Blood transfusion as a risk factor of recurrent thrombosis in ACS patients

Blood transfusion is a common procedure in hospital care, especially in trauma patients and operated patients which loss lots of blood. But the risk of getting a transfused blood might be bigger than we expected, especially in acute coronary syndrome patients. A study by Silvain J et al, proved that transfused blood might increase the platelet reactivity in ACS patients which responsible for the recurrent ischemic event and mortality in ACS patients.

Here's the writing:

Impact of Red Blood Cell Transfusion on Platelet Aggregation and Inflammatory Response in Anemic Coronary and Non-Coronary Patients The TRANSFUSION-2 study 

Johanne Silvain, MD-PhD1; Jérémie Abtan, MD1; Mathieu Kerneis, MD1; Réjane Martin, BCh1; Jonathan Finzi, PharmMD1; Jean-Baptiste Vignalou, MD1; Olivier Barthélémy, MD1; Stephen A. O’Connor, MD1; Charles-Edouard Luyt, MD-PhD2; Nicolas Brechot, MD-PhD2; Anne Mercadier, MD-PhD3; Delphine Brugier, PhD1; Sophie Galier, BCh1; Jean-Philippe Collet, MD-PhD1; Jean Chastre, MD-PhD2; Gilles Montalescot, MD-PhD1

Objectives  To determine whether RBC transfusion increases in-vivo platelet aggregation and inflammation in coronary and non-coronary patients.

Background Red blood cell (RBC) transfusion increases in-vitro platelet activation and aggregation in healthy volunteers, providing a possible explanation for the increase in recurrent ischemic events and mortality reported after RBC transfusion in ACS patients.

Methods Platelet reactivity was measured before and after RBC transfusion in 61 patients (33 ACS patients and 28 non-ACS patients). Relative changes between baseline and post-transfusion measurements of maximum (MPA) and residual platelet aggregation (RPA) were considered with different agonists as well as changes in Vasodilatator-Stimulated Phosphoprotein Platelet Reactivity Index (VASP-PRI) and P-selectin expression. Inflammatory and thrombotic biomarkers were also measured before and after transfusion.

Results After RBC transfusion, platelet reactivity was increased when measured with adenosine diphosphate (ADP)-induced light transmission aggregometry (+11.6% relative increase of MPA; p = 0.004 and +10.8% increase of RPA; p = 0.005) and VASP PRI (relative increase of +20.7%; p=0.002) while there was a non-significant trend towards an increase of P-selectin expression. Similar results were found with the non-specific agonist thrombin receptor activated peptide (TRAP) (relative increase of +11.7% for MPA p=0.04 and+12.7% for RPA; p=0.02) but not with collagen or arachidonic acid agonists. There were no significant differences in inflammatory and thrombotic biomarkers before and after transfusion. 

Conclusions After red blood cell transfusion, there is an increase in platelet reactivity, especially with tests measuring the ADP-P2Y12receptor pathway without significant variation in inflammatory or thrombotic biomarkers. This in-vivo effect may account for the excess in ischemic events observed in the context of ACS treated by PCI and P2Y12inhibitors.

Update in MindMap section

Hi, a new MindMap was made quite quickly this time. Since I'm going to make a new topic about asthma, I'm going to start the opening topic first: Basic lung function under BASIC category.

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Update in Event section

A new emergency medicine event will be held in Singapore. Sign up for early bird now!

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Update in MindMap Section

I'm really sorry for the long delay. I have to put up with lots of things since my M.D. graduation. I'm still in Indonesia, however I'm now on duty in RSUD Kanujoso Djatiwibowo for my internship program.

Enough for the chit-chat...

Well, I just updated the MindMap section for now. The new topic is about pre-eclampsia. I hope this will be helpful and please don't hesitate to give any supportive critiques for me to improve in the future. Thanks

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Update in MindMap Section

Reading too many text at a time may take your time A LOT. Let me just make it simpler for you by having you read in a form of mind map. I'll put a guideline if I think it would be necessary to do so.

The mind maps were self-made. Most of the source was taken from uptodate.com

These are some of the beginnings. I promise you that they will pile up in no time...

List of mind-maps available: - click here to access the mindmap section

1. Pediatric Febrile seizure
2. Pediatric Shock (Basic)
3. Pediatric Shock (Initial evaluation)

Here is one of them: (Pediatric Febrile Seizure)

Something sweet for the wound (#SurvivalGuide)

When you are in a secluded area, where access to medical resources is not possible, you may want to use some alternatives. These alternatives may not be included in any internationally approved guidelines, but good enough to save lives...

#SurvivalGuide 01 

- Something sweet for your wound -

It was 8 PM, you were walking down the forest with your friends, going toward the camp area. When suddenly a friend of yours slipped down two meters below. Luckily, no major trauma happened to her. She was conscious and cried for help; able to stand up an walked by herself. Though, there was blood gushing out from her right hand.

picture was taken from: http://www.todaysplanet.com/pg/beta/lizardlover/pic/vikki_big_bite_wound.jpg (Google picture)

The wound was covered by dirt and the base was hard to identify. Judging the situation, you decided to wash the wound with the drinking water you brought while assessing the function of the distal part, the capillary refill time (CRT), and the bleeding itself. The function was well and the CRT was below two seconds. The bleeding was still ongoing and you decided to rip some cloths to tie up the wound and put pressure on it. You and your friends rushed to the camp area for further assessment of the wound.

After further examinations and more washing with flowing water, three separated open wounds were identified. All of them had clear defined edges and the base of all three wounds were muscles. The bleeding had stopped gushing out, but the next thing to do is to disinfect the wounds and suture them. And none could be done because you had no tools to disinfect nor to suture. You decided to take her to the nearest hospital for further treatment; though, the nearest one would need 12 hours to reach by car. To drive a car in the middle of the night would be risky, so you had no choice but to postpone until morning. But....you worried the risk of infection since they were contaminated, but no povidone iodine or chlorhexidine could be found around the camp. You went to the kitchen and found some cooking ingredients: cooking oil, sugar, salt, honey, milk, and soy sauce. You brought the honey jar out and took a spoonful of it. You had your friend consent to put the honey over the wound and cover the wound up again using the cloth. 

The next day, she was brought to the hospital and had her wound stitched. She was well with no complication of infection.

HONEY?!! You said you use honey to cover the wound?

Yes...I'm all aware about what I wrote, especially about using honey to cover up the wound. Of course you would think what's the deal of using honey on the wound. 

-Honey as antimicrobial-

Besides of its function as beverages, honey had been regarded since long as one of the most efficacious natural resources. Honey has been studied (by Molan PC) in a variety of injury cases and has proven efficacious in promoting wound healing compared to standard treatment some of the examples:

1. Degree burns both mild to severe in adults and children with a faster recovery time compared to using silver sulfadiazine.
2. Wound infection after abdominal surgery with a recovery time much shorter than that of povidone iodine.
3. Decubitus ulcer healing with better proportions within 10 days compared with the use of saline soaked gauze.

Mechanisms of wound healing by honey mainly lies in the effects of antimicrobial, the main reason is because infection is a major cause of complications in the wound. However, the use of honey in wound healing providing additional effect, namely: eliminate the odor in the wound, the wounds debridation effect, and stimulates angiogenesis and growth of fibroblasts that can accelerate wound healing and minimize skin graft omissions or debridement. (by Molan PC - another study from above)

Focusing on its antimicrobial effect, honey has a variety of mechanisms that underlie this mechanism, namely: (Studied by Eddy JJ and Molan PC - more different study from him)

• Hyperosmolar state: hyperosmolar nature of honey can provide benefits in wound healing. With a water content of less than 20%, honey can prevent the occurrence of edema in the wound and cause dehydration in bacteria.
• pH: with a pH ranging from 3.5-5, this might added the nature of honey's bactericidal effect
• Hydrogen peroxide: hydrogen peroxide is a compound of honey which has antimicrobial properties. The content of peroxide in honey is quite unique, because it is activated by the dilution process. The higher the dilution, the higher the hydrogen peroxide content of the honey. It is another advantage of using honey on wounds, because the humidity may maintained by absorbing the water from the wound surrounding and at the same time diluting the honey. It has been observed that the hydrogen peroxide contained in honey may work more effectively because it is produced continuously by glucose oxidase; therefore, hydrogen peroxide will always be available with stable level on the wounds to some extent of time.

That's all for the first #SurvivalGuide edition. Well, you might want to try using honey instead of povidone iodine the next time you come across any wound cases.

Free UpToDate.com? - an accessible and accurate clinical answer for everyone -

Just as the title says, there is a free uptodate.com content in the internet. So, what is UpToDate.com? UpToDate.com is an internet based literature search, a peer-reviewed one, similar to medscape.com. The purpose is to bring a more accessible clinical answer to physician. Therefore, when we (clinicians) are facing the patient on an examination room, or even at the bedside, and having difficulties answering some questions regarding patients' condition, instead of reading thick books in front of them, we may look for answers at the net using smartphones.

Well....even though UpToDate.com is more accessible, the subscription cost may not be that feasible...

Therefore, there is freeuptodate.com that is accessible for anyone and anywhere. It is free and have the same content with uptodate.com. Though the version of articles may be older (last update date will be older) than in uptodate.com, most of the articles are usually have the exact same content. 

One thing you need to remember is that you need to login (at the top right corner) first when you want to read the whole content in freeuptodate.com. You will need to subscribe, but once again, it's free.