Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review.

BACKGROUND: As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. METHODS: We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis. RESULTS: We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline. CONCLUSIONS: Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

A contemporary description of patients' estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center.

BACKGROUND: Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospital-wide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations. STUDY DESIGN AND METHODS: Data were obtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients. RESULTS: Data were included on 59,715 subjects. Mean daily estimated blood loss varied from 8.5 ± 6.5 mL/day onward to 27.2 ± 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations). CONCLUSION: Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy.

Incidence, Survival and Prevalence Statistics of Classical Myeloproliferative Neoplasm in Korea.

The nationwide statistical analysis of each disease of classical myeloproliferative neoplasm (MPN) in Korea has not been reported yet. To this end, we have analyzed incidence rates, survival rates and treatment pattern of polycythemia vera (PV), primary myelofibrosis (MF) and essential thrombocythemia (ET) using Korea National Cancer Incidence Database (KNCIDB) and Health Insurance Review and Assessment Service (HIRA) database. Between 2003 and 2011, a total of 4,342 new cases of MPN were reported to the KNCIDB. ET was the most common, followed by MF and PV. The crude incidence rates for PV, MF, and ET have increased during the period, reaching 0.40, 0.15, and 0.84 per 100,000, respectively. Five-year relative survival rate of all MPN patients was 89.3%, with lowest relative survival rate with MF (53.1%). The prevalence of each disease estimated from HIRA data also increased during the study period. Notably, ET was found to be most prevalent. The prescription rate of hydroxyurea and phlebotomy to PV, MF and ET patients remained constant over the period, and the prescription rate of hydroxyurea was higher in patients with age over 60 years. This is the first Korean nationwide statistics of MPN, using central registry data. This set of data can be utilized to compare the Korean MPN status to international data and guidelines.

Idiopathic erythrocytosis: a study of a large cohort with a long follow-up.

Idiopathic erythrocytosis (IE) is an absolute erythrocytosis with no known cause, diagnosed by exclusion of primary and secondary erythrocytosis. Familial erythrocytosis (FE) is a rare disease and as the rare patients with JAK2-wild-type polycythemia vera (PV) may be misdiagnosed as IE. We compared 78 patients with IE, 21 with FE and 136 with PV in the effort to identify simple features capable of discriminating between them. FE patients were younger at diagnosis either than IE and PV (p < 0.001); IE and FE had lower WBC, platelet counts and higher serum EPO levels, and had splenomegaly and thrombotic events less frequently than PV patients. Phlebotomies to obtain a haematocrit lower than 45 % induce platelet count increase in 70 % of PV but not in IE. Mainly in men, normal spleen, normal platelet counts and no history of thrombosis at diagnosis argue against PV; diagnosis of IE could be supported by means of a cycle of venesection to see how it affects their platelet count. No simple data capable of distinguishing between IE and FE were identified; therefore, a case of sporadic erythrocytosis in a young patient should be investigated as a possible genetic cause.

Current and future treatment options for polycythemia vera.

Patients with polycythemia vera (PV), a myeloproliferative neoplasm characterized by an elevated red blood cell mass, are at high risk of vascular and thrombotic complications and have reduced quality of life due to a substantial symptom burden that includes pruritus, fatigue, constitutional symptoms, microvascular disturbances, and bleeding. Conventional therapeutic options aim at reducing vascular and thrombotic risk, with low-dose aspirin and phlebotomy as first-line recommendations for patients at low risk of thrombotic events and cytoreductive therapy (usually hydroxyurea or interferon alpha) recommended for high-risk patients. However, long-term effective and well-tolerated treatments are still lacking. The discovery of mutations in Janus kinase 2 (JAK2) as the underlying molecular basis of PV has led to the development of several targeted therapies, including JAK inhibitors, and results from the first phase 3 clinical trial with a JAK inhibitor in PV are now available. Here, we review the current treatment landscape in PV, as well as therapies currently in development.

Inpatient preanalytic process improvements.

CONTEXT: Phlebotomy services are a common target for preanalytic improvements. Many new, quality engineering tools have recently been applied in clinical laboratories. However, data on relatively few projects have been published. This example describes a complete application of current, quality engineering tools to improve preanalytic phlebotomy services. OBJECTIVES: To decrease the response time in the preanalytic inpatient laboratory by 25%, to reduce the number of incident reports related to preanalytic phlebotomy, and to make systematic process changes that satisfied the stakeholders. DESIGN: The Department of Laboratory Medicine, General Services Section, at the University of Texas MD Anderson Cancer Center (Houston) is responsible for inpatient phlebotomy in a 24-hour operation, which serves 689 inpatient beds. The study director was project director of the Division of Pathology and Laboratory Medicine's Quality Improvement Section and was assisted by 2 quality technologists and an industrial engineer from MD Anderson Office of Performance Improvement. RESULTS: After implementing each solution, using well-recognized, quality tools and metrics, the response time for blood collection decreased by 23%, which was close to meeting the original responsiveness goal of 25%. The response time between collection and arrival in the laboratory decreased by 8%. Applicable laboratory-related incident reports were reduced by 43%. CONCLUSIONS: Comprehensive application of quality tools, such as statistical control charts, Pareto diagrams, value-stream maps, process failure modes and effects analyses, fishbone diagrams, solution prioritization matrices, and customer satisfaction surveys can significantly improve preset goals for inpatient phlebotomy.

Obtaining blood cultures by venipuncture versus from central lines: impact on blood culture contamination rates and potential effect on central line-associated bloodstream infection reporting.

OBJECTIVE: Reduce the frequency of contaminated blood cultures that meet National Healthcare Safety Network definitions for a central line-associated bloodstream infection (CLABSI). DESIGN: An observational study. SETTING: A 500-bed university-affiliated hospital. METHODS: A new blood culture policy discouraged drawing blood samples from central lines. Phlebotomists were reeducated regarding aseptic technique when obtaining blood samples by venipuncture. The intravenous therapy team was taught how to draw blood samples by venipuncture and served as a backup when phlebotomists were unable to obtain blood samples. A 2-nurse protocol and a special supply kit for obtaining blood samples from catheters were developed. Rates of blood culture contamination were monitored by the microbiology laboratory. RESULTS: The proportion of blood samples obtained for culture from central lines decreased from 10.9% during January-June 2010 to 0.4% during July-December 2012 (P < .001). The proportion of blood cultures that were contaminated decreased from 84 (1.6%) of 5,274 during January-June 2010 to 21 (0.5%) of 4,245 during January-June 2012 (P < .001). Based on estimated excess hospital costs of $3,000 per contaminated blood culture, the reduction in blood culture contaminants yielded an estimated annualized savings of $378,000 in 2012 when compared to 2010. In mid-2010, 3 (30%) of 10 reported CLABSIs were suspected to represent blood culture contamination compared with none of 6 CLABSIs reported from mid-November 2010 through June 2012 (P = 0.25). CONCLUSIONS: Multiple interventions resulted in a reduction in blood culture contamination rates and substantial cost savings to the hospital, and they may have reduced the number of reportable CLABSIs.

Hepcidin level predicts hemoglobin concentration in individuals undergoing repeated phlebotomy.

Dietary iron absorption is regulated by hepcidin, an iron regulatory protein produced by the liver. Hepcidin production is regulated by iron stores, erythropoiesis and inflammation, but its physiology when repeated blood loss occurs has not been characterized. Hepcidin was assayed in plasma samples obtained from 114 first-time/reactivated (no blood donations in preceding 2 years) female donors and 34 frequent (≥3 red blood cell donations in preceding 12 months) male donors as they were phlebotomized ≥4 times over 18-24 months. Hepcidin levels were compared to ferritin and hemoglobin levels using multivariable repeated measures regression models. Hepcidin, ferritin and hemoglobin levels declined with increasing frequency of donation in the first-time/reactivated females. Hepcidin and ferritin levels correlated well with each other (Spearman's correlation of 0.74), but on average hepcidin varied more between donations for a given donor relative to ferritin. In a multivariable repeated measures regression model the predicted inter-donation decline in hemoglobin varied as a function of hepcidin and ferritin; hemoglobin was 0.51 g/dL lower for subjects with low (>45.7 ng/mL) or decreasing hepcidin and low ferritin (>26 ng/mL), and was essentially zero for other subjects including those with high (>45.7 ng/mL) or increasing hepcidin and low ferritin (>26 ng/mL) levels (P<0.001). In conclusion, hepcidin levels change rapidly in response to dietary iron needed for erythropoiesis. The dynamic regulation of hepcidin in the presence of a low levels of ferritin suggests that plasma hepcidin concentration may provide clinically useful information about an individual's iron status (and hence capacity to tolerate repeated blood donations) beyond that of ferritin alone. Clinicaltrials.gov identifier: NCT00097006.

Do perinatal nurses still check for blood return when administering the hepatitis B vaccine?

OBJECTIVE: To describe how changes in recommendations regarding aspirating for blood return prior to intramuscular immunization have diffused into perinatal nurses' practice using the diffusions of innovations theory as a framework and to explore what factors influenced decisions to adopt new administration techniques. DESIGN & SETTING: This descriptive study used a survey design with a convenience sample of hospital-based perinatal nurses. A link to an online survey regarding injection knowledge and practices surrounding administering the hepatitis B vaccine to newborns was distributed to nurse managers in Indiana, and they were asked to forward the link to their staffs. PARTICIPANTS: A total of 72 nurses participated in the survey. RESULTS: The majority of respondents (90%) continued to aspirate with the vaccination. Only 13% knew this practice was no longer recommended. CONCLUSIONS: For the most part, participants were still in the knowledge phase regarding changes in vaccination administration practices. Lack of knowledge, considered a characteristic of the potential adopter, was the primary barrier to change. More research is needed to understand how communication, organizational factors, and the actual innovation factored into the change process. Additional research is needed to examine the practice of aspirating with other injectables.

Hemólisis en las muestras para diagnóstico / Hemolysis in diagnostic samples

La hemólisis es un efecto preanalítico evitable en la mayoría de los casos. Su aparición se debe a la técnica de extracción empleada y a las condiciones de transporte y preparación de las muestras. Su presencia produce error en muchas determinaciones habituales en química clínica, en muchos casos por la mezcla del contenido intraeritrocitario y en algún caso por el efecto interferente de componentes del hematíe, como la hemoglobina. En los laboratorios es necesario detectar y cuantificar la hemólisis en las muestras de forma estandarizada. La mayoría de los analizadores de bioquímica actuales incorporan sistemas de cuantificación espectrofotométrica de la hemoglobina. La influencia de la hemólisis en una magnitud depende de la metodología empleada, por lo que se debería solicitar a los fabricantes de equipos la realización de estudios y una información detallada sobre la influencia de la hemólisis en sus determinaciones, para que cada laboratorio pueda establecer el grado de hemólisis que supone error significativo para una magnitud, de acuerdo con sus especificaciones de calidad (AU)

In most cases, hemolysis is an avoidable preanalytical effect. It can appear as a result of the procedure used during blood specimen collection and also due to transport conditions and sample preparation. Hemolysis can lead to errors in many common determinations in clinical chemistry, mostly due to the leakage of cellular contents into the plasma, and in some cases, by the interfering effect of red blood cells components, such as hemoglobin. Laboratories need to be able to detect and measure hemolysis by a standardized procedure. The majority of current biochemistry analyzers can measure hemolysis by a spectrophotometric method. Nevertheless, the influence of hemolysis depends on the measurement method employed. Laboratories should demand that manufacturers give detailed information and make exhaustive studies regarding the influence of hemolysis on each analyte. This would allow each laboratory to establish the degree of hemolysis that produces a significant error in an analysis and in accordance with the laboratory's quality specifications (AU)

Innovations in central vascular access device insertion.

The new millennium has brought with it many technological advances that have affected every industry, especially healthcare and nursing. The key to success will be the ability of nurses to acclimate to these changes. To accomplish this, nurses need to advance their individual practice and skills, and to pursue and maintain an education in their respective fields. At no other time in healthcare history have so many changes taken place in such a short time, and nurses must remain abreast of changes to ensure career securement, advancement, and the safety of their patients. This article focuses on peripherally inserted central catheters and the changing technology for their insertion, maintenance, and training requirements.

Impact of safety devices for preventing percutaneous injuries related to phlebotomy procedures in health care workers.

BACKGROUND: Use of protective devices has become a common intervention to decrease sharps injuries in the hospitals; however few studies have examined the results of implementation of the different protective devices available. OBJECTIVE: To determine the effectiveness of 2 protective devices in preventing needlestick injuries to health care workers. METHODS: Sharps injury data were collected over a 7-year period (1993-1999) in a 3600-bed tertiary care university hospital in France. Pre- and postinterventional rates were compared after the implementation of 2 safety devices for preventing percutaneous injuries (PIs) related to phlebotomy procedures. RESULTS: From 1993 to 1999, an overall decrease in the needlestick-related injuries was noted. Since 1996, the incidence of phlebotomy-related PIs has significantly decreased. Phlebotomy procedures accounted for 19.4% of all percutaneous injuries in the preintervention period and 12% in the postintervention period (RR, O.62; 95% CI, 0.51-0.72; P < .001). Needlestick-related injuries incidence rate decreased significantly after the implementation of the 2 safety devices, representing a 48% decline in incidence rate overall. CONCLUSIONS: The implementation of these safety devices apparently contributed to a significant decrease in the percutaneous injuries related to phlebotomy procedures, but they constitute only part of a strategy that includes education of health care workers and collection of appropriate data that allow analysis of residuals percutaneous injuries.

Phlebotomy: a treatment of ischaemic necrosis of the femoral head? Analysis of a hypothesis.

The treatment of non-traumatic ischaemic osteonecrosis of the femoral head (ONFH) remains problematical and there is evidently scope to seek for a medical treatment of this disease which often leads to a surgical procedure for hip prosthesis. If we exclude the context of hemoglobin disorders, necrosis appears mainly in adults, when their limb bones contain a fatty marrow. Investigations such as intramedullary pressure measurement and transosseous phlebography suggest a disorder of the intraosseous blood circulation. Various studies in animals and man have provided arguments indicating that a kind of intraosseous 'obesity' due to hyperplasia and/or hypertrophy of the fatty tissue of the femoral marrow play a role in the development of necrosis. In this respect, the blood flow of the yellow marrow is close to ischemia, whereas red marrow flow can be very high. In various conditions, mainly hemolytic anemias, the femoral yellow marrow can convert to red marrow, which has also been described in anemias induced by blood loss. If it is not thought unreasonable to consider ONFH an 'ischemic' disease, these observations are an encouragement to attempt treatment by repeated phlebotomies. This procedure may locally restore red marrow, and then an adequate blood flow which could stabilize or even reverse the lesions if they are diagnosed early.

Técnicas intravenosas no adulto / Adult intravenous techniques

Säo revisadas as técnicas de punçäo e cateterizaçäo para acesso de veias periféricas e centrais. É feita uma breve descriçäo anatômica das opçöes venosas. Säo apresentadas as técnicas de punçäo e cateterismo mais utilizadas. Säo analisadas as complicaçöes decorrentes, salientando a importância do conhecimento e destreza na utilizaçäo desse recurso terapêutico.