The Skeptics Guide to Emergency Medicine SGEM#492: Give Blood – To Anemic Patients with Acute Brain Injuries
Nov 16, 2025
Dr. Alex Weiler, an Emergency Department physician and associate professor, dives into the TRAIN transfusion trial, exploring its significant findings for anemic patients with acute brain injuries. He discusses the trial's impact on transfusion thresholds and the effects on cerebral oxygenation. With a focus on how a liberal transfusion strategy can improve neurological outcomes, Alex evaluates biases in the study design. He also provides practical guidance for clinicians in managing these critical patients, emphasizing communication with families about treatment benefits.
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Brain Injury Changes Transfusion Calculus
- Acute brain injury patients may respond differently to transfusion thresholds than general ICU patients.
- The brain's unique oxygen sensitivity makes anemia more consequential for neurologic outcomes.
TRAIN Trial Design And Primary Outcome
- The TRAIN trial compared liberal (Hb>90) versus restrictive (Hb>70) transfusion targets in acute brain injury.
- Primary outcome was unfavorable neurologic status at six months using the Glasgow Outcome Scale.
Liberal Transfusion Improved Neurologic Outcomes
- The trial randomized 820 patients across 72 ICUs with mixed brain-injury types and severe injury (median GCS 6).
- A liberal strategy reduced unfavorable neurologic outcomes compared to restrictive care.