SYSTEMS PLUS COLLEGE FOUNDATION Balibago, Angeles City College Of Nursing A.Y.

2012-2013

In Partial Fulfillment Of the Requirements in NCM 106-RLE

Current Trends in Management

of
Diabetes Mellitus
Submitted To: Jessica C. Sanchez, RN, MAN

Submitted By: Ma. Cresencia S. Buenafe NUR70A

Date Of Submission: August 16, 2013

Diabetes Management- Future Trends June 2, 2013 12:01:15 AM | By DR. SHASHANK R JOSHI Free Press Journal Research in the diabetes field has taken two main directions: innovations aimed at improving current management methods, and exploring radical new approaches, writes DR. SHASHANK R JOSHI. There has been a considerable rise in prevalence of Diabetes across the world. As per the world health statistics 2012, one in every 10 adults is diabetic with figure increasingly rising among the youth due to unhealthy lifestyle and lack of exercise in their daily routine.The rising trend of weight gain coupled with lack of physical exercise and high level of mental stress in school going children acts as a precursor of future diabetes in them at a younger age particularly in those children who also have a family history of diabetes.

More than 346 million people worldwide are currently suffering from diabetes; and this malady is predicted to become the seventh leading cause of death in the world by the year 2030. Unfortunately, India has one of the largest number of diabetic patients in the world (62.4 million people live with diabetes in India & there are 77.2 million people with pre-diabetes). Currently India is facing an epidemic of diabetes, with a high prevalence in urban areas. The need to better manage and control the rapid rise of diabetes has led to innovations in diabetes monitoring and management therapies to help patients and physicians to better manage the chronic disease with more scientific and accurate results. People with type 1 diabetes and many people with type 2 disease require treatment with insulin to control blood sugar and reduce the risks of complications, including blindness, heart disease and nerve damage

leading to amputations. The main aim of treatment of diabetes is to achieve blood glucose in order to prevent acute and chronic complications, improve quality of life and avoid premature diabetes associated deaths. Research in the diabetes field has taken two main directions: innovations aimed at improving current management methods, and exploring radical new approaches. Improvements in current therapy include making glucose monitoring and insulin delivery less invasive and more patient-friendly, and many significant advances have been made in this context in the past two decades. Among these have been the developments of improved glucose monitoring techniques and minimallyinvasive techniques for sampling blood. New, fast-acting forms of insulin have also been introduced along with novel, and more accurate, ways of insulin delivery through the use of insulin pumps. There has also been considerable research in non-injection dosage forms for insulin, such as inhalable insulin, although products are not approved and pending more clinical data.Once approved, this could herald a new era in Insulin Therapy. Recent Trends in Diabetes Monitoring and Diagnosis: Blood sugar of a person without diabetes is maintained by the body within a normal range irrespective of the amount of food that is consumed by a person. In patients having diabetes, blood sugar spikes within an hour after any meal. This process goes on throughout the day. So the blood sugar of a person with diabetes is continuously changing every minute of the day throughout the persons life. Patients may use glucometers to check blood sugar, but this gives the value of blood sugar only at the particular time when the test is done. However, since blood sugar levels of a patient are changing from minute to minute, checking simply with Blood Glucose Meters may not be sufficient However a more effective way to monitor sugar levels to understand how the blood sugar is changing throughout the day is with the help of a technology called Continuous Glucose Monitoring System (CGMS), which is now also available in India. CGMS is done with the monitor (like ipro 2 etc.) which is attached to the abdominal wall. It reads the sugar levels of the person every 10 seconds and keeps a record every five minutes so that we can get 288 readings per day during the CGMS study period. This data is uploaded on a computer and the data is clearly visible in the form of a graph which any one can understand. The patient gets to see how his or her blood sugar has moved after each and every meal of the day. This gives the person a clear idea as to how much the blood sugar has risen after a particular meal. The patient can then take corrective measures regarding food intake. The doctor can make out how a particular patients blood sugar is changing throughout the day. With this information the doctor can modify the treatment to get better control of blood sugar throughout the day. HbA1c (Glycosylated Hemoglobin) is a very useful test to detect how well blood sugar is controlled over the previous three months. HbA1c indicates the average blood sugar and so it does not give a correct picture of how much fluctuation occur. In fact, if a patient has frequent low blood sugar, it could result in low HbA1c (because HbA1c denotes an average value) and a false sense of security to the patient and doctor, even when the blood sugar is often high and is actually poorly controlled. CGMS is a useful tool to detect this disease.

Another new upcoming diabetes monitoring approach is the use of Implantable Chips. A microchip can detect the amount of glucose in a persons blood and will then transmit this information to a wireless scanner where it can be easily read by the patient. All it will require are some basic instructions, and monitoring ones own glucose level with this product will be simple and accurate. This innovative little device serves as an alternate for the aid of glucose monitoring. Recent Trends in Diabetes Management: Insulin therapy is one of the cornerstones of diabetes management, and its efficacy in early and in late-stage diabetes is well-established. Yet, the first choice of doctors in India for most diabetics has so far been to attempt sugar control through OADs (Oral AntiDiabetics), diet control, exercise and lifestyle changes. One of the key reasons for delaying control through insulin is the resistance and fear in patients, of taking injections daily, particularly selfadministering the same. For Type 1 Diabetes where insulin is required to manage the condition, the traditional diabetes management is done by delivering insulin through Multiple Daily Injection (MDI) through devices such as Insulin pens and Insulin Injections are also available for self-management for Diabetes in India. An excellent alternative to multiple daily injections is Insulin Pump Therapy. By using an insulin pump, patients can match their insulin to their lifestyle rather than trying to adjust their lifestyle to their bodys response to insulin injections. People of all ages, who require insulin to manage their diabetes, can get benefit from this novel therapy.

Reaction and Recommendations When it comes to type 2 diabetes, the most common type of diabetes prevention is a big deal. It's especially important to make diabetes prevention a priority if you're at increased risk of diabetes, for example, if you're overweight or have a family history of the disease. Diabetes prevention is as basic as eating more healthfully, becoming more physically active and losing a few extra pounds and it's never too late to start. Making a few simple changes in your lifestyle now may help you avoid the serious health complications of diabetes down the road, such as nerve, kidney and heart damage. I recommend people with DM should get more physical activity. There are many benefits to regular physical activity. Exercise can help you lose weight, lower your blood sugar and boost your sensitivity to insulin, which helps keep your blood sugar within a normal range Research shows that both aerobic exercise and resistance training can help control diabetes, but the greater benefit comes from a fitness program that includes both. Another would be to get plenty of fiber, it's rough, it's tough but it may help you to reduce your risk of diabetes by improving your blood sugar control and lower your risk of heart disease and promote weight loss by helping you feel full. Foods high in fiber include fruits, vegetables, beans, whole grains, nuts and seeds. I also recommend going for whole grains. Although it's not clear why, whole grains may reduce your risk of diabetes and help maintain blood sugar levels. Try to make at least half your grains whole grains. Many foods made from whole grains come ready to eat, including various breads, pasta products and many cereals. Look for the word "whole" on the package and among the first few items in the ingredient list. You may also have to lose extra weight. If you're overweight, diabetes prevention may hinge on weight loss. Every pound you lose can improve your health, and you may be surprised by how much. Participants in one large study who lost a modest amount of weight around 7 percent of initial body weight and exercise regularly reduced the risk of developing diabetes by almost 60 percent. And lastly, I recommend skipping fad diets and just making healthier choices. Low-carb diets, the glycemic index diet or other fad diets may help you lose weight at first, but their effectiveness at preventing diabetes isn't known nor is their long-term effects. And by excluding

or strictly limiting a particular food group, you may be giving up essential nutrients. Instead, think variety and portion control as part of an overall healthy-eating plan.
You also have to share your concerns about diabetes prevention with your doctor. He or she will applaud your efforts to keep diabetes at bay, and perhaps offer additional suggestions based on your medical history or other factors.

SYSTEMS PLUS COLLEGE FOUNDATION Balibago, Angeles City College Of Nursing A.Y. 2012-2013

In Partial Fulfillment Of the Requirements in NCM 106-RLE

Journal about Anemia

and
Blood Transfusion
Submitted To: Jessica C. Sanchez, RN, MAN

Submitted By: Ma. Cresencia S. Buenafe NUR70A

Date Of Submission: August 16, 2013

Anemia and Blood Transfusions in Critically Ill Patients

M. Kamran Athar, Nitin Puri, and David R. Gerber
1 1 2 3,4,5

Division of Neurocritical Care, Hospital of the University of Pennsylvania, 3 West Gates Building, Philadelphia, PA Inova Health System, Falls Church, VA 22042, USA Edward D Viner Intensive Care Unit, Cooper University Hospital Camden, Camden, NJ 08103, USA Cooper Medical School of Rowan University, Camden, NJ, USA Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Camden, NJ, USA

19104, USA
2 3 4 5

Received 28 May 2012; Revised 11 September 2012; Accepted 30 September 2012 Academic Editor: Franz F. Wagner Copyright 2012 M. Kamran Athar et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Anemia is common in critically ill patients. As a consequence packed red blood cell (PRBC) transfusions are frequent in the critically ill. Over the past two decades a growing body of literature has emerged, linking PRBC transfusion to infections, immunosuppression, organ dysfunction, and a higher mortality rate. However, despite growing evidence that risk of PRBC transfusion outweighs its benefit, significant numbers of critically ill patients still receive PRBC transfusion during their intensive care unit (ICU) stay. In this paper, we summarize the current literature concerning the impact of anemia on outcomes in critically ill patients and the potential complications of PRBC transfusions. 1. Introduction Anemia is a commonly encountered clinical problem in the critically ill [1]. Ninety-five percent of critically ill patients who stay in the intensive care unit (ICU) for 72 hours or greater suffer from anemia and approximately 40% of them receive packed red blood cell (PRBC) transfusions [2, 3]. In 2001, nearly 14 million units of packed red blood cells were transfused, but the physiologic basis for transfusion in the critically ill is not without controversy [4]. In the last two decades transfusion practices have become more restrictive likely in response to prospective research. 2. Mechanisms/Etiologies of Anemia in Critically Ill Patients The etiology of anemia in critical illness is multifactorial and complex. Repeated phlebotomies, gastrointestinal blood loss, and other surgical procedures contribute significantly to the development of anemia [5, 6]. Other factors involved in pathogenesis include coagulopathies, pathogen-associated hemolysis, hypoadrenalism, and nutritional deficiencies [7, 8].

A number of studies have identified potentially correctible nutritional deficienncies in critically ill patients, including deficiencies of iron, B12, and folate. These deficiencies can lead to ineffective erythropoiesis with resultant anemia [9, 10]. Decreased erythropoietin production and/or impaired bone marrow response to erythropoietin may also play an important role in the development of anemia [11]. These effects are mediated by a variety of inflammatory cytokines such as Interleukin-1 (IL-1) and tumor necrosis factor- (TNF-), which inhibit erythropoietin (EPO) production. Furthermore IL-1, IL-6, and TNF- suppress erythropoiesis by direct inhibitory effects on bone marrow [12]. The hyperadrenergic state following severe injury may also induce bone marrow dysfunction and failure of erythropoiesis. This effect may be mediated by IL-6 and interferon- (IFN-), which are released following severe injury and have been shown to inhibit the differentiation and proliferation of erythroid precursor cells [13]. In addition increased levels of hepcidin, an iron regulatory hormone, have been purported to play an important role in the development of anemia of chronic disease (ACD) [1416]. The most common causes of ACD are acute or chronic inflammatory conditions such as infections, cancer, autoimmune diseases, and chronic kidney disease (CKD) [17]. It is characterized by sequestration of iron in macrophages, hypoferremia, and iron-restricted erythropoiesis. ACD is associated with elevated levels of inflammatory cytokines, including IL-1, IL-6, and IFN- [18]. These cytokines induce excess hepcidin production, which has been shown to downregulate ferroportin, an iron export protein on the cell surface of duodenal enterocytes, macrophages, and hepatocytes [19, 20]. Thus high serum levels of hepcidin decrease intestinal iron absorption and block iron export from tissue stores, resulting in functional iron deficiency [14, 21, 22]. 3. Impact of Anemia on Outcomes in Critically Ill Patients 3.1. Anemia and Cardiac Disease Numerous recent studies have shown anemia to be associated with worse outcomes in patients with coronary artery disease. After reviewing the data on nearly 40,000 patients enrolled in trials on acute coronary syndrome (ACS) Sabatine et al. found anemia to be associated with a greater likelihood of death in patients with ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI) [23]. These investigators also found an increased association of anemia with recurrent ischemia or acute MI in patients with NSTEMI. Aronson et al. found that lower nadir hemoglobins in hospitalized patients following MI were strongly associated with increased mortality [24]. Kulier et al., in a study of 5065 patients who underwent coronary artery bypass grafting (CABG), found preoperative anemia and intraoperative blood transfusion to both independently be associated with adverse postoperative neurologic and renal outcomes [25]. In another study of over 6,000 patients undergoing percutaneous intervention, anemia was found to be independently associated with both short-term cardiovascular events and decreased 1-year survival [26]. 3.2. Anemia and Respiratory Failure Respiratory dysfunction has also been associated with anemia in the critically ill. Rady and Ryan in a retrospective study of cardiac surgery patients found anemia (defined as a hematocrit <34%) and massive transfusion (defined as >10 units of blood products) to be significantly associated with the need for reintubation [27].

Khamiees et al. in a prospective observational study found anemia (Hgb < 10g/dL) to be associated with extubation failure in a mixed medical-surgical ICU population [28]. Nevins and Epstein found anemia (mean hematocrit 36) to be associated with poor outcomes in a retrospective study of 166 patients with chronic obstructive pulmonary disease (COPD) receiving mechanical ventilation [29]. Although, data exists showing anemia to be associated with poorer outcomes in mechanically ventilated patients, no significant literature supports the transfusion of PRBC to facilitate weaning patients from mechanical ventilation [30]. 3.3. Anemia and Sepsis Anemia is also a common occurrence in the setting of sepsis [31]. This is in part because mediators of sepsis (e.g., TNF- and IL-1) decrease expression of the erythropoietin gene and protein [32]. The early-goal-directed therapy trial reported by Rivers et al. and the transfusion requirement in critical care Trial (TRICC) performed by Hebert et al. used two different transfusion strategies in critically ill patients [31, 33]. Rivers et al. showed that correcting anemia by transfusing to a hematocrit >30% in early sepsis was associated with improved outcome when included as part of a broader resuscitation regimen [33]. However, it must be remembered that this was one of a number of interventions as part of an early goal directed protocol. It is unclear how much of the improvement in outcome can be attributed to transfusion alone. In the TRICC trial, subgroup analyses of older or more severely ill patients showed no difference in 30-day mortality between the restrictive-strategy and liberal strategy groups. Younger and less ill patients had better outcomes if transfused in a more restrictive manner (i.e., at lower hemoglobin) [31]. 4. Indications for Transfusion 4.1. Transfusion and Tissue Hypoxia The goal of packed red blood cell transfusion in the critically ill is to increase oxygen delivery to and hence consumption by tissues. An increase in hemoglobin should improve patients oxygen carrying capacity and help deliver oxygen to hypoxic tissues. Lactate, a clinically used surrogate of tissue hypoxia, should decrease with improved oxygen consumption. An abundance of literature over the past thirty years demonstrates that this clinical benefit is frequently not realized with transfusion in the critically ill. Shah et al. described their experience with 8 trauma patients who were transfused to a hemoglobin of 10 and had increased oxygen delivery but no increase in oxygen consumption [34]. Dietrich et al. in a larger study in the early nineties transfused volume resuscitated critically ill patients to a hemoglobin of 10g/dL *35]. These patients again had increased calculated oxygen delivery but no increased oxygen uptake, no decrease in lactate, and no increase in cardiac index. Silverman and Tuma used intramucosal gastric pH, a marker for adequacy of tissue oxygenation, to demonstrate that transfusion was inferior to dobutamine in improving oxygen delivery to the splanchnic circulation [36]. Marik and sibbald evaluated 23 critically ill patients with sepsis in a prospective study and demonstrated that transfused patients had no increase in oxygen uptake [37]. Furthermore, they demonstrated that blood older than 15 days decreased patients gastric intramucosal pH, suggesting an impairment in systemic oxygen delivery at the cellular level. Mazza et al. in a prospective study in 2005 showed that transfusing patients to a hemoglobin above 9g/dL was not associated with a significantly decreased lactate or increased mixed venous oxygen saturation, indication no benefit in meeting previously unmet tissue oxygen needs [38]. These studies raise the question: why does the transfusion of packed red blood cells frequently not relieve tissue hypoxia? The mean age of blood transfused in the USA is 17.9 days and extensive literature exists about age-related changes of packed red blood cells [2]. Stored blood cells have decreased amounts of 2,3-diphosphoglycerate which shifts the oxygen disassociation curve to the left, decreasing hemoglobins ability to unload oxygen at the tissue

level.Stored erythrocytes have been shown to lose their deformability resulting in increased aggregation, hemolysis, and the subsequent release of systemic factors associated with organ dysfunction [39, 40]. Fitzgerald et al. demonstrated in rats that transfused blood which was less than 3 days old was associated with an increased systemic oxygen uptake as opposed to blood that was 28 days old [41]. Zallen et al. demonstrated that an increased mean age of blood, especially an age of stored blood greater than 2 weeks, was associated with multiple organ failure [42]. 5. Complications of Transfusion 5.1. Infection Historically, the AIDS crisis forced the critical care community to revaluate the benefits of blood transfusion in the ICU. Due to these concerns blood is now screened for a variety of viral and bacterial infections including HIV and Hepatitis A, B, and C. In the United Kingdom, the risk of acquiring infection due HIV secondary to transfusion is less than one in 2 million [43]. The transmission of infection is only one of the ways blood can affect its potential recipient. In the early seventies, it was observed that renal transplant patients who received a transfusion prior to transplant had increased allograft survival. This finding led to further postulation in the medical literature that the transfusion of blood might affect the recipients immune system. Over the past forty years numerous studies have evaluated the affect of transfusing on transplant survival, cancer recurrence, and host predisposition to infection [44]. Taylor et al., in a retrospective study of 1711 patients demonstrated that transfused patients were six times more likely to develop a nosocomial infection than nontransfused patients [45]. In addition, each unit of PRBC transfused increased patients odds of developing infection by 1.5. Claridge et al. demonstrated in a prospective study of 1593 trauma patients that 33.6% of transfused patients developed infection versus 7.6% patients who did not receive transfusions [46]. They also showed that a linear, dose-response pattern existed, as patients who received more PRBC were more likely to develop infection. Univariate analysis of their data showed that the strongest predictor of developing infection was the transfusion of PRBC in the first 48 hours. Shorr et al. conducted an important secondary analysis of the CRIT study involving 284 ICUs and 4,892 patients to evaluate for blood stream infections (BSIS) in the critically ill [47]. These investigators demonstrated that three factors were associated with new BSI in the ICU: the initial use of cephalosporins, higher sequential organ failure assessment score, and PRBC transfusion. The importance of their work is that the data came from multiple ICUs unlike single-center studies mentioned previous and the patient populations were heterogeneous. Shorr et al. did another secondary analysis of the CRIT study and demonstrated that both small (1-2 units) and large (>2 units) volume transfusions were independent risk factors for the development of ventilator-associated pneumonia [48]. In cardiac surgery patients the transfusion of PRBC has been similarly associated with increased risk of infection [30]. However, Ali et al. in a prospective, singlecenter study of 234 patients demonstrated that PRBC was not associated with increased risk of infection in postoperative cardiac surgery patients [49]. Multiple large well-designed trials suggest that PRBC predispose patients to infection likely to due the immunomodulation of the patients immune system, but as Ali et al. study demonstrates that debate in this area still exists. 5.2. Transfusion-Related Acute Lung Injury (TRALI) This is a clinical syndrome that presents as acute hypoxemia and noncardiogenic pulmonary edema generally occurring within six hours of a transfusion [50]. The incidence varies and is estimated at 1 in 5,000 blood and blood components [51]. According to an FDA report presented at the TRALI conference in 2004, it is now the leading

cause of transfusion-related death in the United States. TRALI is characterized by increased pulmonary microvascular permeability. Leukocyte antibodies and biologically active substances such as lipids and cytokines are thought to be responsible for this increased permeability [52, 53]. 6. Impact of Blood Transfusion on Clinical Outcomes 6.1. Large Studies about Transfusion Outcome A growing body of evidence now suggests that correcting anemia by transfusion often either provides no benefit or is harmful. The TRICC trial showed a significant increase in cardiac and pulmonary complications and a trend toward increased mortality in the liberal transfusion group during patients intensive care stay. In subgroup analysis, younger (age < 55yrs) or less critically ill (APACHE II scores < 20) patients randomized to a liberal strategy had a statistically significant increase in mortality [31]. The CRIT study found that the number of blood transfusions was independently associated with both length of stay and mortality in ICU patients [2]. A cohort analysis within the CRIT study found blood transfusion to be independently associated with development of acute respiratory distress syndrome (ARDS) [54]. In 2002, Vincent et al. published a prospective observational study (Anemia and Blood Transfusion in Critically Ill Patients ABC) evaluating the blood sampling, hemoglobin levels, and transfusion rates in 146 Western European ICUs [3]. They concluded that receipt of a blood transfusion increased a patients odds of dying and increased patients length of stay in the ICU. In 2008, Vincent el al. published another prospective observational study that included 198 European ICUs [55]. This study showed that transfused patients had a lower mortality than nontransfused patients at 30 days when patient populations were matched by propensity scores. Significant debate exists about the use of a propensity score for statistical analysis including the inability to balance unmeasured clinical variables in the studied populations [56]. Vincent et al. have spurred further debate about the need for another prospective trial comparing a liberal versus conservative blood transfusion strategy in the critically ill, especially in the era of leukodepletion of PRBC transfusions. 6.2. Transfusion Impact on Cardiac Disease Data from the initial TRICC trial demonstrated that patient in the liberal transfusion arm (i.e., those transfused at a threshold hemoglobin of 9g/dL versus 7g/dL for the restrictive group) had a higher incidence of both pulmonary edema and MI [31].Subsequently, a subgroup analysis of patients from the TRICC trial with heart disease failed to demonstrate any significant mortality outcomes between groups. However, patients in the liberal transfusion group had a greater incidence of organ dysfunction [57]. Wu et al. reviewed Medicare data on almost 79,000 patients aged >65 years admitted with a diagnosis of acute MI [58]. They found an association between blood transfusion and improved survival when admission hematocrit was <33%. Any benefit of transfusion was lost at a hematocrit >33%, and patients with hematocrit >36% who were transfused had an increased risk of death compared with nontransfused patients. Yang et al. found that blood transfusion was a risk factor for death and the combined end point of death or MI in patients with non-ST-elevation ACS [59]. Rao et al. found a similar association with blood transfusion for patients with ACS for hematocrits more than 25% [60]. Below this value there was no difference in mortality between transfused and nontransfused patients. Sabatine et al. [23] found differing results for patients with STEMI and those with non-ST-elevation ACS. Patients with STEMI and hemoglobin levels <12g/dL had improved outcomes when transfus ed. Conversely, patients with non-ST-elevation ACS were found to have worse outcomes if transfused, regardless of their hemoglobin level.

Numerous studies in cardiac surgery patients have identified blood transfusion to be independently associated with increase in infectious complications, myocardial infarction (MI), stroke, renal failure, prolonged mechanical ventilation, atrial fibrillation, hospital length of stay, and mortality [6163]. 6.3. Blood Conservation Patients in the ICU on average have 41ml of blood drawn over a 24-hour period with sicker patients requiring more frequent blood draws leading to even greater blood loss [3]. Older literature has estimated that patients with an arterial catheter could lose greater than 900 mL during their stay [64]. Educational programs about reduced sampling, point of care testing, and closed arterial line system have all been recommended [3]. 6.4. Alternatives to Transfusion Ideally, mechanisms would exist to decrease or eliminate the need of blood transfusion altogether. Critically ill patients with anemia have been shown to have an inappropriately low erythropoietin response to their disease [65]. Corwin et al. in two studies demonstrated that transfusion requirements were decreased in critically patients treated with erythropoietin. However, in their third study erythropoietin treatment did not significantly alter the rate of transfusion in the critically ill. Mortality was nonsignificantly different in the medical population, but significantly lower in trauma patients at 140 days, although this decrease in mortality was unrelated to any difference in transfusion rates in the groups that received and did not receive erythropoietin. This observation led the authors to hypothesize that erythropoietin decreases mortality in trauma patients by mechanisms other than the reduction in PRBC requirements [66]. Erythropoietin is not recommended in critically ill medical patients unless other medical indications exist and can be used in trauma patients who will be in the ICU for greater than 48 hours. Another mechanism for reducing PRBC transfusion is artificial oxygen carriers or hemoglobin substitutes. Hemoglobin substitutes can be divided into two categories, perfluorocarbons and modified hemoglobins. Perfluorocarbons transport both oxygen and carbon dioxide but require patients to be on 100% oxygen. The advantages of perfluorocarbons over PRBC are their lack of potential infection transmission and their long halflives. They have been shown to decrease the need for blood transfusions in patients with elective noncardiac surgeries. Further studies need to be done to determine their utility in the critically ill [67]. Although, bovine, old human, and recombinant-based hemoglobin-based oxygen carriers (HBOC) have been heavily researched for thirty years only one HBOC is approved for clinical use. Hemopure (Biopure http://www.biopure.com/) was approved in 2001 to help reduce the amount of blood transfusion in anemic surgical patients in South Africa. The utility of these hemoglobin-based blood products currently is thought to be the ability to decrease allogenic PRBC transfusion and provide a blood substitute in situations where blood is unavailable (combat). Significant debate exists as to whether there are more myocardial infarctions in patients who receive HBOC as one meta-analysis suggested [68]. The National Heart, Lung, and Blood Institute in 2006 convened a conference to examine the difficulties with the development of HBOCS. The results of the conference were that HBOC show potential to have clinical utility, but concerns over side effects have impeded their approval by regulatory agencies [69]. Conflict of Interests The authors declare that they have no conflict of interests.

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Reaction and Recommendtions

Anemia is the most common disorder of the blood. It is a condition in which the blood is deficient in red blood cells or deficient in hemoglobin. Either of these conditions can cause a lack of oxygen to be delivered to all parts of the body. Resulting in symptoms such as; fatigue, cold hands, loss of appetite, pallor and weakness.

Severe anemia can weaken the immune system, cause poor co-ordination and mental fuzziness and impair wound healing To prevent anemia you need to eat well balanced meals including iron rich foods. If you have anemia, avoid beverages and foods containing caffeine, it interferes with the body's ability to absorb iron. Avoid tannins, they also get in the way of iron absorption as well as foods high in oxalic acids; which include almonds, asparagus, beans, beets, cashews, chocolate, kale and rhubarb.

While most cases of anemia are caused by simple nutrition deficiencies, it can also be a symptom of a more serious medical problem. The only way to get a definite diagnosis of anemia is to get a blood test. If you suspect you have anemia, do not begin a supplement program until you have a diagnosis from your physician. In order to cure anemia, the erythrocyte-proliferation processes must be resumed at a normal rate. There must also be striken a balance between these processes and the destruction rate of the aged cells. Where anemia is also caused by disorders of the thesaurus organs, these will be cured by normalizing the energy flow and reactivating the dysfunctional acupoints. Active substances from specific herbs are used in order to regenerate the innervation and the vascularisation in the sclerosed areas of bone marrow. The processes are enhanced of assimilation of iron and necessary nutrients for a good development of erythropoiesis. At immune level, the processes are enhanced that cleanse the body of pathogen agents and infections. Depending on the type of anemia and on its triggering causes, the treatment protocol will be adapted to restore erythropoiesis within normal limits.