European Heart Journal Advance Access originally published online on September 17, 2007
European Heart Journal 2007 28(20):2551-2552; doi:10.1093/eurheartj/ehm337
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Nosocomial anaemia: reply
Department of Cardiology
Rambam Medical Center
Bat Galim
PO Box 9602
Haifa 31096
Israel
Department of Cardiology
Rambam Medical Center
Bat Galim
PO Box 9602
Haifa 31096
Israel
Department of Cardiology
Rambam Medical Center
Bat Galim
PO Box 9602
Haifa 31096
Israel
E-mail address: d_aronson{at}rambam.health.gov.il
We appreciate Dr Liron's comments regarding our article. Because the focus of our study was to examine the relationship between changes in haemoglobin during hospital course and post-hospital discharge outcome, we excluded patients who died during the index hospitalization. This allowed that every patient would have three haemoglobin measurements (baseline, nadir and discharge).1 It also excluded cases in which severe bleeding during hospital course may have contributed directly to mortality.
Blood loss due to diagnostic phlebotomy has been mainly described in ventilated surgical intensive care patients, particularly with arterial lines.2,3 The quoted article of patients who had more than 500 mL blood withdrawn refers to four patients who were hospitalized for 36–65 days.2 However, blood loss due to diagnostic phlebotomy is much lower in general medical wards,3–5 including medical intensive care units.4 The mean volume of blood drawn per day has been reported to be 16–42 mL in the intensive care setting2–4,6 and 4–12 mL in general wards.3,4 In a study of 2654 patients in general wards and intensive care units, diagnostic blood loss of 200 mL or less occurred in 95% of patients during hospital stay.4 In our study, the median length of hospital stay was 7 days (inter-quartile range 6–10), with about half of the time spent in the intensive care unit.
Previous studies in patients with acute coronary syndromes have shown haemoglobin drops that were even greater than those observed in our study. In patients with acute myocardial infarction, Tahnk-Johnson et al. observed haemoglobin decrease of 
3.0 g/dL in 22% of patients receiving thrombolysis during the first 24 h of hospitalization.7 They concluded that phlebotomy loss accounted for only a fraction of the haemoglobin decline in their patients. In a large contemporary population of patients with non-ST-segment elevation acute coronary syndromes, median haematocrit declined from 41 to 35% during hospital stay in patients not receiving blood transfusion and from 35 to 26% in patients receiving blood transfusion.8
The anaemia that developed in many of our patients during their hospital course can be clearly described as nosocomial anaemia. However, we believe that laboratory-related blood loss was not a major contributor to the development of anaemia in our patient population. Thrombolytic, antithrombotic, and antiplatelet therapy along with coronary revascularization largely account for the magnitude of haemoglobin drop observed in our study.
Notwithstanding, we agree with Dr Liron that diagnostic blood loss may contribute to the development of anaemia in hospitalized patients. Blood testing should be performed with a clear indication, using the minimal sample volume required. In addition, judicious dosing of antithrombotic medications, proper selection of patients for invasive procedures, and the use of safer anticoagulant agents may prevent bleeding complications and anaemia and improve patient outcome.
References
- Aronson D, Suleiman M, Agmon Y, Suleiman A, Blich M, Kapeliovich M, Beyar R, Markiewicz W, Hammerman H. Changes in haemoglobin levels during hospital course and long-term outcome after acute myocardial infarction. Eur Heart J (2007) 28:1289–1296.
[Abstract/Free Full Text] - Shaffer C. Diagnostic blood loss in mechanically ventilated patients. Heart Lung (2007) 36:217–222.[CrossRef][ISI][Medline]
- Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med (1986) 314:1233–1235.[Abstract]
- Wisser D, van Ackern K, Knoll E, Wisser H, Bertsch T. Blood loss from laboratory tests. Clin Chem (2003) 49:1651–1655.
[Abstract/Free Full Text] - Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med (2005) 20:520–524.[CrossRef][ISI][Medline]
- Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, Meier-Hellmann A, Nollet G, Peres-Bota D. Anemia and blood transfusion in critically ill patients. JAMA (2002) 288:1499–1507.
[Abstract/Free Full Text] - Tahnk-Johnson ME, Sharkey SW. Impact of thrombolytic therapy on hemoglobin change after acute myocardial infarction. Am J Cardiol (1993) 71:869–872.[CrossRef][ISI][Medline]
- Yang X, Alexander KP, Chen AY, Roe MT, Brindis RG, Rao SV, Gibler WB, Ohman EM, Peterson ED. The implications of blood transfusions for patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol (2005) 46:1490–1495.
[Abstract/Free Full Text]
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