Stroke

Should I use a hemoglobin level of 7 or 8 g/dL as a threshold for blood transfusion in my hospitalized patient?

FA Manian MD, MPH, , , , , , , , , , , 1 Comment

Unlike its previous 2012 guidelines that recommended overlapping hemoglobin level triggers of 7 g/dL to 8 g/dL for most inpatients, the 2016 guidelines from AABB (formerly known as the American Association of Blood Banks) assigns 2 distinct tiers of hemoglobin transfusion triggers: 7 g/DL for hemodynamically stable adults, including those in intensive care units, and 8 g/dL for patients undergoing cardiac or orthopedic surgery or with preexisting cardiovascular disease1 , often defined as history of coronary artery disease, angina, myocardial infarction, stroke, congestive heart failure, or peripheral vascular disease2,3.  

These recommendations are based on an analysis of over 30 randomized trials, taking into account the potential risks of withholding transfusions, including 30-day mortality, and myocardial infarction. The new 2-tier recommendation specifically excludes those with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia.

The guidelines also emphasize that good clinical practice dictates considering not only the hemoglobin level but the overall clinical context when considering blood transfusion in patients. These factors include alternative therapies to transfusion, rate of decline in hemoglobin level, intravascular volume status, dyspnea, exercise tolerance, light-headedness, chest pain considered of cardiac origin, hypotension, tachycardia unresponsive to fluid challenge, and patient preferences.

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References

  1. Carson JL, Guyatt G, Heddle NW. Clinical practice guidelines from the AABB red blood cell transfusion thresholds and storage. JAMA. Doi:10.1001/jama.2016.9185. Published online October 12, 2016. https://www.ncbi.nlm.nih.gov/pubmed/27732721
  2. Carson JL, Duff A, Poses RM, et al. Effect of anemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996;348:1055-60. https://www.ncbi.nlm.nih.gov/pubmed/8874456
  3. Carson JL, Siever F, Cook DR, et al. Liberal versus restrictive blood transfusion strategy: 3-year survial and cause of death results from the FOCUS randomized controlled trial. Lancet 2015;385:1183-1189. https://www.ncbi.nlm.nih.gov/pubmed/25499165
Should I use a hemoglobin level of 7 or 8 g/dL as a threshold for blood transfusion in my hospitalized patient?

Does electroconvulsive therapy (ECT) pose a risk of embolic stroke in patients with atrial fibrillation (AF)?

FA Manian MD, MPH, , , , , , Leave a comment

Acute embolic stroke in the setting of AF without anticoagulation after ECT has been reported in a single case report in the absence of conversion to normal sinus rhythm (1). Several cases of episodic or persistent conversion to normal sinus rhythm (NSR) in patients with AF undergoing ECT have also been reported (in the absence of embolic stroke), leading some to recommend anticoagulation therapy in such patients (2), though no firm data exist.

The mechanism by which ECT promotes cardioversion from AF to NSR is unclear as direct electrical influence of ECT on the heart is thought to be negligible (1). Arrhythmias such as atrial flutter and AF have also been reported after ECT (1). Curiously, ECT is associated with increased 5- hydroxytryptamine (5- HT2)-receptor densities of platelets in patients with depression which may enhance platelet reactivity and increase the risk of embolic stroke (3) even in the absence of cardioversion.

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References

  1. Suzuki H, Takano T, Tominaga M, et al. Acute embolic stroke in a patient with atrial fibrillation after electroconvulsive therapy. J Cardiol Cases 2010; e12-e14. https://www.sciencedirect.com/science/article/pii/S1878540910000113
  2. Petrides G, Fink M. Atrial fibrillation, anticoagulation, electroconvulsive therapy. Convulsive Therapy 1996;12:91-98. https://journals.lww.com/ectjournal/Abstract/1996/06000/Atrial_Fibrillation,_Anticoagulation,_and.4.aspx
  3. Stain-Malmgren R, Tham A, Ǻberg-Wistedt A. Increased platelet 5-HT2 receptor binding after electroconvulsive therapy in depression. J ECT 1998;14:15-24. https://europepmc.org/abstract/med/9661089
Does electroconvulsive therapy (ECT) pose a risk of embolic stroke in patients with atrial fibrillation (AF)?

Which motor test may be the most useful maneuver when examining a patient suspected of having a stroke?

FA Manian MD, MPH, , , , , Leave a comment

When limited by the number of motor tests that can be performed on a patient suspected of having a stroke, the pronator drift may be your best bet! The sensitivity of this test has varied from 22% to as high as 94% for patients within a week of having a stroke; it is highly specific, however (1,2).

 An advantage of this maneuver is that it can point to subtle lesions in the corticospinal tract (CST) often missed by formal strength testing.

To perform the test, ask the patient to hold his or her arms straight out in front with palms facing upwards and eyes closed for 20-30 seconds. Slight pronation of one hand and flexion of the elbow suggests mild drift. Additional downward drift of the entire arm may also be present with more severe deficits (3). Interestingly, if one arm drifts upward this suggests a lesions outside the CST, possibly a cerebellar or parietal lesion, which may be equally concerning.

 

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References

  1. Louis ED, King D, Sacco R, et al. Upper motor neuron signs in acute stroke: prevalence, interobserver reliability, and timing of initial examination. J Stroke Cerebrovasc Dis 1995;5:49-55. https://www.ncbi.nlm.nih.gov/pubmed/26486559 
  2. Anderson NE, Mason DF, Fink JN. Detection of focal cerebral hemisphere lesions using the neurological examination. J Neurol Neurosurg Psychiatry 2005;76:545-49. https://jnnp.bmj.com/content/jnnp/76/4/545.full.pdf 
  3. Campbell, WW. In DeJong’s The Neurologic Examination-6th Ed, p389-392, 2005. Lippincott Williams&Wilkins, Philadelphia.

 

Contributed in part by Alexis Roy, Harvard Medical Student, Boston, MA.

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Which motor test may be the most useful maneuver when examining a patient suspected of having a stroke?

How do I interpret an elevated serum C-reactive protein (CRP) and normal erythrocyte sedimentation rate (ESR) or vice-versa?

FA Manian MD, MPH, , , , , , , , , , , , Leave a comment

Discordance between serum CRP and ESR is not uncommon (1,2). This phenomenon may be due to a variety of factors including the fact that the kinetics of these two tests is quite different, as discussed in another P4P Post.

In a study of CRP/ESR discordance (defined as results differing by 2 or 3 quartiles) in adults, a high CRP/low ESR profile was more likely to be associated with  urinary, GI, blood stream, and pulmonary infections, myocardial infarction, and venous thromboembolism and less likely to be associated with bone and joint infections (1).

In the same study, a high ESR/low CRP was associated with connective tissue diseases, such as systemic lupus erythematosus and strokes (1).

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References

1. Feldman M, Aziz B, Kang GN, et al. C-reactive protein and erythrocyte sedimentation rate discordance: frequency and causes in adults. Translational Research 2013;161:37-43. https://www.ncbi.nlm.nih.gov/pubmed/22921838

2. Colombet I, Pouchot J, Kronz V. Agreement between erythrocyte sedimentation rate and C-reactive protein in hospital practice. Am J Med 2010;123:864.e7-863.e13.https://www.ncbi.nlm.nih.gov/pubmed/20800157

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How do I interpret an elevated serum C-reactive protein (CRP) and normal erythrocyte sedimentation rate (ESR) or vice-versa?