = 0.048) and the liberal group tended to have a better neurological status at 6 months (p = 0.06). CONCLUSIONS The trial reached feasibility criteria. The restrictive group had lower hemoglobin concentrations and received fewer RBC transfusions. Hospital mortality was lower and neurological status at 6 months favored the liberal group. TRIAL REGISTRATION ClinicalTrials.gov, NCT02203292 . Registered on 29 July 2014.
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Effects of liver function on ionized hypocalcaemia following rapid blood transfusion
Chung HS, Cho SJ, Park CS
Journal of International Medical Research. 2012;40((2):):572-82.
Abstract
OBJECTIVE Hypocalcaemia detrimentally affects the cardiovascular system and massive transfusion-related hypocalcaemia is particularly severe in end-stage liver disease patients undergoing liver transplantation (LT). This study, therefore, compared the severity and duration of ionized hypocalcaemia between patients with normal and impaired liver function. METHODS Patients (n = 26 per group) were transfused at a rate of 10 ml/kg within 10 min with packed red blood cells (PRBCs) during LT (group LP) or spinal surgery (group SP), or were infused with 0.9% normal saline during spinal surgery (group SN). Serum levels of ionized calcium were assessed before (T(0)), just after (T(1)), and at 20 (T(2)) and 60 min (T(3)) after transfusion. RESULTS Transfusion with PRBCs caused more severe ionized hypocalcaemia than 0.9% normal saline at T(1). In contrast to the faster (20 min) normalization in group SP, ionized hypocalcaemia in group LP persisted at T(3). Serum ionized calcium levels at T(3) showed correlations with vital signs, blood glucose, serum potassium, base deficit and lactate. CONCLUSION Rapid blood transfusion caused more severe and prolonged ionized hypo calcaemia in patients with liver dysfunction than in those with normal liver function.
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5.
Intraoperative transfusion threshold and tissue oxygenation: a randomised trial
Nielsen K, Dahl B, Johansson PI, Henneberg SW, Rasmussen LS
Transfusion Medicine. 2012;22((6):):418-25.
Abstract
BACKGROUND AND OBJECTIVES Transfusion with allogeneic red blood cells (RBCs) may be needed to maintain oxygen delivery during major surgery, but the appropriate haemoglobin (Hb) concentration threshold has not been well established. We hypothesised that a higher level of Hb would be associated with improved subcutaneous oxygen tension during major spinal surgery. MATERIALS AND METHODS Fifty patients aged 18 years or older scheduled for spinal fusion with instrumentation were included and randomised to receive RBCs at either a Hb concentration of 7.3 g dL (-1) (restrictive group) or a Hb concentration of 8.9 g dL (-1) (liberal group) (Registration no.: H-C-2009-072). Oxygen tension was measured with a polarographic electrode placed subcutaneously over the left deltoid muscle. The primary endpoint was subcutaneous oxygen tension at the time most patients were still undergoing surgery. RESULTS Forty-eight patients were included in the intention-to-treat analysis; 25 patients in the restrictive group and 23 patients in the liberal group. The median change in subcutaneous oxygen tension 60 min after surgical incision was -0.79 and -0.75 kPa in the restrictive and the liberal groups, respectively (P = 0.78). No significant difference was found in the lowest subcutaneous oxygen tension; -2.07 vs. -1.95 kPa in the restrictive and the liberal groups, respectively (P = 0.85). CONCLUSION A Hb concentration transfusion threshold of 8.9 g dL (-1) was not associated with a higher subcutaneous oxygen tension during major spinal surgery than a threshold of 7.3 g dL (-1), but the trial was compromised by methodological difficulties. 2012 The Authors. Transfusion Medicine 2012 British Blood Transfusion Society.