Hematology / Renal (October 2017)
AIR: Renal
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
7 comments
Beam et al
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Remember just recently, we had a hematology faculty come to conference telling us about our protocol for discharging low risk patients with DVT on NOAC (Novel anticoagulants).
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This paper is very relevant and provides support for possibly doing the same win low-risk small PE’s. However the numbers are pretty small, but the literature is mounting.
Long and Koyfman et al.
– a concise review of transfusion threshold and potential complications. Definitely core content that we don’t often always think much about.
– In fact, Muhammad and I had a patient getting transfused early this year and she developed SOB and pulm edema, and we recognized TRALI and admitted her to the MICU.
Beam et al.
-Strengths: good risk stratification of potential participants up front using POMPE-C and Hestia, classification of clot type, planned for close follow up with participants, relatively long study period
-Limitations: Only 82% of patients had a follow-up visit, small sample size
– Main outcomes: recurrence of DVT or PE, clinically significant bleed, mortality
-Change in practice: I did not consider giving lovenox prior to administration of rivaroxaban before dc from the ED. This makes a lot of sense. I think providers are generally less likely to discharge someone with a PE from the ED, no matter the size, but if more evidence becomes available on the safety of doing so, I hope the culture around this will change. It is also important to consider the likelihood our patients will be able to pick up there medications and get timely follow-up, which continues to be a challenge.
Long
-Change in practice: Although I aim to be conservative when deciding to transfuse a patient, I think there needs to be an added level in caution when patients come in with chronic anemia and a slow GI (non-variceal) bleed. I was impressed by the evidence that transfusions can be particularly harmful in this population.
-Debunked: I thought the risk of infection was slim to none and while the risk of infection with communicable viruses remains low, there is an appreciable risk of bacterial infection with transfusions. I also thought that there was more evidence to support transfusions after MI to higher Hb thresholds- seems like more data on this is needed.
– Learned: Indications for washed/leukoreduced/irradiated blood and more about the complications of transfusion, storage time for blood and the benefits of storing for less amount of time
-Areas of further research: As the article mentions, when we should be transfusing patients after an MI, TBI, or stroke. I am also curious about symptomatic improvement after transfusions- many of our patients requiring transfusion are chronically ill and it is difficult to attribute symptoms to anemia exclusively. Do patient’s report feeling better after transfusion and does this correlate with rise in hemoglobin or degree of anemia?
Beam
-strengths- they had realistic exclusion criteria that let 27% of PE patients be discharged.
-limitations- arbitrary cutoffs, 3 patients that fell out of follow-up would have made study miss cutoffs, no comparison group.
-outcome, no major bleeding risk, 3 patients had recurrent embolism.
-practice- I like the system of discharge from ED. With many of our patients, they have trouble with insurance and social factors that meet exclusion criteria.
Beam et al
Prospective cohort, small number 71 DVT 35 PE, significant % admitted: 73% PE, 49% DVT not only due meeting Hestia criteria but “other reasons” which are not explained; great research topic that needs further evaluation but reassuring no major bleeding or re-occurence of VTE; maybe more applicable to community setting, feel like the difficult to apply to BMC population due to xarelto costs, lack of pt education, time constraints; would love to do this more and will see how Lahey deals with low risk PE/DVT when I rotate soon, great we have support of heme department and a protocol to dc but still not common in our ED
Long et al
Great review of the transfusion reactions. We transfuse so often and I wonder how well we educate our pt about the risks of all these reactions. Need to incorporate more of that into my consent. Good reminder of irradiated vs leukoreduced vs washed. Of note, I recently had a pt who had a ?transfusion reaction listed in her chart but did not specify details. I called the blood bank to see if I should ordered washed RBC and they told me all their blood is washed. Reaction risk higher if RBCs are >21 days. More research about transfusion threshold for TBI.