RBWH ICU JOURNAL CLUB NOVEMBER 2014

Summary Questions asked Jistorical background Trial design Patients Results Discussion

Questions asked Does higher Hb threshold improve neurological outcome Does EPO do more than just estimulate the bone marrow

Evolution Silver, CCM 2006; EPO decreases the need for RBC transfusions in critically ill Corwin, NEJM 2007; More VTE but maybe improved mortality in trauma Napolitano, JTrauma, 2008; 40.000IU EPO improves mortality by 50% at 29 days(n=2760) EAST, CCM, 2009; Level 2 recommendation on EPO administration in general trauma Desjardins, CC, 2012. A Systematic Review (n=4100) could not find a difference in Hb threshold and outcomes in TBI

EPO upregulates antiapoptosis messenger in brain (and spine) J Exp Med. Sep 15, 2003; 198(6): 971–975. doi:  10.1084/jem.20021067

What about Hb thresholds?

Trial design Multiple level 1 or 2 trauma centres in Houston 2X2 design Enrolment within 6 hours from injury EPO or no EPO Transfusion thresholds 7 or 10g/dL Blinded for EPO but not for Hb threshold Power of study changed with EPO dosing

500IU EPO/Kg @ $1.35/100IU

Patients N= 200; x4 groups but in reality x6 Closed head injury with GCS>3 Changed EPO dosing Blinding for EPO

Outcomes Glasgow outcome score Mortality Respiratory failure Infections EPO levels

Results No difference in outcome scores with either intervention Perhaps more VTE’s in the high Hb group

Discussion EPO costs money and probably gives no benefit Blood costs money Blood is a scarce resource and could cause harm NOT giving blood in hemodyanmic stable non bleeding patients is safe