Red Blood Cell Transfusion Practices in the Neurointensive Care Unit: A Narrative Review

Abstract

Anemia is common in neurointensive care unit (NICU) patients and is one of the common causes of systemic insults to the brain. Though the recent literature favors restrictive blood transfusion practices over liberal transfusion to correct anemia in the general ICU, whether a similar practice can be adopted in NICU patients is doubtful due to lack of strong evidence. Impairment of cerebral autoregulation and cardiac function following acute brain injury affects the body's compensatory mechanism to anemia and renders the brain susceptible to anemic hypoxia at different hemoglobin (Hb) thresholds. Hence, red blood cell transfusion (RBCT) practice based on a single Hb threshold value might be inappropriate. On the other hand, allogenic RBCT has its own risks, both in short and in long run, leading to adverse outcomes. Thus, instead of relying only on arbitrary Hb values, a better way to decide the need for RBCT in NICU patients is to target parameters based on systemic and regional cerebral oxygenation. This approach will help us to individualize RBCT practices. In this narrative review, based on the available literature, authors have discussed the impact of anemia and blood transfusion on the immediate and late neurological outcomes and the current role of regional brain monitoring in guiding blood transfusion practices. In the end, authors have tried to update on the current RBCT practices in neurosurgical and neuromedical patients admitted to the NICU.

Keywords

red blood cell transfusion - neurointensive care unit - anemia - acute brain injury

• References

• 1 Hébert PC, Wells G, Blajchman MA. et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340 (06) 409-417
• 2 Lacroix J, Hébert PC, Hutchison JS. et al; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356 (16) 1609-1619
• 3 Holst LB, Haase N, Wetterslev J. et al; TRISS Trial Group; Scandinavian Critical Care Trials Group. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014; 371 (15) 1381-1391
• 4 Carson JL, Stanworth SJ, Roubinian N. et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10: CD002042
• 5 Carson JL, Guyatt G, Heddle NM. et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA 2016; 316 (19) 2025-2035
• 6 Allport LE, Parsons MW, Butcher KS. et al. Elevated hematocrit is associated with reduced reperfusion and tissue survival in acute stroke. Neurology 2005; 65 (09) 1382-1387
• 7 Kimberly WT, Wu O, Arsava EM. et al. Lower hemoglobin correlates with larger stroke volumes in acute ischemic stroke. Cerebrovasc Dis Extra 2011; 1 (01) 44-53
• 8 Kramer AH, Zygun DA, Bleck TP, Dumont AS, Kassell NF, Nathan B. Relationship between hemoglobin concentrations and outcomes across subgroups of patients with aneurysmal sub-arachnoid hemorrhage. Neurocrit Care 2009; 10 (02) 157-165
• 9 Sekhon MS, McLean N, Henderson WR, Chittock DR, Griesdale DE. Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic brain injury. Crit Care 2012; 16 (04) R128
• 10 Yang CJ, Hsiao KY, Su IC, Chen IC. The association between anemia and the mortality of severe traumatic brain injury in emergency department. J Trauma 2011; 71 (06) E132-E135
• 11 Litofsky NS, Martin S, Diaz J. et al. The negative impact of anemia in outcome from traumatic brain injury. World Neurosurg 2016; 90: 82-90
• 12 Kramer AH, Gurka MJ, Nathan B, Dumont AS, Kassell NF, Bleck TP. Complications associated with anemia and blood transfusion in patients with aneurysmal subarachnoid hemorrhage. Crit Care Med 2008; 36 (07) 2070-2075
• 13 English SW, Chassé M, Turgeon AF. et al; Canadian Critical Care Trials Group. Anemia prevalence and incidence and red blood cell transfusion practices in aneurysmal subarachnoid hemorrhage: results of a multicenter cohort study. Crit Care 2018; 22 (01) 169
• 14 Boutin A, Moore L, Lauzier F. et al. Transfusion of red blood cells in patients with traumatic brain injuries admitted to Canadian trauma health centres: a multicentre cohort study. BMJ Open 2017; 7 (03) e014472
• 15 Hemoglobin concentrations for the diagnosis of anemia and assessment of severity. vitamin and mineral nutrition information system. Geneva, Switzerland: World Health Organization; 2011. (WHO/NMH/NHD/MNM/11.1). Available at: http://apps.who.int/iris/bitstream/10665/85839/3/WHO_NMH_NHD_MNM_11.1_eng.pdf?ua=1 Accessed December 25, 2018
• 16 Lelubre C, Bouzat P, Crippa IA, Taccone FS. Anemia management after acute brain injury. Crit Care 2016; 20 (01) 152
• 17 Gupta G, Wadhwa C, Garg R, Dhaiya RS, Kaushal RK. Impact of coagulation profile on outcome of head injury. J Clin Diagn Res 2016; 10 (01) PC04-PC06
• 18 Sahuquillo J, Munar F, Baguena M, Poca MA, Pedraza S, Rodríguez-Baeza A. Evaluation of cerebrovascular CO₂-reactivity and autoregulation in patients with post-traumatic diffuse brain swelling (diffuse injury III). Acta Neurochir Suppl (Wien) 1998; 71: 233-236
• 19 Sahoo S, Sheshadri V, Sriganesh K, Madhsudana Reddy KR, Radhakrishnan M, Umamaheswara Rao GS. Effect of hyperoxia on cerebral blood flow velocity and regional oxygen saturation in patients operated on for severe traumatic brain injury – the influence of cerebral blood flow autoregulation. World Neurosurg 2017; 98: 211-216
• 20 Taccone FS, Citerio G. Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring. Advanced monitoring of systemic hemodynamics in critically ill patients with acute brain injury. Neurocrit Care 2014; 21 (Suppl. 02) S38-S63
• 21 Madjdpour C, Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth 2005; 95 (01) 33-42
• 22 Chau JK, Harris JR, Seikaly HR. Transfusion as a predictor of recurrence and survival in head and neck cancer surgery patients. J Otolaryngol Head Neck Surg 2010; 39 (05) 516-522
• 23 Leal-Noval SR, Rincón-Ferrari MD, Marin-Niebla A. et al. Transfusion of erythrocyte concentrates produces a variable increment on cerebral oxygenation in patients with severe traumatic brain injury: a preliminary study. Intensive Care Med 2006; 32 (11) 1733-1740
• 24 Zygun DA, Nortje J, Hutchinson PJ, Timofeev I, Menon DK, Gupta AK. The effect of red blood cell transfusion on cerebral oxygenation and metabolism after severe traumatic brain injury. Crit Care Med 2009; 37 (03) 1074-1078
• 25 Surve RM, Muthuchellappan R, Rao GS, Philip M. The effect of blood transfusion on central venous oxygen saturation in critically ill patients admitted to a neurointensive care unit. Transfus Med 2016; 26 (05) 343-348
• 26 Muthuchellappan R, Shaikh NA, Surve RM, Ganne URS, Philip M. Regional cerebral tissue oxygen saturation changes following blood transfusion in neuro-intensive care unit patients—a pilot observational study. Transfus Med 2018; 28: 304-309
• 27 Leal-Noval SR, Arellano-Orden V, Muñoz-Gómez M. et al. Red blood cell transfusion guided by near infrared spectroscopy in neurocritically ill patients with moderate or severe anemia: a randomized, controlled trial. J Neurotrauma 2017; 34 (17) 2553-2559
• 28 Napolitano LM, Kurek S, Luchette FA. et al; EAST Practice Management Workgroup; American College of Critical Care Medicine (ACCM) Taskforce of the Society of Critical Care Medicine (SCCM). Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. J Trauma 2009; 67 (06) 1439-1442
• 29 Patient blood management guidelines. Lyneham, ACT: National Blood Authority Australia; 2012 Available at: http://www.blood.gov.au/pbm-guidelines Accessed November 14, 2018
• 30 Retter A, Wyncoll D, Pearse R. et al; British Committee for Standards in Haematology. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol 2013; 160 (04) 445-464
• 31 Klein AA, Arnold P, Bingham RM. et al. Association of Anaesthetists of Great Britain and Ireland. AAGBI guidelines: the use of blood components and their alternatives. Anaesthesia 2016; 71: 829-842
• 32 Tasker RC, Turgeon AF, Spinella PC. Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI); Pediatric Critical Care Blood Research Network (BloodNet), and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Recommendations on RBC transfusion in critically ill children with acute brain injury from paediatric critical care transfusion and anaemia expertise initiative. Pediatr Crit Care Med 2018; 19 9S (Suppl. 01) S133-S136
• 33 Huijben JA, Volovici V, Cnossen MC. et al; CENTER-TBI investigators and participants. Variation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Crit Care 2018; 22 (01) 90
• 34 Badenes R, Oddo M, Suarez JI. et al. Hemoglobin concentrations and RBC transfusion thresholds in patients with acute brain injury: an international survey. Crit Care 2017; 21 (01) 159
• 35 Bouma GJ, Muizelaar JP, Stringer WA, Choi SC, Fatouros P, Young HF. Ultra-early evaluation of regional cerebral blood flow in severely head-injured patients using xenon-enhanced computerized tomography. J Neurosurg 1992; 77 (03) 360-368
• 36 Lee JH, Kelly DF, Oertel M. et al. Carbon dioxide reactivity, pressure autoregulation, and metabolic suppression reactivity after head injury: a transcranial Doppler study. J Neurosurg 2001; 95 (02) 222-232
• 37 Steyerberg EW, Mushkudiani N, Perel P. et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 2008; 5 (08) e165 discussion e165
• 38 Van Beek JG, Mushkudiani NA, Steyerberg EW. et al. Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007; 24 (02) 315-328
• 39 Griesdale DE, Sekhon MS, Menon DK. et al. Hemoglobin area and time index above 90 g/L are associated with improved 6-month functional outcomes in patients with severe traumatic brain injury. Neurocrit Care 2015; 23 (01) 78-84
• 40 Salim A, Hadjizacharia P, DuBose J. et al. Role of anemia in traumatic brain injury. J Am Coll Surg 2008; 207 (03) 398-406
• 41 Al-Dorzi HM, Al-Humaid W, Tamim HM. et al. Anemia and blood transfusion in patients with isolated traumatic brain injury. Crit Care Res Pract 2015; 2015: 1-7
• 42 Elterman J, Brasel K, Brown S. et al; Resuscitation Outcomes Consortium Investigators. Transfusion of red blood cells in patients with a prehospital Glasgow coma scale score of 8 or less and no evidence of shock is associated with worse outcomes. J Trauma Acute Care Surg 2013; 75 (01) 8-14 discussion 14
• 43 East JM, Viau-Lapointe J, McCredie VA. Transfusion practices in traumatic brain injury. Curr Opin Anaesthesiol 2018; 31 (02) 219-226
• 44 George ME, Skarda DE, Watts CR, Pham HD, Beilman GJ. Aggressive red blood cell transfusion: no association with improved outcomes for victims of isolated traumatic brain injury. Neurocrit Care 2008; 8 (03) 337-343
• 45 Robertson CS, Hannay HJ, Yamal JM. et al; Epo Severe TBI Trial Investigators. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA 2014; 312 (01) 36-47
• 46 Warner MA, O'Keeffe T, Bhavsar P. et al. Transfusions and long-term functional outcomes in traumatic brain injury. J Neurosurg 2010; 113 (03) 539-546
• 47 Leal-Noval SR, Muñoz-Serrano Á, Arellano-Orden V. et al. Effects of red blood cell transfusion on long-term disability of patients with traumatic brain injury. Neurocrit Care 2016; 24 (03) 371-380
• 48 McCredie VA, Piva S, Santos M. et al. The impact of red blood cell transfusion on cerebral tissue oxygen saturation in severe traumatic brain injury. Neurocrit Care 2017; 26 (02) 247-255
• 49 Oddo M, Levine JM, Kumar M. et al. Anemia and brain oxygen after severe traumatic brain injury. Intensive Care Med 2012; 38 (09) 1497-1504
• 50 Yamal JM, Rubin ML, Benoit JS. et al. Effect of hemoglobin transfusion threshold on cerebral hemodynamics and oxygenation. J Neurotrauma 2015; 32 (16) 1239-1245
• 51 Sekhon MS, Griesdale DE, Czosnyka M. et al. The effect of red blood cell transfusion on cerebral autoregulation in patients with severe traumatic brain injury. Neurocrit Care 2015; 23 (02) 210-216
• 52 Timofeev I, Carpenter KL, Nortje J. et al. Cerebral extracellular chemistry and outcome following traumatic brain injury: a microdialysis study of 223 patients. Brain 2011; 134 (Pt 2) 484-494
• 53 Hutchinson PJ, Jalloh I, Helmy A. et al. Consensus statement from the 2014 International Microdialysis Forum. Intensive Care Med 2015; 41 (09) 1517-1528
• 54 Bell DL, Kimberly WT, Yoo AJ. et al. Low neurologic intensive care unit hemoglobin as a predictor for intra-arterial vasospasm therapy and poor discharge modified Rankin scale in aneurysmal subarachnoid haemorrhage-induced cerebral vasospasm. J Neurointerv Surg 2015; 7 (06) 438-442
• 55 Ayling OGS, Ibrahim GM, Alotaibi NM, Gooderham PA, Macdonald RL. Anemia after aneurysmal subarachnoid hemorrhage is associated with poor outcome and death. Stroke 2018; 49 (08) 1859-1865
• 56 Stein M, Brokmeier L, Herrmann J. et al. Mean hemoglobin concentration after acute subarachnoid hemorrhage and the relation to outcome, mortality, vasospasm, and brain infarction. J Clin Neurosci 2015; 22 (03) 530-534
• 57 Smith MJ, Le Roux PD, Elliott JP, Winn HR. Blood transfusion and increased risk for vasospasm and poor outcome after sub-arachnoid hemorrhage. J Neurosurg 2004; 101 (01) 1-7
• 58 Kumar MA, Boland TA, Baiou M. et al. Red blood cell transfusion increases the risk of thrombotic events in patients with subarachnoid hemorrhage. Neurocrit Care 2014; 20 (01) 84-90
• 59 Festic E, Rabinstein AA, Freeman WD. et al. Blood transfusion is an important predictor of hospital mortality among patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2013; 18 (02) 209-215
• 60 Kumar MA, Levine J, Faerber J. et al. The effects of red blood cell transfusion on functional outcome after aneurysmal sub-arachnoid hemorrhage. World Neurosurg 2017; 108: 807-816
• 61 Oddo M, Milby A, Chen I. et al. Hemoglobin concentration and cerebral metabolism in patients with aneurysmal subarachnoid hemorrhage. Stroke 2009; 40 (04) 1275-1281
• 62 Kurtz P, Schmidt JM, Claassen J. et al. Anemia is associated with metabolic distress and brain tissue hypoxia after subarachnoid hemorrhage. Neurocrit Care 2010; 13 (01) 10-16
• 63 Kurtz P, Helbok R, Claassen J. et al. The effect of packed red blood cell transfusion on cerebral oxygenation and metabolism after subarachnoid hemorrhage. Neurocrit Care 2016; 24 (01) 118-121
• 64 Dhar R, Zazulia AR, Videen TO, Zipfel GJ, Derdeyn CP, Diringer MN. Red blood cell transfusion increases cerebral oxygen delivery in anemic patients with subarachnoid hemorrhage. Stroke 2009; 40 (09) 3039-3044
• 65 Dhar R, Zazulia AR, Derdeyn CP, Diringer MN. RBC transfusion improves cerebral oxygen delivery in subarachnoid hemorrhage. Crit Care Med 2017; 45 (04) 653-659
• 66 Naidech AM, Bendok BR, Ault ML, Bleck TP. Monitoring with the Somanetics INVOS 5100C after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2008; 9 (03) 326-331
• 67 Diringer MN, Bleck TP, Claude Hemphill III J. et al; Neurocritical Care Society. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15 (02) 211-240
• 68 Tanne D, Molshatzki N, Merzeliak O, Tsabari R, Toashi M, Schwammenthal Y. Anemia status, hemoglobin concentration and outcome after acute stroke: a cohort study. BMC Neurol 2010; 10: 22
• 69 Kellert L, Herweh C, Sykora M. et al. Loss of penumbra by impaired oxygen supply? Decreasing hemoglobin levels predict infarct growth after acute ischemic stroke: Stroke: Relevant Impact of Hemoglobin, Hematocrit and Transfusion (STRAIGHT)—an observational study. Cerebrovasc Dis Extra 2012; 2 (01) 99-107
• 70 Barlas RS, Honney K, Loke YK. et al. Impact of hemoglobin levels and anemia on mortality in acute stroke: analysis of UK Regional Registry Data, Systematic Review, and Meta-Analysis. J Am Heart Assoc 2016; 5 (08) e003019
• 71 Bhatia RS, Garg RK, Gaur SP. et al. Predictive value of routine hematological and biochemical parameters on 30-day fatality in acute stroke. Neurol India 2004; 52 (02) 220-223
• 72 Kellert L, Schrader F, Ringleb P, Steiner T, Bösel J. The impact of low hemoglobin levels and transfusion on critical care patients with severe ischemic stroke: STroke: RelevAnt Impact of HemoGlobin, Hematocrit and Transfusion (STRAIGHT)—an observational study. J Crit Care 2014; 29 (02) 236-240
• 73 Sharma K, Johnson DJ, Johnson B, Frank SM, Stevens RD. Hemoglobin concentration does not impact 3-month outcome following acute ischemic stroke. BMC Neurol 2018; 18 (01) 78
• 74 Ke Z, Zhao Y, Wang C, Cai Z. The alliance with expanding blood volume and correcting anemia is an effective therapeutic measure for the adult anemia patients of acute cerebral infarction. Int J Neurosci 2018; 128 (05) 429-434
• 75 Dexter F, Hindman BJ. Effect of haemoglobin concentration on brain oxygenation in focal stroke: a mathematical modelling study. Br J Anaesth 1997; 79 (03) 346-351
• 76 Kumar MA, Rost NS, Snider RW. et al. Anemia and hematoma volume in acute intracerebral hemorrhage. Crit Care Med 2009; 37 (04) 1442-1447
• 77 Sheth KN, Gilson AJ, Chang Y. et al. Packed red blood cell transfusion and decreased mortality in intracerebral hemorrhage. Neurosurgery 2011; 68 (05) 1286-1292
• 78 Petrikov SS, Titova IuV, Solodov AA, Guseĭnova KhT, Krylov VV. Effect of hemotransfusion on brain oxygenation and metabolism in patients with intracranial hemorrhages [in Russian]. Anesteziol Reanimatol 2009; 5 (05) 32-35
• 79 Javed I, Sultan T, Rehman ZU, Yaseen MR. Clinical spectrum and outcome of cerebral venous sinus thrombosis in children. J Coll Physicians Surg Pak 2018; 28 (05) 390-393
• 80 Liu K, Song B, Gao Y. et al. Long-term outcomes in patients with anemia and cerebral venous thrombosis. Neurocrit Care 2018; 29 (03) 463-468
• 81 Alan N, Seicean A, Seicean S, Neuhauser D, Weil RJ. Impact of preoperative anemia on outcomes in patients undergoing elective cranial surgery. J Neurosurg 2014; 120 (03) 764-772
• 82 Ali Z, Hassan N, Mehdi S, Shah MA, Bijli AH, Khan T. A review of the blood transfusion practices in neuroanesthesia in the perioperative period in a tertiary care hospital. Int J Res Med Sci 2017; 5 (05) 1858-1861
• 83 Vassal O, Desgranges FP, Tosetti S. et al. Risk factors for intraoperative allogeneic blood transfusion during craniotomy for brain tumor removal in children. Paediatr Anaesth 2016; 26 (02) 199-206
• 84 Kisilevsky A, Gelb AW, Bustillo M, Flexman AM. Anaemia and red blood cell transfusion in intracranial neurosurgery: a comprehensive review. Br J Anaesth 2018; 120 (05) 988-998
• 85 Le Roux PD, Elliott JP, Winn HR. Blood transfusion during aneurysm surgery. Neurosurgery 2001; 49 (05) 1068-1074 discussion 1074–1075
• 86 Bhatnagar S, Udaya IB, Umamaheswara RaoGS. An audit of blood transfusion In elective neuro-surgery. Indian J Anaesth 2007; 51 (03) 200-204
• 87 Cha CW, Deible C, Muzzonigro T, Lopez-Plaza I, Vogt M, Kang JD. Allogeneic transfusion requirements after autologous donations in posterior lumbar surgeries. Spine 2002; 27 (01) 99-104
• 88 Brecknell JE, McLean CA, Hirano H, Malham GM. Disseminated intravascular coagulation complicating resection of a malignant meningioma. Br J Neurosurg 2006; 20 (04) 239-241
• 89 Eom KS, Kim JM, Kim TY. Disseminated intravascular coagulation in a patient undergoing removal of metastatic brain tumor. J Korean Neurosurg Soc 2008; 44 (05) 341-344
• 90 Atzil S, Arad M, Glasner A. et al. Blood transfusion promotes cancer progression: a critical role for aged erythrocytes. Anesthesiology 2008; 109 (06) 989-997
• 91 Kudo H, Fujita H, Hanada Y, Hayami H, Kondoh T, Kohmura E. Cytological and bacteriological studies of intraoperative autologous blood in neurosurgery. Surg Neurol 2004; 62 (03) 195-199 discussion 199–200
• 92 Patil H, Garg N, Navakar D, Banabokade L. Clinical experience of autologous blood transfusion in neurosurgery: prospective study in central India. World Neurosurg 2018; 115: e539-e543
• 93 Awada WN, Mohmoued MF, Radwan TM, Hussien GZ, Elkady HW. Continuous and noninvasive hemoglobin monitoring reduces red blood cell transfusion during neurosurgery: a prospective cohort study. J Clin Monit Comput 2015; 29 (06) 733-740
• 94 Oppitz PP, Stefani MA. Acute normovolemic hemodilution is safe in neurosurgery. World Neurosurg 2013; 79 (05) [phone]
• 95 McGirr A, Pavenski K, Sharma B, Cusimano MD. Blood conservation in neurosurgery: erythropoietin and autologous donation. Can J Neurol Sci 2014; 41 (05) 583-589
• 96 Hooda B, Chouhan RS, Rath GP, Bithal PK, Suri A, Lamsal R. Effect of tranexamic acid on intraoperative blood loss and transfusion requirements in patients undergoing excision of intracranial meningioma. J Clin Neurosci 2017; 41: 132-138
• 97 Hirsch GH, Menard MR, Anton HA. Anemia after traumatic spinal cord injury. Arch Phys Med Rehabil 1991; 72 (03) 195-201
• 98 Frisbie JH. Anemia and hypoalbuminemia of chronic spinal cord injury: prevalence and prognostic significance. Spinal Cord 2010; 48 (07) 566-569
• 99 Purvis TE, Goodwin CR, De la Garza-Ramos R. et al. Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients. Spine J 2017; 17 (09) 1255-1263
• 100 Epstein NE. Perioperative visual loss following prone spinal surgery: a review. Surg Neurol Int 2016; 7 (Suppl. 13) S347-S360
• 101 Neunhoeffer F, Hofbeck M, Schuhmann MU. et al. Cerebral oxygen metabolism before and after RBC transfusion in infants following major surgical procedures. Pediatr Crit Care Med 2018; 19 (04) 318-327
• 102 Mann SA, Williams III LA, Marques MB, Pham HP. Hospital-acquired anemia due to diagnostic and therapy-related blood loss in inpatients with myasthenia gravis receiving therapeutic plasma exchange. J Clin Apher 2018; 33 (01) 14-20
• 103 Zareifar S, Hosseinzadeh HR, Cohan N. Association between iron status and febrile seizures in children. Seizure 2012; 21 (08) 603-605