Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review.

This is a narrative review of the published evidence for bleeding management in critically ill patients in different clinical settings in the intensive care unit (ICU). We aimed to describe "The Ten Steps" approach to early goal-directed hemostatic therapy (EGDHT) using point-of-care testing (POCT), coagulation factor concentrates, and hemostatic drugs, according to the individual needs of each patient. We searched National Library of Medicine, MEDLINE for publications relevant to management of critical ill bleeding patients in different settings in the ICU. Bibliographies of included articles were also searched to identify additional relevant studies. English-language systematic reviews, meta-analyses, randomized trials, observational studies, and case reports were reviewed. Data related to study methodology, patient population, bleeding management strategy, and clinical outcomes were qualitatively evaluated. According to systematic reviews and meta-analyses, EGDHT guided by viscoelastic testing (VET) has been associated with a reduction in transfusion utilization, improved morbidity and outcome in patients with active bleeding. Furthermore, literature data showed an increased risk of severe adverse events and poor clinical outcomes with inappropriate prophylactic uses of blood components to correct altered conventional coagulation tests (CCTs). Finally, prospective, randomized, controlled trials point to the role of goal-directed fibrinogen substitution to reduce bleeding and the amount of red blood cell (RBC) transfusion with the potential to decrease mortality. In conclusion, severe acute bleeding management in the ICU is still a major challenge for intensive care physicians. The organized and sequential approach to the bleeding patient, guided by POCT allows for rapid and effective bleeding control, through the rational use of blood components and hemostatic drugs, since VET can identify specific coagulation disorders in real time, guiding hemostatic therapy with coagulation factor concentrates and hemostatic drugs with individual goals.

Recent Malignant Melanoma Epidemiology in Upper Silesia, Poland. A Decade-Long Study Focusing on the Agricultural Sector.

The aim of the present study was to create spatial and spatio-temporal patterns of cutaneous malignant melanoma (MM) incidence in Upper Silesia, Poland, using the largest MM database (<4K cases) in Central Europe, focusing on the agricultural sector. The data comprised all the registered cancer cases (C43, according to the International Classification of Diseases after the 10th Revision) between the years 2004-2013 by the Regional Cancer Registries (RCRs) in Opole and Gliwice. The standardized incidence ratios (SIRs), spatio-temporal growth rates (GRs), and disease cluster relative risks (RRs) were estimated. Based on the regression coefficients, we have indicated irregularities of spatial variance in cutaneous malignant melanoma, especially in older women (≥60), and a possible age-migrating effect of agricultural population density on the risk of malignant melanoma in Upper Silesia. All the estimates were illustrated in choropleth thematic maps.

The Effect of Different Doses of Intravenous Dexmedetomidine on the Properties of Subarachnoid Blockade: A Systematic Review and Meta-Analysis.

BACKGROUND: Dexmedetomidine is a sedative and analgesic medication which has gained an increased usage as an adjuvant to both general and regional anaesthesia in recent years. In this systematic review and meta-analysis, we examined the changes to the characteristics of subarachnoid block when accompanied with intravenous dexmedetomidine. Our aim is to evaluate the effects of different doses of intravenous dexmedetomidine on the sensory and motor blockade duration of a single shot spinal anaesthetic and the incidence of any associated side effects. METHODS: We searched published randomized clinical trials (RCTs) from January 1992 to April 2019 that investigated the use of IV dexmedetomidine with spinal anaesthesia. After considering our inclusion and exclusion criteria, we included 15 RCTs with 985 patients. We analyzed the duration of sensory and motor blockade and the related adverse effects in relation to different doses of IV dexmedetomidine. RESULTS: Intravenous dexmedetomidine, with loading dose of 1 mcg/kg, prolonged the sensory blockade duration of spinal anaesthesia by a mean difference of 49.6 min, P<0.001, and motor blockade duration by a mean difference of 44.7 min, P<0.001, while a loading dose of 0.5 mcg/kg prolonged the sensory blockade by a mean difference of 43.06 min, P<0.001, and motor blockade duration by a mean difference of 29.09 min, P<0.001. Dexmedetomidine-related side effects were higher in patients receiving larger doses; the incidence of bradycardia was higher (OR=3.53, P<0.001) and incidence of hypotension showed a 1.29 fold increase when compared to the control group (P=0.065). CONCLUSION: The administration of intravenous dexmedetomidine in conjunction with spinal anaesthesia can significantly prolong the duration of both sensory and motor blockade. The use of larger loading doses of dexmedetomidine was associated with a larger side-effect profile with minimal beneficial changes when compared to lower loading doses.

Selected Hematological Biomarkers to Predict Acute Mortality in Emergency Department Patients. Recent Polish Hospital Statistics.

BACKGROUND: Complete blood count (CBC), red cell distribution width (RDW), mean platelet volume (MPV), mean corpuscular volume (MCV), mean cell hemoglobin (MCH), mean cell hemoglobin concentration (MCHC), or platelet (PLT) count are referred as predictors of adverse clinical outcomes in patients. The aim of the research was to identify potential factors of acute mortality in Polish emergency department (ED) patients by using selected hematological biomarkers and routine statistical tools. METHODS: The study presents statistical results on patients who were recently discharged from inpatient facilities within one month prior to the index ED visit. In total, the analysis comprised 14,881 patients with the first RDW, MPV, MCV, MCH, MCHC, or PLT biomarkers' measurements recorded in the emergency department within the years 2016-2019 with a subsequent one month of all-cause mortality observation. The patients were classified with the codes of the International Statistical Classification of Diseases and Related Health Problems after 10th Revision (ICD10). RESULTS: Based on the analysis of RDW, MPV, MCV, MCH, MCHC, and PLT on acute deaths in patients, we establish strong linear and quadratic relationships between the risk factors under study and the clinical response (P < 0.05), however, with different mortality courses and threats. In our statistical analysis, (1) gradient linear relationships were found for RDW and MPV along an entire range of the analyzed biomarkers' measurements, (2) following the quadratic modeling, an increasing risk of death above 95 fL was determined for MCV, and (3) no relation to excess death in ED patients was calculated for MCH, MCHC, and PLT. CONCLUSION: The study shows that there are likely relationships between blood counts and expected patient mortality at some time interval from measurements. Up to 1 month of observation since the first measurement of an hematological biomarker, RDW and MPV stand for a strong relationship with acute mortality of patients, whereas MCV, MCH, MCHC, and PLT give the U-shaped association, RDW and MPV can be established as the stronger predictors of early deaths of patients, MCV only in the highest levels (>95 fL), whereas MCH, MCHC, and PLT have no impact on the excess acute mortality in ED patients.

Red Blood Cells Mean Corpuscular Volume (MCV) and Red Blood Distribution Width (RDW) Parameters as Potential Indicators of Regenerative Potential in Older Patients and Predictors of Acute Mortality - Preliminary Report.

This study presents the statistical results of patients who had been recently discharged from hospital within one month after their treatment in the emergency department (ED). Using routine (14,881) MCV and RDW measurements and statistical tools, we could predict acute mortality in these patients (N = 1158), adjusted for age. It is likely that an increase in the MCV and RDW parameters may correlate in some of our older patients with a poor prognosis with an increased level of circulating IGF-I, which affects red blood cell parameters. The research presents the prognostic statistics of the analyzed clinical factors as well as speculates on the potential correlation of these parameters with the regenerative potential of stem-cell compartment. Analysis shows that both MCV and RDW are statistically significant (Area Under Curve [AUC], lower CI 95% >50%) predictors of acute mortality in ED patients. The classification of patients based on their MCV threshold (= 92.2 units) indicates a proper clinical prognosis in nearly 6 of 10 subjects (AUC >58%), whereas taking into account RDW (=13.8%) indicates a proper clinical prognosis in no more than 7 of 10 individuals. The report concludes that by employing strongly fitting (95%) quadratic modeling of the ORs against the biomarkers studied, one can notice a similar relationship between MCV and RDW as diagnostic tools to predict regenerative potential and clinical outcomes in older patients. Although RDW alone had a 10% higher diagnostic value in terms of predicting early death in the emergency department in patients that were admitted to the ED and subsequently hospitalized, also taking the MCV measurement improved accuracy in predicting clinical outcomes by 2.5% compared to RDW alone.

Clinical Profiles of Selected Biomarkers Identifying Infection and Cancer Patients: A Gorzów Hospital Example.

INTRODUCTION: Many pathobiological processes that manifest in a patient's organs could be associated with biomarker levels that are detectable in different human systems. However, biomarkers that promote early disease diagnosis should not be tested only in personalized medicine but also in large-scale diagnostic evaluations of patients, such as for medical management. OBJECTIVE: We aimed to create an easy algorithmic risk assessment tool that is based on obtainable "everyday" biomarkers, identifying infection and cancer patients. PATIENTS: We obtained the study data from the electronic medical records of 517 patients (186 infection and 331 cancer episodes) hospitalized at Gorzów Hospital, Poland, over a one and a half-year period from the 1st of January 2017 to the 30th of June 2018. METHODS AND RESULTS: A set of consecutive statistical methods (cluster analysis, ANOVA, and ROC analysis) was used to predict infection and cancer. For in-hospital diagnosis, our approach showed independent clusters of patients by age, sex, MPV, and disease fractions. From the set of available "everyday" biomarkers, we established the most likely bioindicators for infection and cancer together with their classification cutoffs. CONCLUSIONS: Despite infection and cancer being very different diseases in their clinical characteristics, it seems possible to discriminate them using "everyday" biomarkers and popular statistical methods. The estimated cutoffs for the specified biomarkers can be used to allocate patients to appropriate risk groups for stratification purposes (medical management or epidemiological administration).

The value of the thromboelastometry heparinase assay (HEPTEM) in cardiac surgery.

The thromboelastometry INTEM clotting time (CT) with heparinase (HEPTEM) is frequently used to detect residual heparin after cardiopulmonary bypass (CPB) in cardiac surgery. This study investigated whether the HEPTEM CT reflects the presence of residual heparin and the association of the protamine-to-heparin ratio to the INTEM and HEPTEM CT. We retrospectively evaluated thromboelastometry data that were obtained before CPB and after protamine infusion following CPB in two tertiary hospitals. The number of patients with an INTEM: HEPTEM ratio (IH-ratio) > 1, suggesting residual heparin, were quantified. Moreover, the influence of different protamine-to-heparin-dosing-ratios (P:H) on the INTEM and HEPTEM CT was evaluated in the clinical setting and in blood drawn from healthy volunteers. An INTEM: HEPTEM CT ratio > 1.1 was observed in 16 % of the patients prior to CPB, and in 15 % after protamine administration. Interestingly, 23 % and 36 % of the patients had an HEPTEM CT exceeding the INTEM CT before CPB and following protamine administration. The HEPTEM CT was longer than the INTEM CT in patients with a P:H-ratio of 1:1 (265 ± 132 vs 260 ± 246 s; p=0.002) or P:H-ratio of 1.3:1 (357 ± 174 vs 292 ± 95 s; p=0.001). Increasing P:H-ratios induced a prolonged HEPTEM CT in fresh blood. In conclusion, limited agreement was observed between INTEM and HEPTEM clotting time in the absence of heparin. INTEM comparison to HEPTEM may not always reliably reflect the presence of residual heparin, while protamine may additionally affect the latter test. These observations complicate HEPTEM results interpretation in clinical situations with suspected residual heparin effect after protamine.