Utilidad del hierro intravenoso en el perioperatorio del paciente anciano con fractura de cadera

Introducción: La transfusión de sangre alogénica en los pacientes que se someten a intervención quirúrgica aumenta la incidencia de infecciones, la mortalidad y la estancia hospitalaria. El hierro intravenoso es una alternativa a la transfusión alogénica que puede contribuir a la recuperación de las pérdidas sanguíneas de forma rápida y segura. Objetivos: comprobar la eficacia y seguridad del hierro-sacarosa intravenoso en los pacientes ancianos intervenidos quirúrgicamente de fractura de cadera para ver si este tratamiento reduce sus necesidades transfusionales, su morbimortalidad y su estancia hospitalaria. Material y Método: se realizó un estudio experimental prospectivo, controlado, aleatorizado y abierto con 200 pacientes intervenidos de fractura de cadera osteoporótica en el Hospital Reina Sofía de Córdoba. Al grupo A (grupo control, 100 pacientes) no se le administró ningún tratamiento especial y al grupo B (grupo tratado, 100 pacientes) se le administraron 600 mg de hierro-sacarosa intravenoso repartidos en 3 dosis de 200 mg cada 48 horas. Se realizaron determinaciones analíticas al ingreso, 24 horas y 7º día postintervención. Se recogieron la necesidad de transfusión, el número de concentrados transfundidos, la mortalidad, la incidencia de infecciones urinarias, respiratorias y de la herida quirúrgica y la duración de la estancia hospitalaria. Se realizaron contrastes bivariantes, un modelo de Regresión Lineal Múltiple y un estudio de supervivencia mediante una Regresión de Cox para encontrar los factores predictores del número de concentrados necesarios y de la mortalidad. Resultados: La diferencia en el porcentaje de pacientes transfundidos (41,3% en el grupo A frente a 33,3% en el grupo B) y en el número de concentrados necesarios (0,87±1,21 en el grupo A frente a 0,76±1,16 en el grupo B) no alcanzaron la significación estadística. Tampoco hubo diferencias al contrastar la incidencia de infecciones, la morbimortalidad y la estancia hospitalaria entre ambos grupos. Los pacientes del grupo B presentaron niveles de hematocrito al 7º día postoperatorio significativamente superiores a los del medido a las 24 horas de la intervención, hallazgo que no se encontró en el grupo A. Conclusiones: las necesidades transfusionales, la morbimortalidad y el tiempo de estancia hospitalaria 20 de los pacientes ancianos intervenidos de fractura de cadera son independientes del tratamiento con hierro-sacarosa intravenoso, aunque los pacientes tratados con dicho fármaco experimentan una recuperación más rápida de las pérdidas sanguíneas sufridas por la fractura y por la intervención quirúrgica. Se confirman la seguridad y escasez de efectos secundarios del tratamiento

Nutritional supplementation for hip fracture aftercare in older people

Background: Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010.  Objectives: To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture.  Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015.  Selection criteria: Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture.  Data collection and analysis: Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and ’unfavourable outcome’ defined as the number of trialparticipants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea.  Main results: We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates. Eighteen trials evaluated oral multinutrient feeds that provided non-protein energy, protein, vitamins and minerals. There was low-quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications(e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low-quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low-quality evidence from six studies (334 participants), oral supplements may result in lower numbers with ’unfavourable outcome’ (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low-quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05).Only very low-quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95%CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia. There is very low-quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated.There is very low-quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non-functioning gastrointestinal tracts, which is unlikely in this trial.Four trials tested increasing protein intake in an oral feed. These provided low-quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low-quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea.Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1-alpha-hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha-ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low- or very low-quality evidence of no clear effect on mortality or complications, where reported.Based on low-quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125).  Authors’ conclusions: There is low-quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low-quality evidence that oral supplements may reduce ’unfavourable outcome’ (death or complications) and that they do not result in an increased incidenceof vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation