In this episode I’ll:

1. Discuss an article about bloodless treatment of anemia.

2. Answer the drug information question “Which antibiotics should be given to a patient with necrotizing pancreatitis?”

3. Share a resource I use to teach pathophysiology.

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Article

Outcomes of Protocol-Driven Care of Critically Ill Severely Anemic Patients for Whom Blood Transfusion Is Not an Option

Lead author: Aryeh Shander

Published in Critical Care Medicine June 2016

Background

Englewood Hospital and Medical Center has managed patients for whom blood transfusion is not an option using a bloodless protocol, which has been in place since 1994.

Purpose

The purpose of the study was to compare the outcomes of severely anemic critically ill patients for whom transfusion is not an option (“bloodless” patients) with transfused patients.

Methods

The study was a single center cohort study of 178 bloodless and 441 transfused consecutive patients who were severely anemic and critically ill. Patients had at least 1 hemoglobin level below 8 g/dL within 24 hours of ICU admission. The study period spanned from 1996 to 2011.

Results

The primary outcome was in-hospital mortality. Transfused patients were older, had higher hemoglobin level at admission, and had higher Acute Physiology and Chronic Health Evaluation II score. Hospital mortality rates were 24.7% in bloodless and 24.5% in transfused patients (odds ratio, 1.01; 95% CI, 0.68–1.52; p = 0.95). No significant difference in ICU readmission or positive blood culture results was observed.

Conclusion

The authors concluded that:

The overall risk of mortality in severely anemic critically ill bloodless patients appeared to be comparable with transfused patients…Use of a protocol to manage anemia in these patients in a center with established patient blood management and bloodless medicine and surgery programs is feasible and likely to contribute to improved outcome, whereas more studies are needed to better delineate the impact of such programs.

Discussion

The bloodless protocol used at this center is quite interesting. It is included with the supplementary documents.

All bloodless patients with low hemoglobin receive 100 mg of IV iron daily for 10 days, a one time dose of vitamin B12, and daily folic acid and vitamin C.

Epoetin alfa is dosed according to the level of anemia. Patients with a hemoglobin > 7 g/dL receive 40,000 units weekly. Patients with a hemoglobin from 5 to 7 g/dL receive 20,000 units daily, and patients with hemoglobin < 5 g/dL receive 20,000 units every 12 hours.

The protocol is quite detailed and involves a lab draw schedule.

Drug information question

Q: Which antibiotics should be given to a patient with necrotizing pancreatitis?

A: If they are indicated, give an antibiotic known to penetrate pancreatic abscesses.

This is really a trick question. Antibiotics are no longer considered indicated for the initial treatment of patients with pancreatitis, even if they present with necrotizing pancreatitis.

Patients that deteriorate or fail to improve after 7 to 10 days in the hospital may be evaluated for infected necrosis. In this case antibiotics may be administered prophylactically, pending the results of fine needle aspiration and cultures.

Antibiotics known to penetrate pancreatic necrosis such as carbapenems, quinolones, and metronidazole should be considered.

Resource

One pathophysiology topic that many students and new pharmacists often have trouble with is remembering the path that blood takes through the veins, heart, and lungs. This knowledge is important for understanding concepts about venous thromboembolism or septic emboli from endocarditis.

I’ve got a guaranteed method of teaching this concept for life, and it involves the alternative rock band They Might Be Giants. This band was formed in the 1980s, and somewhere in the 2000s they switched over to children’s songs, including one titled “The Blood Mobile”:



After listening to that song and watching the music video you’ll never forget this pathophysiology concept!

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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