The anti-CD47 monoclonal antibody, one of the immune checkpoint inhibitors, can interfere with pretransfusion testing by binding to the cluster of differentiation 47 (CD47) proteins expressed on the surface of red blood cells (RBCs). We report the experience of mitigating interference in the pretransfusion test in two patients treated with ALX148, an anti-CD47 monoclonal antibody, by using multiple RBC alloadsorption. Two patients with a history of advanced head and neck squamous cell carcinoma were referred for a pretransfusion and cross-matching test. The blood group type of the two patients was B, RhD＋, but antibody screening, autocontrol, direct globulin, and cross-matching of the RBC units showed high-intensity agglutination. Medical records revealed that the patients were enrolled in an anti-CD47 monoclonal antibody clinical trial. To eliminate interference by the drug, we attempted alloadsorption using pooled O, RhD＋ RBCs, and the patient’s plasma in the ratio of 4:1. After three alloadsorption sessions using pooled allogeneic RBCs, the antibody screening and cross-matching issues of the globulin phase were resolved. The method used in this case is meaningful in that it can be easily used when drug interference occurs in a blood bank. (Korean J Blood Transfus 2023;34:26-31)

BACKGROUND: Thoracic epidural anesthesia (TEA) is increasingly used to reduce stress response, pain and pulmonary complication of patients under coronary artery bypass graft (CABG). However, effects of TEA on blood flow of grafted coronary artery are scarcely noticed. Imbalance between blood flow of grafted coronary artery and myocardial oxygen demand can bring about perioperative myocardial ischemia. Thus we evaluated the effect of TEA on blood flow of coronary grafts. METHODS: Twenty seven patients with triple-vessel coronary artery disease under CABG were recruited. Left internal mammary artery, radial artery, and great saphenous vein were anastomosed to left anterior descending artery, obtuse marginalis, and posterior descending artery, respectively. Before surgery, an epidural catheter was inserted. Total intravenous anesthesia was undertaken using fentanyl, midazolam and vecuronium. After grafts anastomosis, blood flow of grafted coronary artery was measured using transit-time flowmeter (TTFM) before weaning from CPB. And then, mixture of 2% lidocaine 10 ml, fentanyl 50microgram and bicarbonate 1 mEq was injected via epidural catheter. Under the constant pump flow, the blood flow of grafted coronary artery before, 10 and 20 minutes after drug administration were measured using TTFM. RESULTS: The blood flow of coronary artery grafts was similar in three time interval, irrespective of grafted artery. There are no significant differences in changes in coronary blood flow associated with epidural lidocaine injection among 3 types of grafted artery. CONCLUSIONS: The present study shows that there are no significant effects of TEA on blood flow of newly grafted coronary artery after CABG.
Anesthesia, Epidural ; Anesthesia, Intravenous ; Arteries* ; Catheters ; Coronary Artery Bypass ; Coronary Artery Disease ; Coronary Vessels* ; Fentanyl ; Flowmeters ; Humans ; Lidocaine* ; Mammary Arteries ; Midazolam ; Myocardial Ischemia ; Oxygen ; Radial Artery ; Saphenous Vein ; Tea ; Transplants* ; Vecuronium Bromide ; Weaning

PURPOSE: Acute aortic diseases, such as aortic dissection and aortic aneurysm, can be life-threatening vascular conditions. In this study, we compared outcomes before and after the implementation of a critical pathway (CP) for patients with acute aortic disease at the emergency department (ED). MATERIALS AND METHODS: This was a retrospective observational cohort study. The CP was composed of two phases: PRE-AORTA for early diagnosis and AORTA for prompt treatment. We compared patients who were diagnosed with acute aortic disease between pre-period (January 2010 to December 2011) and post-period (July 2012 to June 2014). RESULTS: Ninety-four and 104 patients were diagnosed with acute aortic disease in the pre- and post-periods, respectively. After the implementation of the CP, 38.7% of acute aortic disease cases were diagnosed via PRE-AORTA. The door-to-CT time was reduced more in PRE-AORTA-activated patients [71.0 (61.0, 115.0) min vs. 113.0 (56.0, 170.5) min; p=0.026]. During the post-period, more patients received emergency intervention than during the pre-period (22.3% vs. 36.5%; p=0.029). Time until emergency intervention was reduced in patients, who visited the ED directly, from 378.0 (302.0, 489.0) min in the pre-period to 200.0 (170.0, 299.0) min in the post-period (p=0.001). The number of patients who died in the ED declined from 11 to 4 from the pre-period to the post-period. Hospital mortality decreased from 26.6% to 14.4% in the post-period (p=0.033). CONCLUSION: After the implementation of a CP for patients with acute aortic disease, more patients received emergency intervention within a shorter time, resulting in improved hospital mortality.
Acute Disease ; Adult ; Aged ; Aneurysm, Dissecting/diagnosis/mortality/*surgery ; Aorta ; Aortic Aneurysm/diagnosis/mortality/*surgery ; Aortic Diseases/diagnosis/mortality/*surgery ; *Critical Pathways ; Emergency Service, Hospital/*organization & administration ; Female ; Hospital Mortality ; Humans ; Male ; Middle Aged ; Outcome and Process Assessment (Health Care) ; Postoperative Complications/mortality ; Republic of Korea/epidemiology ; Retrospective Studies ; Time Factors ; Treatment Outcome ; Vascular Surgical Procedures/*methods

PURPOSE: Among the survivors of a ST elevation myocardial infarction (STEMI), higher platelet volume indices (mean platelet volume, MPV; platelet distribution width, PDW) are associated with impaired reperfusion and ventricular dysfunction. This study examined the relationship between the platelet volume indices and 30-day mortality with STEMI patients who underwent primary percutaneous coronary intervention (PCI). METHODS: This retrospective cohort study included patients presenting to the emergency department with STEMI between January 2011 and May 2016. The platelet volume indices were measured serially, using an automatic hematology analyzer, from admission to 24 hours after admission. The prognostic value of MPV, PDW for the 30-day mortality was determined by Cox proportional hazards model analysis. RESULTS: A total of 608 STEMI patients, who underwent reperfusion, were enrolled in this study. According to the multivariable Cox proportional hazard model, higher MPV (hazard ratio [HR], 1.414; 95% confidence interval [CI], 1.024-1.953; p=0.035) and PDW (HR, 1.043; 95% CI, 1.006-1.083; p=0.024) values at time-24 (24 hours after admission) were significant risk factors for the 30-day mortality. A MPV value >8.6 fL (HR, 5.953; 95% CI, 2.973-11.918; p<0.001) and PDW value >56.1% (HR, 5.117; 95% CI, 2.640-9.918; p<0.001) at time-24 were associated with an increased risk of 30-day mortality. CONCLUSION: The platelet volume indices without an additional burden of cost or time, can be measured rapidly and simply. Higher MPV and PDW levels predict independently the 30-day mortality in patients with STEMI after PCI.
Blood Platelets* ; Cohort Studies ; Emergency Service, Hospital ; Hematology ; Humans ; Mean Platelet Volume ; Mortality* ; Myocardial Infarction* ; Percutaneous Coronary Intervention ; Platelet Activation ; Prognosis ; Proportional Hazards Models ; Reperfusion ; Retrospective Studies ; Risk Factors ; Survivors ; Ventricular Dysfunction

PURPOSE: Mechanical bowel obstruction (MBO) is a common emergency problem resulting in high morbidity and mortality. The delta neutrophil index (DNI), reflecting the fraction of circulating immature granulocytes, is associated with increased mortality in patients with infection and/or systemic inflammation. This study was conducted to investigate the relationship between DNI and 30-day mortality in patients with MBO. METHODS: We retrospectively identified consecutive patients (>18 years old) with MBO admitted to the emergency department from January 1, 2013 to April 30, 2015. The diagnosis of MBO was confirmed using clinical and radiological findings. The DNI was determined on each day of hospitalization. The outcome of interest was the 30-day mortality and the prognostic value of DNI for 30-day mortality was ascertained by Cox proportional hazards model analysis. RESULTS: A total of 518 patients with MBO were included in this study. According to multivariate Cox proportional hazard models, higher DNI at admission (hazard ratio [HR], 1.080; 95% confidence interval [CI], 1.036-1.126; p<0.001) was a strong independent predictor of short-term mortality. Among patients with MBO, a DNI >1.9% on admission (HR, 9.410; 95% CI, 2.671-33.145; p<0.001) was associated with increased 30-day mortality. Furthermore, the accuracy of DNI for predicting 30-day mortality was superior to that of other parameters. CONCLUSION: The DNI can be measured rapidly and simply on emergency department admission without additional cost or time burden. Increased DNI values are associated with 30-day mortality in patients with MBO.
Diagnosis ; Emergencies ; Emergency Service, Hospital ; Granulocytes ; Hospitalization ; Humans ; Inflammation ; Mortality* ; Neutrophils* ; Proportional Hazards Models ; Retrospective Studies

Objective: The early prediction of multiple organ dysfunction syndrome (MODS) in trauma patients and provision ofprompt treatment may improve their outcomes. We investigated the efficacy of the mean platelet volume (MPV) for predictingMODS in cases of severe trauma. Methods: This retrospective, observational cohort study was performed with patients prospectively integrated in a criticalpathway of TRAUMA. We analyzed the severe trauma patients admitted to the emergency department (ED), based onthe Advanced Trauma Life Support guideline, between January 1, 2011 and May 31, 2017. The outcomes were developedfrom MODS at least 48 hours after ED admission. Results: A total of 348 patients were enrolled. An increase in the MPV at 12 hours (odds ratio [OR], 2.611; P<0.001) wasa strong independent predictor of MODS development. The increasing predictability of MODS was closely associatedwith an MPV at 12 hours>8.6 fL (OR, 4.831; P<0.001). The area under the receiver operating characteristic curve(AUROC) value of the MPV at 12 hours (0.751; 95% confidence interval [CI], 0.687-0.818; P<0.01) was not inferior thanthat of Acute Physiology and Chronic Health Evaluation II score, injury severity score, lactate, and total CO2 for predictingMODS. Conclusion MPV was an independent predictor of MODS development in severe trauma patients. Emergency physicianscan use the MPV as an ancillary biomarker for predicting MODS.

OBJECTIVE: Only a few studies have examined the role of lactate reflecting on tissue hypoperfusion determining the severity of postpartum hemorrhage (PPH) patients in the emergency department (ED). This study evaluated the utility of the arterial lactate level as a prognostic marker of severity in PPH patients admitted to an ED. METHODS: This retrospective, observational cohort study was conducted on patients integrated prospectively in a critical pathway of SPEED (Severance Protocol to save postpartum bleeding through Expeditious care Delivery). Adult primary PPH patients admitted to the ED between July 1, 2010 and March 31, 2017 were analyzed. The outcomes were the development of severe PPH including death, hysterectomy, surgical treatment, and massive transfusion. RESULTS: A total of 112 patients were enrolled in this study. An increase in the arterial lactate value was a strong independent predictor of severe PPH. The increasing predictability of severe PPH was closely associated with an arterial lactate ≥3.15 mL/L at admission (odds ratio, 13.870; P < 0.001). CONCLUSION: Lactate is an independent predictor of severe PPH and is suitable for a rapid and simple estimation of the severity of PPH. Emergency physicians can use lactate to determine the initial treatment strategies more precisely.
Adult ; Cohort Studies ; Critical Pathways ; Emergencies ; Emergency Service, Hospital ; Hemorrhage ; Humans ; Hysterectomy ; Lactic Acid ; Postpartum Hemorrhage ; Postpartum Period ; Prognosis ; Prospective Studies ; Retrospective Studies

OBJECTIVE: The early prediction of acute kidney injury (AKI) in sepsis and the provision of prompt treatment may improve the outcomes. This study investigated the efficacy of the lactate/albumin ratio (LAR) in predicting severe AKI in cases of septic shock. METHODS: This retrospective, observational cohort study was performed on patients integrated prospectively in a critical pathway of early-goal-directed therapy (EGDT)/SEPSIS. Adult patients with septic shock, who were admitted to the emergency department with a normal kidney function or stage 1 disease based on the Acute Kidney Injury Network classification between January 1, 2014 and September 30, 2017, were analyzed. The outcomes were the development of sepsis-induced severe AKI within 7 days. RESULTS: A total of 343 patients were enrolled. An increase in the LAR value at admission (odds ratio [OR], 1.85; P=0.001) was a strong independent predictor of the development of severe AKI. The increasing predictability of AKI was closely associated with a L/A ratio≥0.794 at admission (OR, 14.66; P < 0.001). The area under the receiver operating characteristic curve value of the L/A ratio (0.821; 95% confidence interval [CI], 0.774–0.861; P < 0.01) was higher than that of lactate (0.795; 95% CI, 0.747–0.838; P < 0.01) for predicting severe AKI (P=0.032). CONCLUSION: L/A ratio was found to be an independent predictor of the development of severe AKI in septic shock. The prognostic performance of the L/A ratio for predicting AKI of critically ill sepsis patients was superior to that of lactate measurements.
Acute Kidney Injury ; Adult ; Albumins ; Classification ; Cohort Studies ; Critical Illness ; Critical Pathways ; Emergencies ; Emergency Service, Hospital ; Humans ; Kidney ; Lactic Acid ; Prognosis ; Prospective Studies ; Retrospective Studies ; ROC Curve ; Sepsis ; Shock, Septic

PURPOSE: We evaluated the blood urea nitrogen (BUN)/albumin (B/A) ratio in patients with acute cholangitis to determine the prognostic significance of the B/A ratio as a marker of early mortality in critically ill patients with acute cholangitis. METHODS: We retrospectively analyzed medical records in two emergency departments (ED) and screened eligible adult patients who were admitted to the ED with acute cholangitis. The B/A ratio was evaluated as the BUN value divided by albumin level on each hospital day. The clinical outcome was mortality after 28 days. RESULTS: A total of 461 patients with acute cholangitis were included in this study. Multivariate Cox proportional hazard models showed that higher B/A ratio on ED admission (day 1) (Hazard Ratio (HR): 1.182; 95% Confidence Interval (CI): 1.076-1.298, p<0.001) and day 4 (HR: 1.192; 95% CI: 1.019-1.395, p=0.028) were independent risk factors for mortality at 28 days. Our study showed that the increased 28-day mortality was associated with a B/A ratio >6.83 on day 1 (HR: 4.065; 95% CI: 4.123-43.737, p<0.001) and a higher B/A ratio (>6.26) on day 4 (HR: 7.16; 95% CI: 1.412-36.333, p=0.018) in patients with acute cholangitis. Conclusion: The ratio of BUN to albumin on ED admission is a promising prognostic marker of 28-day mortality in patients with acute cholangitis. CONCLUSION: The ratio of BUN to albumin on ED admission is a promising prognostic marker of 28-day mortality in patients with acute cholangitis.
Adult ; Albumins ; Blood Urea Nitrogen ; Cholangitis* ; Critical Illness ; Emergency Service, Hospital ; Humans ; Medical Records ; Mortality* ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors