Anderson, Brenda

Importance Anemia is a common complication of surgery and acute illness that is associated with adverse clinical outcomes. The role of anemia prevention and treatment strategies in this setting remains unclear. Objective To evaluate the effect of a multifaceted anemia management bundle vs standard care on posthospitalization hemoglobin recovery and multidimensional functional outcomes in survivors of acute illness. Design, Setting, and Participants This parallel group randomized clinical trial, known as the Practical Anemia Bundle for Sustained Blood Recovery, was conducted at postsurgical and medical intensive care units at a large US medical center. Critically ill patients (aged ≥18 years) with moderate to severe anemia (hemoglobin concentration <10 g/dL) were enrolled between March 2022 and November 2023. Participants were randomly assigned 1:1 to the intervention or standard care group. Intention-to-treat analyses were performed between July 2024 and January 2025. Intervention The intervention bundle was delivered throughout the duration of hospitalization and included optimized phlebotomy practices, clinical decision support, and pharmacological anemia treatment with intravenous iron. Main Outcomes and Measures The primary outcome was the mean difference in hemoglobin concentration at 1 month after hospital discharge. Results A total of 100 patients (median [IQR] age, 68 [61-72] years; 57 men [57.0%]; 65 [65.0%] with postsurgical admission to the intensive care unit) were enrolled during acute illness. Forty-nine patients (49.0%) were assigned to receive the intervention, and 51 (51.0%) were assigned to receive standard care. Hemoglobin concentration at 1 month after discharge was greater in patients receiving the intervention vs standard care (median [IQR], 12.2 [11.8-13.0] g/dL vs 11.5 [10.2-12.6] g/dL; adjusted mean difference, 0.69 [95% CI, 0.13-1.20] g/dL; P = .02). Conclusions and Relevance This randomized clinical trial found that a multifaceted anemia prevention and treatment bundle was feasible, was well tolerated, and improved posthospitalization hemoglobin concentrations up to 3 months in critically ill adults. These findings can inform the design of future trials. Trial Registration ClinicalTrials.gov Identifier: NCT05167734

Introduction: Post-Cardiopulmonary Bypass (CPB) coagulopathy results in bleeding, transfusion and re-exploration, and increases morbidity, mortality and cost. Some studies have reported a relationship between individual factor levels and chest tube drainage as a marker of bleeding, but few have reported that relationship for multiple factors. Methods: With IRB approval and informed consent, 98 patients, ages 18 - 85, undergoing cardiac surgery with cardiopulmonary bypass (CPB) were studied. Factor levels measured five minutes post-protamine included fibrinogen (FIB), and factors II, V, VII, VIII, Von Willebrand Factor Antigen (VWF Ag), Ristocetin Cofactor (VWF Activity), IX, X, XI and XIII. Linear regression models examined the relationship between factor levels and post-op chest tube drainage over 24 hours as a surrogate marker for bleeding. An effect size (ES) was calculated so that each factor deficiency multiplied by the ES and the patient's weight in kg would estimate the contribution of that factor to bleeding. Factors were ranked from most to least impact on bleeding. Conversely, said ES would estimate the decrease in bleeding achieved by a percentage increase in a deficient factor level if such factor was known to be deficient. Results: F:II was 1st (most associated with bleeding), ES = -0.137, 95% CI -0.214 - -0.059, p < 0.001; F:X was 2nd, ES = -0.130, 95% CI -0.202 - -0.058, p < 0.001; F:VII ES = -0.121, 95% CI -0.198 - -0.045, p = 0.002; F:XI ES = -0.109, 95% CI -0.16 - -0.058, p < 0.001; F:IX ES = -0.100; 95% CI -0.135 - -0.065, p < 0.001; F:V ES = - 0.065; 95% CI -0.114 - -0.016, p = 0.011; F:XIII ES = - 0.055; 95% CI -0.099 - -0.011, p = 0.016; FIB ES = - 0.042; 95% CI -0.063 - -0.022, p < 0.001; F:VIII ES = - 0.007; 95% CI -0.020 - 0.006, p = 0.318; VWF Ag ES = 0.002; 95% CI -0.016 - 0.019, p = 0.855; VWF Activity ES = 0.004; 95% CI -0.015 - 0.023, p = 0.671. Conclusions: Factors VIII, VWF Ag and Ristocetin Cofactor demonstrated no relationship with bleeding, perhaps because they are elevated as acute-phase reactants. In theory, raising F:II level post-CPB by 30% in an 80 kg patient might decrease bleeding by 328 ml, and raising F:X level post-CPB by 30% in an 80 kg patient might decrease bleeding by 312 ml, etc. A weakness of this study is that the sample size was too small to perform a multi-variate analysis considering all factor levels. Still, the data suggest four-factor prothrombin complex concentrate (PCC) might be a more effective treatment for post-CPB coagulopathy than FFP. The data do not confirm cause and effect; that would require a large study with control and treatment arms. If multiple factor levels could be measured in a rapid and cost-effective manner it might aid in targeted treatment of post-CPB coagulopathy. The data suggest that work should be performed to better elucidate the contribution of coagulation factor deficiencies to post-CPB bleeding, as improved treatment of such factor deficiencies might decrease bleeding and transfusion requirements.

Background: Acute kidney injury (AKI) survivors are at heightened risk for poor short- and long-term health outcomes. Even among those who recover after an AKI episode, the risk for chronic kidney disease is 4- to 6-fold higher than in patients without AKI, underscoring the importance of identifying methods to improve AKI survivorship. Objective: The purpose of this report was to describe the development and feasibility of a novel multidisciplinary approach to caring for AKI survivors at care transitions (ACT). Design: Observational process improvement initiative. Setting: Single academic medical center in the United States. Patients: The studied population was adults with stage 3 AKI not discharging on dialysis who were established with a primary care provider (PCP) at our institution. Methods: An electronic health record tool was developed prior to implementation to identify AKI survivors. The ACT program encompassed engaging patients in the hospital, delivering education by nephrology-trained nurses before discharge, completing recommended laboratory testing after discharge, and conducting structured kidney-focused follow-up with a pharmacist and a PCP within 7 to 14 days after discharge. Patients could be referred for nephrology evaluation at the discretion of the PCP. Results: Preliminary data demonstrated that most AKI survivors of interest could be identified, educated, and followed up with this model. This strategy appeared feasible, scalable, and maximized the unique expertise of each member of the multidisciplinary team. Limitations: Small sample size, future assessment of process, clinical, and patient-reported outcomes needed. Conclusions: The multidisciplinary ACT workflow supported by clinical decision support was feasible and addressed gaps in existing care transition models. Team-based care delivery in primary care appears to be a mechanism to extend the capacity for kidney health monitoring for AKI survivors.