NetWorks: SEALs help physicians, blood storage questions, more. . .
Clinical Research
The unrecognized battlefield in our hospitals: Lessons from the US Navy SEALs
Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. It is characterized by a vicious cycle of emotional exhaustion, detachment from others, and a feeling of decreased accomplishment. Severe BOS is seen in up to 45% of physicians and 33% of nurses who work in ICUs.1
BOS has far-reaching consequences, being associated with an alarmingly high prevalence of posttraumatic stress disorder (PTSD) and substance abuse, almost equivalent to that experienced by veterans returning from war.2 BOS also is associated with self-reported suboptimal patient care practices.3This crisis has long been underrecognized, but now that we have identified the problem, where does that leave us? There are currently no quality studies evaluating how to best treat and prevent BOS/PTSD in health-care professionals. Previous studies have focused on addressing organizational factors to alleviate job stressors, but the psychosocial characteristics of the individual have been largely ignored.
Our medical education has historically focused on an individual’s intelligence quotient (IQ), but developing an individual’s emotional quotient (EQ) is just as valuable. It has long been known that Navy SEALs have the lowest prevalence of PTSD among combat veterans due partially to their specific training in emotional resilience and adaptive psychosocial coping mechanisms.
For this reason, the research team at the University of Texas Health Science Center at San Antonio is collaborating with the US Navy SEAL team to design and validate a tool that teaches critical care staff resilience training similar to what their combat trainees undergo. The goal is to curb these alarming trends in BOS and create a paradigm shift in medical education within medical and nursing schools.
Bravein Amalakuhan, MD
Fellow-in-Training Member
References
1. Embriaco N, Azoulay E, Barrau K, et al. Am J Respir Crit Care Med. 2007;175(7):686.
2. Mealer ML, Shelton A, Berg B, et al. Am J Respir Crit Care Med. 2007;175(7):693.
3. Shanafelt TD, Bradley KA, Wipf JE, et al. Ann Intern Med. 2002;136(5):358.
Critical Care
End of the era for age of blood concerns?
Blood transfusions are common in critically ill patients, with two in five adults admitted to an ICU receiving a transfusion.1,2 Recently, randomized trials have found that more restrictive thresholds for transfusions are associated with improved outcomes.3,4 One theorized explanation for this somewhat counterintuitive association is that the prolonged storage time (i.e., the age of the blood being transfused) might affect outcomes.
There have been three recent publications that help to shed some more light on this. First, Lacroix et al.5 performed a multicenter randomized blinded trial in over 2,400 critically ill patients in 64 centers comparing new blood (mean storage (±SD) of 6.1±4.9 days) vs old blood with storage of 22.0±8.4 days (P less than .001). There was no statistically significant difference in 90-day mortality.5
The second study is a meta-analysis by Alexander et al.6 The investigators looked at 12 trials and 5,229 patients and compared “fresh blood” or blood stored for 3-10 days to “older blood” stored for longer durations. They found that there was no difference in mortality and no difference in adverse events, such as acute transfusion reactions, when comparing the two groups.
Lastly, Heddle et al.7 conducted a randomized trial that compared outcomes in 20,858 hospitalized patients transfused with fresh blood (mean storage time 13.0±7.6 days) to older blood (mean storage time 23.6±8.9 days). They found no differences in mortality when comparing those transfused with fresh vs. old blood (8.7% vs. 9.1%). In addition, there was no difference when examining the predetermined subgroups, including those undergoing cardiovascular surgery, those with cancer, and those admitted to the ICU.
So, is this the end of an era for health-care provider concern about how long blood can be stored to be safe for ICU patients? Possibly.
There may still be high-risk populations (such as patients receiving massive transfusions) for which age of the blood does matter. In addition, it is still unclear based on the present data as to whether blood stored between 35 and 42 days has any significant inherent risk.
However, these publications among others suggest that the age of transfused blood may not matter, even in critically ill patients. Therefore, the present storage practices of many blood banks around the United States and beyond are validated by the present publications regarding the scarce resource of blood.
Christopher L. Carroll, MD, MS, FCCP
Steering Committee Member
Steven Greenberg, MD, FCCP
Steering Committee Member
References
1. Corwin HL, Gettinger A, Pearl RG, et al. Crit Care Med. 2004;32(1):39.
2. Vincent JL, Baron JF, Reinhart K, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. JAMA. 2002;288(12):1499.
3. Holst LB, Haase N, Wetterslev J, et al.; TRISS Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2014;371(15):1381.
4. Lacroix J, Hebert PC, Hutchison JS, et al.; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. N Engl J Med. 2007;356(16):1609.
5. Lacroix J, Hebert P, Fergusson DA, et al. N Engl J Med. 2015;372:1410.
6. Alexander PE, Barty R, Fei Y, et al. Blood. 2016;127(4):400.
7. Heddle NM, Cook RJ, Arnold DM, et al. N Engl J Med. 2016;375(2):1937.
