Article ID: WMC001836
2046-1690
A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients Corresponding Author: Dr. Sami Bahlas, Article, Department of Internal Medicine King Abdul Aziz University Hospital Jeddah, Saudi Arabia - Saudi Arabia Submitting Author: Dr. Christine N Grace, Publication, Publication - Egypt
Article ID: WMC001836 Article Type: Research articles Submitted on:04-Apr-2011, 09:05:28 AM GMT
Published on: 04-Apr-2011, 06:16:26 PM GMT
Article URL: http://www.webmedcentral.com/article_view/1836 Subject Categories:GENERAL MEDICINE Keywords:Blood Transfusion, Anemia, Hemoglobin, Normocytic Normochromic How to cite the article:Bahlas S , Faydhi A , Ahmed M . A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients . WebmedCentral GENERAL MEDICINE 2011;2(4):WMC001836 Additional Files: Anemia and blood transfusion
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A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients Author(s): Bahlas S , Faydhi A , Ahmed M
Abstract Objective: To quantify the incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to examine the relationship of anemia and RBC transfusion in clinical outcomes. Design: The cohort study included 100 critically ill patients from King Abd El Aziz University Hospital, Saudi Arabia in 2010. Complete blood count was done detecting types and causes of anemia, and accordingly patients were divided into two groups those who received blood transfusion versus those who did not. Anemic patients were identified, when having Hemoglobin (Hb) less than 14g/dl in males and Hb less than 12g/dl in females. The study contained 23% Saudi patients and 77% non-Saudi patients. There were 53% enrolled males and 47% females with an average age of 59.74 + 2.03 years. The data was analyzed based on the overall and the blood transfusion basis (50/50) Results: The study enrolled 100 patients, 50% of whom had blood transfusion. 82% of the patients in the ICU had anemia, mainly Normocytic Normochromic. There is an association between blood transfusion and mortality in critically ill patients, as 66% of patients, who had transfusion, died. Conclusion: Although critically ill patients with anemia have an increased risk of death, especially in the case of blood transfusion (66% of patients who received a transfusion died), however each of them must be assessed individually.
Introduction Anemia is a common problem among critically ill patients that the majority of them need blood transfusion during their stay in the intensive care unit (ICU). However, the decision to transfuse is not always clearly defined and in the recent years, this issue has seen considerable debate and controversy.[1] Two decades ago, a hematocrit between 0.20 and 0.25 was considered an urgent indication for transfusion, but at the turn of this century, maintaining
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a hematocrit at this level is considered to be "bestpractice medicine".[2] Although the definition and grading of anemia varies among different organizations, most of them agree that a hemoglobin level below 6.5 g/dl indicates severe or life-threatening anemia.[3] Anemia of critical illness, a commonly encountered clinical situation, is hematologically similar to that of chronic anemia, except that its onset is generally sudden. The etiology is usually multifactorial, occurring as a consequence of direct inhibitory effects of inflammatory cytokines, erythropoietin deficiency, blunted erythropoietic response, blood loss, nutritional deficiencies, and renal insufficiency. Although anemia is not well tolerated by critically ill patients, aggressive treatment of anemia can be just as detrimental as no treatment. [3] It can also be due to reduced erythropoiesis, or increased red cell destruction.[1] The possible relationship between blood transfusion and poor outcome has led many to review their transfusion practices. There are two main reasons to give a blood transfusion in a critically ill patient: 1. To increase tissue oxygenation: The hemoglobin level is, with the cardiac output and the PaO2, an essential determinant of oxygen transport. Nevertheless, increasing hemoglobin levels via transfusion will not necessarily increase tissue oxygenation. Indeed, increasing the number of red blood cells can increase blood viscosity, which in turn can decrease cardiac output, and hence, limit oxygen delivery. In addition, a reduction in the hematocrit can have beneficial effects on the microcirculation, with oxygen extraction capacities being greater when the hematocrit is reduced whether under physiological conditions[4] or during sepsis.[5] It should also be stressed that blood transfusion rarely increases oxygen uptake, except under extreme conditions, where oxygen uptake is directly dependent on oxygen delivery, essentially in circulatory shock associated with hyperlactatemia[6,7,8] or in severe anemia with hemoglobin levels generally less than 6 g/dl. Hebert and Chin-Yee[9] identified 14 studies, in which the impact of blood transfusion on oxygen kinetics was assessed, and noted that only five reported an increase in VO2 following transfusion. 2. To avoid myocardial ischemia: During anemia, the increased cardiac output (due to decreased viscosity and adrenergic stimulation) augments myocardial
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oxygen demands, and patients with acute myocardial instability tolerate anemia poorly.[10] Anemia, because of its associated morbidity and mortality, is of a clinical importance in critically ill patients. Among patients who have normal hemoglobin levels on admission to an intensive care unit (ICU), nearly all become anemic during the course of their ICU stay.[11,12] The whole transfusion issue has become a hot area of debate in the last five years; triggered by the study by Hebert et al[13]noting that a more restrictive transfusion protocol (transfusions given when the hemoglobin concentration drops below 7.0 g/dl and hemoglobin concentrations maintain at 7.0-9.0 g/dl) was at least as effective and possibly more than a more conservative approach (transfusions given when the hemoglobin concentration fall below 10.0 g/dl and hemoglobin concentrations maintain at 10.0-12.0 g/dl).[1] Study Objectives: To assess the prevalence of anemia and study the association of blood transfusion and mortality in critically ill patients.
Methodology It is a cohort study; it recruited 100 critically ill patients divided into 2 group, 50 of whom received blood transfusion versus the remaining 50, who did not. Enrolled patients were evaluated to detect the association of anemia in critically ill patients and the incidence of mortality with blood transfusion. The data was analyzed based on overall and blood transfusion. Statistical Methodology Frequency statistics (number, percent) were mainly calculated for all the measurements. Comparability was assessed using chi-square test for categorical variables, like sex, etc. and t-test for continuous variables, like Hb levels.
Results Out of the 100 patients, 82% (82 patients) were anemic with Hb average of 10.06 + 0.28, 48 of whom had blood transfusion. There was a very high significance between the patients who had blood transfusion and those who did not. (P value=0.000)
Discussion
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A study shows that nearly half the patients admitted to an ICU have Hb levels less than 10 g/l, while another study showed that two-thirds of patients admitted to an ICU have Hb levels less than 10 g/l [2] and this was close to another study that showed that 29% of the patients had a hemoglobin concentration of less than 10 g/dl. [1] The mortality rate of patients who received a transfusion versus who did not was 66% versus 34% showing a similar very high significant rate (P-value 0.001), similar as another study that included 3534 patients from 146 Western European ICUs.[2] Sepsis was the most common clinical setting associated with anemia for 72% of the patients followed by Chronic Renal Failure in 56% of the patients. Another study, also, showed that sepsis was the most common association with anemia followed by chronic renal failure. [2] The complications of blood transfusion include volume overload, febrile reactions and fatal hemolytic reactions, which may all contribute to increased mortality rate.[15,16,17,18,19,] In our study, anemic patients had a shorter duration of stay in the ICU (7.3 days) compared to normal patients (8.5 days), this result was contradicting to another study that showed that anemic patients had a longer ICU stay (P-value < 0.001).[1] The relationship of anemia and red blood cell transfusion with clinical outcomes, in anemia and blood transfusion in the critically ill study, was examined before.[2] They found that as the number of red blood cell units transfused increased, the longer ICU & hospital stay increased, in addition to increased mortality rate. [3]
Conclusion In the recent years, we have seen conflicting reports for the association of blood transfusion with different outcomes,[1] leading to no universally accepted treatment guidelines for managing anemia, in addition to different practices performed among clinicians, hospitals, regions, and countries. [20] Thus, each patient must be individually assessed and the decision to transfuse the patient should be based on many parameters including clinical condition, age, pre-existing and current disease processes, oxygenation parameters with indexes of tissue hypoxia available, as well as the traditional hemoglobin values. [1]
References
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1. Vincent JL, Yalavatti G. Transfusion practice in the ICU: When to transfuse?. Indian J Crit Care Med 2003 ;7:237-41. 2. Naveen Manchal, S Jayaram, A prospective cohort study on anemia and blood transfusion in critically ill patients. Indian Journal of Critical Care Medicine, 2007 | Volume : 11 | Issue : 4,Page : 182-185. 3. Kwame Asare, PharmD, Anemia of Critical Illness. Pharmacotherapy Publications. Posted: 12/05/2008; Pharmacotherapy. 2008;28(10):1267-1282. 4. Van der Linden P, Gilbert E, Engelman E, Schmartz D, Vincent JL. Effects of anesthetic agents on systemic critical O2 delivery. J Appl Physiol 1991;71:83-93. 5. Creteur J, Sun Q, Abid O, De Backer D, Van der LP, Vincent JL. Normovolemic hemodilution improves oxygen extraction capabilities in endotoxic shock. J Appl Physiol 2001;91:1701-7. 6. Fenwick JC, Dodek PM, Ronco JJ, Phang PT, Wiggs B, Russell JA. Increased concentrations of plasma lactate predict pathological dependence of oxygen consumption on oxygen delivery in patients with adult respiratory distress syndrome. J Crit Care 1990;5:81-7. 7. Bakker J, Vincent JL. The oxygen supply dependency phenomenon is associated with increased blood lactate levels. J Crit Care 1991;6:152-9. 8. Gilbert EM, Haupt MT, Mandanas RY, Huaringa AJ, Carlson RW. The effect of fluid loading, blood transfusion and catecholamine infusion on oxygen delivery and consumption in patients with sepsis. Am Rev Respir Dis 1986;134:873-8. 9. Hébert PC, Chin-Yee I. Should old red cells be transfused in critically ill patients? In: Vincent JL, editor. 2000 Yearbook of Intensive Care and Emergency Medicine. Heidelberg: Springer 2000:494-506. 10. Wu WC, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001;345:1230-6. 11. Corwin HL, Parsonnet K, Gettinger A. RBC transfusion in the ICU: Is there a reason? Chest 1995;108:767-71. 12. Corwin HL, Gettinger A, Pearl RG, et al. The CRIT study: anemia and blood transfusion in the critically ill—current clinical practice in the United States. Crit Care Med 2004;32:39-52. 13. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:409-17. 14. Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, et al. effect of anemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996;348:1055-60. 15. Edna TH,
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Bjerkeset T. Association between blood transfusion and infection in injured patients. J Trauma 1992;33:659-61. 16. Stephan F, Montblanc Jd, Cheffi A, Bonnet F. Thrombocytopenia in critically ill surgical patients: A case-control study evaluating attributable mortality and transfusion requirements. Crit Care 1999;3:151-8. 17. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine: First of two parts-blood transfusion. N Engl J Med 1999;340:438-47. 18. Thurer RL. Blood transfusion in cardiac surgery. Can J Anesth 2001;48:S6-12. 19. Vamvakas ES, Moore SB, Cabanela M. Blood Transfusion and septic complications after hip replacement surgery. Transfusion 1995;35:150-6. 20. Shander A. Anemia in the critically ill. Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, NJ 07631, USA.
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Illustrations Illustration 1 1
Patients’ Demographics: The study cohort of 100 patients, 50% of whom had blood transfusion, while the other 50% did not. The study contained 23% Saudi patients, 13% of whom had blood transfusion, while the remaining 10 % did not; and 77% non-Saudi patients, 37% of whom had a transfusion and the remaining 40% did not. There were 53% enrolled males and 47% females with average age of 59.74 + 2.03 years. Table (1) shows the sample characteristics: Overall Sex:
Age:
Males Females Mean + SE Range
Nationality :
Saudi Non Saudi
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53% (53) 47% (47) 59.74 + 2.03 14 – 97 years 23% (23) 77% (77)
Blood Transfusion 26% (26) 24% (24) 56.72 + 2.89 years
No Blood Transfusion 27% (27) 23% (23) 62.76 + 2.82 years
14 – 90 years
21 – 97 years
13% (13)
10% (10)
37% (37)
40% (40)
P-Valu e 0.842
0.138
0.476
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Table (2) shows the level of Hemoglobin: Overall Anemic: Hb range:
Yes No Mean + SE Range
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82% (82) 18% (18) 10.06 + 0.28 4.9 – 16.1
Blood Transfusio n
No Blood Transfusio n
P-Value
96% (48) 4% (2)
68% (34) 32% (16)
0.000
8.82 + 0.31
11.3 + 0.39
4.9 – 14
5.4 – 16.1
0.000
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The predominant peripheral smear picture was of Normocytic normochromic type (68%). The others were microcytic hypochromic with 25% showing a leukemoid reaction. There was no significance between patients who received blood transfusion and those who did not. Figure 1: The predominant peripheral smear picture was Normocytic Normochromic
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Sepsis was the most common clinical setting associated with anemia in 72% of the patients followed by Chronic Renal Failure in 56% of the patients. The others being gastrointestinal bleeding, hemolysis and internal hemorrhage. The blood transfusion group, also, had the same most common clinical setting associated with anemia as sepsis, which was 76% of the cases followed by Chronis renal failure in 62%. There was no significance between patients who received blood transfusion and those who did not. Figure 2: Causes of anemia identified in the study
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The mortality rate of the 100 patients studied was 50% (50 patients), 66% (33 patients) of whom were given blood transfusion, while the other 34% (17 patients) had no blood transfusion showing a very high significant rate (P-value 0.001). The mortality rate, in those who were transfused at Hb< 7 g/l, was 80% compared to 40% of the mortality rate, in those who were transfused at Hb>10 g/l (P-value 0.015). The duration of stay in the ICU for patients who got blood transfusion was 10.94 + 1.5 compared to 4.1 + 0.79 in patients who had no blood transfusion having a very high significant rate (P-value 0.000). The range of blood units received by patients was 3.32 + 0.3. Table (3) shows the mortality and morbidity rates: Overall Mortality: Duration of ICU Stay:
Yes No Mean + SE Range
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50% (50) 50% (50) 7.52 + 0.91 1 – 54 days
Blood Transfusio n
No Blood Transfusio n
P-Value
66% (33) 34% (17)
34% (17) 66% (33)
0.001
10.94 + 1.5
4.1 + 0.79
1 – 54 days
1 – 32 days
0.000
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Reviews Review 1 Review Title: Review
of A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients Posted by Dr. Romi Sinha on 15 Dec 2011 05:55:05 AM GMT 1
Is the subject of the article within the scope of the subject category?
Yes
2
Are the interpretations / conclusions sound and justified by the data?
Partly
3
Is this a new and original contribution?
No
4
Does this paper exemplify an awareness of other research on the topic?
No
5
Are structure and length satisfactory?
No
6
Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience?
Yes
7
Can you suggest any reductions in the paper, or deletions of parts?
No
8
Is the quality of the diction satisfactory?
No
9
Are the illustrations and tables necessary and acceptable?
No
10
Are the references adequate and are they all necessary?
Yes
11
Are the keywords and abstract or summary informative?
No
Rating: 2 Comment: The aim of the paper is somewhat obscure. The author wants to examine clinical outcomes in critically ill patient who are anaemic and are transfused versus patients who are anaemic and not transfused.
The methodology section is inadequate; does not explain how the study cohort was selected , no time period mentioned. Was anaemia evluated on admission to ICU or at what point of time in iCU is not explained. What triggers are used to transfuse patients in the index ICU
result section is very inadequate. The details with the illustration should be in results sections. demographic details, reason for transfusion should be included.
It is known that patients transfused in ICU are sicker patient and no indices such as APACHE score has been used to adjust for the confounding factors.
A simple statistical test will not explain the association of transfusion and mortality , need to include a number of other variables such as age, sex, diagnoses, APACHE scores.
Competing interests: none
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Invited by the author to make a review on this article? : No Experience and credentials in the specific area of science: transfusion research , medical background Publications in the same or a related area of science: No How to cite: Sinha R.Review of A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients [Review of the article ' A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients ' by ].WebmedCentral 1970;2(12):REVIEW_REF_NUM1262
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Review 2 Review Title: Hematological
review
Posted by Dr. Chris Rizk on 04 May 2011 07:10:43 AM GMT 1
Is the subject of the article within the scope of the subject category?
Yes
2
Are the interpretations / conclusions sound and justified by the data?
Yes
3
Is this a new and original contribution?
No
4
Does this paper exemplify an awareness of other research on the topic?
Yes
5
Are structure and length satisfactory?
Yes
6
Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience?
Yes
7
Can you suggest any reductions in the paper, or deletions of parts?
No
8
Is the quality of the diction satisfactory?
Yes
9
Are the illustrations and tables necessary and acceptable?
Yes
10
Are the references adequate and are they all necessary?
Yes
11
Are the keywords and abstract or summary informative?
Yes
Rating: 7 Comment: Anemia in critical care cases considered one of the most big serous proplems faced doctors with critical care cases, The studies should do on the big numbers to be more accuracy.
Competing interests: no Invited by the author to make a review on this article? : Yes Experience and credentials in the specific area of science: internal medicine Publications in the same or a related area of science: No How to cite: Rizk C.Hematological review[Review of the article ' A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients ' by ].WebmedCentral 1970;2(5):REVIEW_REF_NUM720
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Review 3 Review Title: Review
on Anemia Paper
Posted by Dr. Remon Talaat on 19 Apr 2011 02:02:37 PM GMT 1
Is the subject of the article within the scope of the subject category?
Yes
2
Are the interpretations / conclusions sound and justified by the data?
Partly
3
Is this a new and original contribution?
Yes
4
Does this paper exemplify an awareness of other research on the topic?
Yes
5
Are structure and length satisfactory?
Yes
6
Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience?
No
7
Can you suggest any reductions in the paper, or deletions of parts?
No
8
Is the quality of the diction satisfactory?
Yes
9
Are the illustrations and tables necessary and acceptable?
Yes
10
Are the references adequate and are they all necessary?
Yes
11
Are the keywords and abstract or summary informative?
Yes
Rating: 7 Comment: I was recommending to increase the number of subjects included in this study if there is possibility, otherwise, I think it is good paper and add to the scientific community Competing interests: No Invited by the author to make a review on this article? : Yes Experience and credentials in the specific area of science: MOre than 9 years in research and clinical exposure Publications in the same or a related area of science: No How to cite: Talaat R.Review on Anemia Paper[Review of the article ' A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients ' by ].WebmedCentral 1970;2(4):REVIEW_REF_NUM690
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Review 4 Review Title: A
Review on Prospective Study on Anemia and Blood Transfusion in Critically ill Patients Posted by Dr. Abu Dzarr on 12 Apr 2011 02:32:00 PM GMT 1
Is the subject of the article within the scope of the subject category?
Yes
2
Are the interpretations / conclusions sound and justified by the data?
No
3
Is this a new and original contribution?
No
4
Does this paper exemplify an awareness of other research on the topic?
Yes
5
Are structure and length satisfactory?
No
6
Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience?
Yes
7
Can you suggest any reductions in the paper, or deletions of parts?
Yes
8
Is the quality of the diction satisfactory?
No
9
Are the illustrations and tables necessary and acceptable?
No
10
Are the references adequate and are they all necessary?
Yes
11
Are the keywords and abstract or summary informative?
Yes
Rating: 2 Comment: 2) The authors indicate that they wish to address two research questions: Firstly on the prevalence of anaemia. Secondly on the association of blood transfusion and mortality in critically ill patients. For the prevalence study, what was the sample population? I gathered from the write up that the author had used the same 100 subjects for the second research question to answer the first question as well. This is inappropriate. For a prevalence study we include those with and without anaemia, whereas for the second research question, we only study on those with anaemia. What were the inclusion and exclusion criteria? I noticed that this was mentioned in the abstract. However more importantly these information should be explicitly detailed in the methodology section. For the second research question, what was sampling method for the 100 subject. The author said, 50 of whom received blood transfusion versus the remaining 50 who did not. Was there any randomisation done? How was the patients selected to receive or not to receive transfusion? What was the Hb level which triggered transfusion? Are the two groups of patients comparable in terms of Apache scores or other prognostic indices? Obviously anyone with milder anaemia may have less severe disease. Obviously this will lead to lower transfusion requirement and less mortality. I beleive the design of this study as vaguely presented in this write-up is open to bias leading to a flawed conclusion. 3) I suspect that the intention of the author is to validate the findings of Hebert's study regarding blood transfusion in critically ill patient on their population. The idea is not original but should be allowed as the population addressed here is ethnically different from those of Hebert's. 5, 6 & 7) The methodology and result sections need to be rewritten. These are the two areas that the authors should focus on for any paper to carry any scientific merits. The methods should be explicitly outlined. The authors could duplicate Hebert's protocol. Apparently the author had scattered the results around with tables and charts. The result section is almost void of any information and appeared unintelligible. 8) Some of the sentences are confusing. For example in the result section, the author wrote: There was a very high significance between the pateints who had blood transfusion and those who did not. (P=0000) My comment: Significance of what? 9) I have problem understanding table 2. The title of a graph should summarize the idea represented by the figure. I find title for figure 1 and 2 as inappropriate. Why would the author state the title for figure 1
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as: The predominant peripheral smear picture was normochromic normocytic. Invited by the author to make a review on this article? : No Experience and credentials in the specific area of science: I am a clinician experienced in internal medicine/haematology which indicates critical care Publications in the same or a related area of science: No How to cite: Dzarr A.A Review on Prospective Study on Anemia and Blood Transfusion in Critically ill Patients[Review of the article ' A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients ' by ].WebmedCentral 1970;2(4):REVIEW_REF_NUM666
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Review 5 Review Title: Statistics
Matter
Posted by Dr. Thomas F Heston on 11 Apr 2011 04:29:38 PM GMT 1
Is the subject of the article within the scope of the subject category?
Yes
2
Are the interpretations / conclusions sound and justified by the data?
No
3
Is this a new and original contribution?
Yes
4
Does this paper exemplify an awareness of other research on the topic?
Yes
5
Are structure and length satisfactory?
No
6
Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience?
Yes
7
Can you suggest any reductions in the paper, or deletions of parts?
No
8
Is the quality of the diction satisfactory?
Yes
9
Are the illustrations and tables necessary and acceptable?
Yes
10
Are the references adequate and are they all necessary?
Yes
11
Are the keywords and abstract or summary informative?
Yes
Rating: 4 Comment: The results section of this manuscript is inadequate. Comparing the clinical outcomes of those who received a transfusion compared to those that did not is a simple statistical test that needs to be performed on their data. Without these results the manuscript is pretty meaningless. Please do a more thorough statistical analysis of your data, and ideally include the data in your manuscript.
Thank you for publishing your research on this interesting subject.
Competing interests: no Invited by the author to make a review on this article? : No Experience and credentials in the specific area of science: Fellow of the American Academy of Family Physicians. Publications in the same or a related area of science: No How to cite: Heston T.Statistics Matter[Review of the article ' A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients ' by ].WebmedCentral 1970;2(4):REVIEW_REF_NUM662
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Review 6 A Review on prospective study on anemia and blood transfusion in critically ill patients Review Title:
Posted by Dr. Neriyana S Satish on 05 Apr 2011 03:26:05 AM GMT 1
Is the subject of the article within the scope of the subject category?
Yes
2
Are the interpretations / conclusions sound and justified by the data?
Partly
3
Is this a new and original contribution?
Yes
4
Does this paper exemplify an awareness of other research on the topic?
Yes
5
Are structure and length satisfactory?
No
6
Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience?
No
7
Can you suggest any reductions in the paper, or deletions of parts?
No
8
Is the quality of the diction satisfactory?
Yes
9
Are the illustrations and tables necessary and acceptable?
Yes
10
Are the references adequate and are they all necessary?
Yes
11
Are the keywords and abstract or summary informative?
Yes
Rating: 5 Comment: The investigators should clarify the critically ill patients, An ICU will admit patients with multiple disorders which is threatening life, and anemia could be a part of the multi-organ failure, so symptomatically treating the patient will only improve the lab parameters but may not improve the outcome or prognosis. So if the authors had clearly defined the inclusion and exclusion criteria, the study would have given greater information. Competing interests: No Invited by the author to make a review on this article? : No Experience and credentials in the specific area of science: Published a paper on measurement of red cell sizes and classification of anemia. Publications in the same or a related area of science: Yes References: the article is in press, A SIMPLE IMAGING METHOD FOR DEMONSTRATING RED CELL SIZES TO LIFE SCIENCES STUDENTS. National journal of Basic Medical Sciences, published from salem, Tamil Nadu, India. Will be published in May 2011. How to cite: Satish N. A Review on prospective study on anemia and blood transfusion in critically ill patients[Review of the article ' A Prospective Study on Anemia and Blood Transfusion in Critically ill Patients ' by ].WebmedCentral 1970;2(4):REVIEW_REF_NUM643
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