Blood conservation in the critically ill.
OBJECTIVE
Anemia of critical illness is common among intensive care unit patients. A blood management pilot program was initiated to study the pharmacodynamic response of epoetin alfa in critically ill patients and assess the impact of the use of a standardized order set of pharmaceuticals, including epoetin alfa and intravenous iron sucrose, on the quantity of red blood cell units transfused in the adult intensive care unit.


CONCLUSIONS
A pre-printed order set was developed which included baseline and follow-up laboratory monitoring and pharmaceutical options for iron, either intravenous and/or oral, folic acid, ascorbic acid, cyancobalamin, and weight-based epoietin alfa. Laboratory studies included: hemoglobin/hematocrit, reticulocyte count, absolute reticulocyte count, immature reticulocyte fraction obtained at baseline, and on day three and day five; in addition, iron, total iron binding capacity, transferrin saturation, and ferritin were obtained at baseline and on day five. An average hemoglobin response of 0.8 g/dL five days after administration of epoetin alfa was demonstrated in a diverse population of critically ill patients. Patients who received intravenous iron did not have a difference in mortality as compared to those patients who did not receive intravenous iron; however, there was a significantly longer length of stay. The cost of epoetin alfa was $64,000 over 10 months (approximately 8-10 patients/month). Transfusions of RBCs in adult intensive care unit decreased over the initial five months of the pilot study.


CONCLUSIONS
Use of erythropoiesis stimulating agents (ESAs) in the critically ill is controversial. Implementing a standardized approach in the pharmaceutical management of anemia in the critically ill patient is possible. Limitations with the order set and standardized protocol included errors in selection of dose/weight, incomplete laboratory/monitoring, and inconsistent prospective/concurrent review to guide therapy. The determination of the cost-effectiveness of epoetin alfa therapy in anemia of critical illness was not the purpose of this project, but will be the focus of future studies.
Intensive Care Unit, St. Agnes Hospital Pharmacy, Baltimore, MD 21229, USA. jthomas@stagnes.org
Jennifer
J
Thomas
Anthony
A
Martinez
D000328:Adult; D000368:Aged; D000740:Anemia / Q000188:drug therapy* / Q000401:mortality; D015142:Baltimore; D001769:Blood / Q000187:drug effects; D001774:Blood Chemical Analysis; D002985:Clinical Protocols; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000628:therapy; D016527:Drug Costs; D016903:Drug Monitoring; D000068817:Epoetin Alfa; D017707:Erythrocyte Transfusion / Q000706:statistics & numerical data*; D004921:Erythropoietin / Q000008:administration & dosage* / Q000191:economics / Q000494:pharmacology; D005260:Female; D005290:Ferric Compounds / Q000008:administration & dosage* / Q000191:economics / Q000494:pharmacology; D000077605:Ferric Oxide, Saccharated; D005937:Glucaric Acid; D006397:Hematinics / Q000008:administration & dosage* / Q000191:economics / Q000494:pharmacology; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010865:Pilot Projects; D011994:Recombinant Proteins
D005290:Ferric Compounds; D006397:Hematinics; D011994:Recombinant Proteins; D004921:Erythropoietin; D000068817:Epoetin Alfa; D000077605:Ferric Oxide, Saccharated; D005937:Glucaric Acid