Transfusión en trauma craneoencefálico / Transfusion traumatic brain injury

Julio 16, 2018. No. 3143

Lo Mejor de Octavio Paz. PDF Trasfusión en trauma craneoencefálico Transfusion practices in traumatic brain injury Curr Opin Anaesthesiol. 2018 Apr;31(2):219-226. doi: 10.1097/ACO.0000000000000566. East JM1, Viau-Lapointe J1, McCredie VA1,2. Author information Abstract PURPOSE OF REVIEW: The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. RECENT FINDINGS: Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. SUMMARY: Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion. PDF Lesión hemorrágica progresiva después de una lesión cerebral traumática grave: efecto de los umbrales de transfusión de hemoglobina. Progressive hemorrhagic injury after severe traumatic brain injury: effect of hemoglobin transfusion thresholds. Vedantam A1, Yamal JM2, Rubin ML2, Robertson CS1, Gopinath SP1. Author information J Neurosurg. 2016 Nov;125(5):1229-1234. Epub 2016 Mar 4. Abstract OBJECT. There is limited literature available to guide transfusion practices for patients with severe traumatic brain injury (TBI). Recent studies have shown that maintaining a higher hemoglobin threshold after severe TBI offers no clinical benefit. The present study aimed to determine if a higher transfusion threshold was independently associated with an increased risk of progressive hemorrhagic injury (PHI), thereby contributing to higher rates of morbidity and mortality. METHODS The authors performed a secondary analysis of data obtained from a recently performed randomized clinical trial studying the effects of erythropoietin and blood transfusions on neurological recovery after severe TBI. Assigned hemoglobin thresholds (10 g/dl vs 7 g/dl) were maintained with packed red blood cell transfusions during the acute phase after injury. PHI was defined as the presence of new or enlarging intracranial hematomas on CT as long as 10 days after injury. A severe PHI was defined as an event that required an escalation of medical management or surgical intervention. Clinical and imaging parameters and transfusion thresholds were used in a multivariate Cox regression analysis to identify independent risk factors for PHI. RESULTS Among 200 patients enrolled in the trial, PHI was detected in 61 patients (30.5%). The majority of patients with PHI had a new, delayed contusion (n = 29) or an increase in contusion size (n = 15). The mean time interval between injury and identification of PHI was 17.2 ± 15.8 hours. The adjusted risk of severe PHI was 2.3 times higher for patients with a transfusion threshold of 10 g/dl (95% confidence interval 1.1-4.7; p = 0.02). Diffuse brain injury was associated with a lower risk of PHI events, whereas higher initial intracranial pressure increased the risk of PHI (p < 0.001). PHI was associated with a longer median length of stay in the intensive care unit (18.3 vs 14.4 days, respectively; p = 0.04) and poorer Glasgow Outcome Scale scores (42.9% vs 25.5%, respectively; p = 0.02) at 6 months. CONCLUSIONS A higher transfusion threshold of 10 g/dl after severe TBI increased the risk of severe PHI events. These results indicate the potential adverse effect of using a higher hemoglobin transfusion threshold after severe TBI. KEYWORDS: EPO = erythropoietin; ER = emergency room; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; PHI = progressive hemorrhagic injury; PT = prothrombin time; PTT = partial thromboplastin time; RCT = randomized controlled trial; TBI = traumatic brain injury; hemoglobin transfusion threshold; progressive hemorrhagic injury; secondary brain injury; severe traumatic brain injury PDF Efecto de la eritropoyetina y el umbral de transfusión en la recuperación neurológica después de la lesión cerebral traumática: un ensayo clínico aleatorizado. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. Robertson CS1, Hannay HJ2, Yamal JM3, Gopinath S1, Goodman JC4, Tilley BC3; Epo Severe TBI Trial Investigators, Baldwin A1, Rivera Lara L1, Saucedo-Crespo H1, Ahmed O1, Sadasivan S1, Ponce L1, Cruz-Navarro J1, Shahin H1, Aisiku IP5, Doshi P5, Valadka A5, Neipert L2, Waguspack JM2, Rubin ML3, Benoit JS3, Swank P3. Author information JAMA. 2014 Jul 2;312(1):36-47. doi: 10.1001/jama.2014.6490. Abstract IMPORTANCE: There is limited information about the effect of erythropoietin or a high hemoglobin transfusion threshold after a traumatic brain injury. OBJECTIVE: To compare the effects of erythropoietin and 2 hemoglobin transfusion thresholds (7 and 10 g/dL) on neurological recovery after traumatic brain injury. ...Intravenous erythropoietin (500 IU/kg per dose) or saline. Transfusion threshold maintained with packed red blood cells. ....CONCLUSIONS AND RELEVANCE: In patients with closed head injury, neither the administration of erythropoietin nor maintaining hemoglobin concentration of greater than 10 g/dL resulted in improved neurological outcome at 6 months. The transfusion threshold of 10 g/dL was associated with a higher incidence of adverse events. These findings do not support either approach in this setting. PDF Curso de Alta Especialidad en Medicina del Dolor y Paliativa 2019 Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Ciudad de México Convocatoria / Announcement  Ver Programa Información / Information Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Curso Regional de Sur Sureste de Medicina del Dolor y Cuidados Paliativos Agosto 24-25. Oaxaca, México Informacion / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Contro glicémico y trauma cerebral / Glycaemic control and brain injury

Enero 24, 2018. No. 2973

Objetivos de control glucémico después de una lesión cerebral traumática: una revisión sistemática y un metanálisis. Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis. Hermanides J1,2, Plummer MP3, Finnis M4, Deane AM5, Coles JP6, Menon DK6. Author information Crit Care. 2018 Jan 19;22(1):11. doi: 10.1186/s13054-017-1883-y. Abstract BACKGROUND: Optimal glycaemic targets in traumatic brain injury (TBI) remain unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing intensive with conventional glycaemic control in TBI requiring admission to an intensive care unit (ICU). ..... CONCLUSIONS: This meta-analysis of intensive glycaemic control shows no association with reduced mortality in TBI. Intensive glucose control showed a borderline significant reduction in the risk of poor neurological outcome, but markedly increased the risk of hypoglycaemia. These contradictory findings should motivate further research. KEYWORDS: Glucose control; Glycaemia; Intensive insulin therapy; Systematic review; Traumatic brain injury PDF Hiperglucemia en el paciente neurocrítico Grupo de Estudio de Nutrición y Neurointesivismo Diaeta (B.Aires) 2015; 33(150):7-11 Resumen Introducción. El enfermo neurocrítico desarrolla una respuesta a la lesión hipermetabólica e hipercatabólica. En tal circunstancia, aumentan las glucemias producto de la insulino resistencia propia del estrés metabólico. La hiperglucemia en estos pacientes, se asocia con un aumento de la morbilidad y mortalidad. Marco teórico. La actividad cerebral requiere un alto consumo energético, utilizando principalmente el 30% de la glucosa plasmática. El aporte de glucosa debe ser continuo, debido a que el cerebro no dispone de reservas. El gradiente entre los valores plasmáticos y cerebrales de glucosa es de 110-126 mg/dl, lo que sugiere puntos de corte más amplios en el control glucémico de estos pacientes. Se ha visto que una reducción drástica en los valores de glucemia por controles estrictos (<110 mg/dl) favorece un incremento en la relación lactatopiruvato y glutamato del cerebro, aumentando el daño cerebral. Argumentación. Se presentan distintos argumentos para el control de glucemias estricto (<110 mg/dl) versus el manejo convencional (<180 mg/dl). Se observó mayor incidencia de mortalidad asociada a hipoglucemias por controles estrictos con tratamiento intensivo de insulina. La Asociación Dietética Americana (ADA) recomienda para pacientes críticos que el nivel de glucosa debe mantenerse entre 140 y 180 mg/dl, en este punto coinciden guías americanas y europeas. Conclusión. Dado que los hallazgos de los estudios sugieren que el objetivo de normoglucemia no necesariamente beneficiaría al paciente y podría ser perjudicial, las publicaciones actuales no recomiendan el uso de objetivos glucémicos bajos en pacientes neurocríticos. Palabras clave: neurocrítico, diabetes, glucemia, insulina, adulto. PDF Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information World Congress on Regional Anesthesia & Pain Medicine April 19-21, 2018, New York City, USA Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org