REMI 1977. Efecto de la eritropoyetina y del umbral de transfusión en la recuperación neurológica del TCE cerrado

Artículo originalEffect of Erythropoietin and Transfusion Threshold on Neurological Recovery After Traumatic Brain Injury: A Randomized Clinical Trial. Claudia S. Robertson, MD; H. Julia Hannay, PhD; José-Miguel Yamal, PhD; et al. JAMA 2014; 312(1): 36-47. [Resumen] [Artículos relacionados] [Web JAMA]
Introducción: Los pacientes con TCE desarrollan a menudo anemia que puede causar lesión cerebral secundaria. La eritropoyetina se ha empleado para tratar esta anemia porque en modelos experimentales, además de mejorar la anemia, tiene un efecto neuroprotector y puede mejorar la supervivencia. Esto último se ha visto también en algunos ensayos clínicos de pequeño tamaño. La anemia también se ha tratado con transfusiones de concentrado de hematíes, pero esto tiene sus complicaciones  y en diversos estudios se ha demostrado que la mayoría de los pacientes críticos no se benefician de mantener un nivel elevado de hemoglobina. Este ensayo clínico, con un diseño factorial 2 x 2, se diseño para comparar los efectos de la administración de eritropoyetina y las transfusiones con dos umbrales diferentes (7 y 10 g/dL de Hb) en la recuperación neurológica.
ResumenSe trata de un ECA de 200 pacientes con TCE cerrado e incapacidad para responder a órdenes, que fueron asignados a tratamiento con eritropoyetina o placebo y a transfusión con un umbral de 7 o 10 g/dL de Hb. Los desenlaces primarios fueron el fallo de la eritropoyetina en mejorar la recuperación neurológica en un 20% y la mejoría de la recuperación neurológica con un umbral de transfusión de 10 g/dL, sin aumentar las complicaciones, ambos a los 6 meses. La dosis de eritropoyetina se disminuyó durante el estudio, tras 74 pacientes, debido a los resultados del estudio EPO Stroke. La recuperación neurológica se midió mediante la escala GOS dicotomizada como favorable (buena recuperación o discapacidad moderada) y desfavorable (discapacidad grave, estado vegetativo o muerte). No hubo interacción entre los grupos de eritropoyetina y transfusión. Comparados con placebo (resultado favorable en un 38,2%, IC 95% 28,1%-49,1%), los dos regímenes de eritropoyetina fueron fútiles. La tasa de buen resultado neurológico con un umbral de transfusión de 7 g/dL fue del 42,5% y del 33,0% para el de 10 (IC 95% -0,06 a 0,25; P = 0,28). Con el umbral de 10 hubo mayor incidencia de fenómenos tromboembólicos (21,8% contra 8,1%, OR 0,32; IC 95% 0,12 a 0,79, P = 0,009).
Comentario: Elevar la hemoglobina bien mediante el uso de eritropoyetina, bien mediante transfusión, no ha resultado útil para mejorar la supervivencia con buen estado neurológico en el TCE cerrado en este estudio. Además, el mayor número de transfusiones necesario para mantener el umbral de 10, hace que las complicaciones sean más frecuentes. Varios ensayos previos ya han mostrado que el umbral de 7 g/dL de Hb es seguro en varios tipos de pacientes críticos. Los resultados de este ensayo confirman esos resultados y agregan un nuevo tipo de pacientes en los que se puede aplicar la estrategia restrictiva.
Ramón Díaz-Alersi
Hospital U. Puerto Real, Cádiz.
© REMI, Julio 2014

  1. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Carson JL, Carless PA, Hebert PC. Cochrane Database Syst Rev 2012; 4: CD002042. [PubMed
  2. Transfusion strategies for acute upper gastrointestinal bleeding. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C. N Engl J Med 2013; 368: 11-21.[PubMed] [Texto completo] [REMI
  3. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, Fukushima J, Kalil Filho R, Sierra DB, Lopes NH, Mauad T, Roquim AC, Sundin MR, Leão WC, Almeida JP, Pomerantzeff PM, Dallan LO, Jatene FB, Stolf NA, Auler JO Jr. JAMA 2010; 304: 1559-1567. [PubMed] [Texto completo] [REMI
  4. Liberal or restrictive transfusion in high-risk patients after hip surgery. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J; FOCUS Investigators. N Engl J Med 2011; 365: 2453-2462. [PubMed] [Texto completo] [REMI
  5. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. Rohde JM, Dimcheff DE, Blumberg N, Saint S, Langa KM, Kuhn L, Hickner A, Rogers MA. JAMA 2014; 311: 1317-1326. [PubMed][Texto completo] [REMI]
Búsqueda en PubMed
  • Enunciado: Umbral de transfusión y seguridad en el paciente crítico 
  • Sintaxis: transfusion threshold AND safety AND (critical care OR critically ill) 
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Talking, Teaching & Technology – Victoria Brazil @SocraticEM at St Emlyn’s

St Emlyns - Meducation in Virchester #FOAMed

You probably know by now that SMACC Gold was awesome. There simply aren’t enough superlatives to describe the magnitude of inspiration on offer from the world’s finest critical care speakers.  Putting together a programme like SMACC’s was an incredible feat – where would you even start?   The answer to that question comes naturally – […]

The post Talking, Teaching & Technology – Victoria Brazil @SocraticEM at St Emlyn’s appeared first on St Emlyns.

MORE SMACC GOLD with Dr Steve McGloughlin – The Dying Traveller

Dr Steve McGloughlin is a great speaker. He used to work with me at RFDS Cairns when he was still a registrar so it was great catching up with him since his transition to being a consultant at the esteemed Alfred hospital in Melbourne!

Filed under: Emergency medicine and critical care, FOAMEd, Interviews of interesting people, SMACCGOLD Tagged: dying-traveller, SMACCGOLD, steve-mcgloughlin

#FOAM Review 4th edition


Welcome to the fourth edition of the #FOAM Review! The idea of the FOAM review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Look out for the #FOAM review curriculum and indexing page in the next few weeks as we continue to update the website! 


BUT FIRST A QUICK TANGENT! If you haven't already, let us know what is YOUR 'go to' tool and meds for the standard intubation! Click on image to the left and share your practice with the world! We will publish interactive info-graphic next week with the results!


INTUBATION CHECKLISTS [MULTIMODAL]: We intubate in the emergency room daily. and often encounter the difficult airway. Do you use a checklist/algorithm for when @$!^@ hits the fan? Check out some approaches from experts below: 

ANKLE-BRACHIAL INDEX [VIDEO/BLOG]: Patient presenting with a cold leg? Oh and by the way, they mention they have diabetes, HTN and 40 pack year smoking history. You should probably check their pulses, or an ABI if you can't palpate anything. High yield video on the technique here and excellent pocket resource regarding acute limb ischemia on ALiEM. 


POCUS IN SOB [BLOG]: POCUS for respiratory complaints may improved likelihood of diagnosis at 4 hours but does it improve patient outcomes? Read two different posts from St. Emlyns & EM Literature of Note on the recent Lancet article regarding POCUS in patients with respiratory symptoms. Or get in on the twitter discussion here

Original Article: Point-of-Care Ultrasonography in Patients Admitted With Respiratory Symptoms: a Single-Blind, Randomised Controlled Trial

LATRODECTUS ANTIVENOM: [BLOG]: The RAVE-II study is out in the Annals of EM may be practice changing. We enjoyed the succinct review at EBM Wild. Read it for yourself


Original Article: Randomized Controlled Trial of Intravenous Antivenom Versus Placebo for Latrodectism

More FOAMed.


MANAGEMENT OF DOG BITES [BLOG]: Do we still need to allow dog bites to heal by secondary intention? Should antibiotic prophylaxis be standard of care? Take a look at the evidence at Rebel EM. 


FLUID MANAGEMENT [PODCAST]: There has been quite a bit of talk regarding maintaining the glycocalyx during fluid resuscitation. Listen to the SMACC lecture by Jeremy Cohen, hosted on The Intensive Care Network, and think about what your strategy should be.


VERTIGO [PODCAST]: The HINTS exam is your friend when a patient presents with vertiginous symptoms. Tips to distinguish between central and peripheral etiology at The Washington University Emergency Medicine Journal Club. 


BURNS [BLOG]: Step by step breakdown on key questions you need to answer about major burn management at LITFL. Minor burns need love too so check out the bottom line need to know at Don't Forget the Bubbles. 

See you next week.


#FOAM review is brought to you by Michael Macias. If you want to recommend content you think should be added to our curriculum, send me an email, I would love to hear from you.