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Red blood cell transfusion in critically ill patients with traumatic brain injury: an international survey of physicians’ attitudes

  • Paule Lessard Bonaventure
  • Francois Lauzier
  • Ryan Zarychanski
  • Amélie Boutin
  • Michèle Shemilt
  • Manoj Saxena
  • Parjam Zolfagari
  • Donald Griesdale
  • David K. Menon
  • Simon Stanworth
  • Shane English
  • Michaël Chassé
  • Dean A. Fergusson
  • Lynne Moore
  • Andreas Kramer
  • Amélie Robitaille
  • John Myburgh
  • Jamie Cooper
  • Peter Hutchinson
  • Alexis F. TurgeonEmail author
  • the Canadian Critical Care Trials Group and the Canadian Traumatic Brain Injury Research Consortium
Reports of Original Investigations

Abstract

Introduction

Restrictive transfusion strategies have been advocated in critically ill patients. Nevertheless, considerable uncertainty exists regarding optimal transfusion thresholds in traumatic brain injury (TBI) patients because the injured brain is susceptible to hypoxemic damage. We aimed to identify the determinants of red blood cell (RBC) transfusion and the perceived optimal transfusion thresholds in adult patients with moderate-to-severe TBI.

Methods

We conducted an electronic, self-administered survey targeting critical care specialists and neurosurgeons from Canada, Australia, and the United Kingdom caring for TBI patients. The questionnaire was initially developed by a panel of experts using a structured process (domains/items generation and reduction). The questionnaire was validated for clinical sensibility, reliability, and content.

Results

The response rate was 28.7% (218/760). When presented with the hypothetical scenario of a young adult TBI patient, a wide range of transfusion practices was observed, with 47 (95% confidence interval [CI], 41 to 54)% favouring RBC transfusion at a hemoglobin level of ≤ 70 g·L–1 in the acute phase of care, while 73 (95% CI, 67 to 79)% would use this trigger in the plateau phase of care. Multiple trauma, neuro-monitoring data, hemorrhagic shock, and planned surgery were the main factors that influenced the need for transfusion. The lack of clinical evidence and guidelines was responsible for uncertainty regarding RBC transfusion strategies in this patient population.

Conclusion

In our survey about critically ill TBI patients, transfusion practice was found to be mainly influenced by the acuity of care, patient characteristics, and neuro-monitoring. Clinical equipoise regarding optimal transfusion strategy is believed to be mainly attributed to the lack of clear clinical evidence and guidelines. Appropriate randomized-controlled trials are required to determine the optimal transfusion strategies in TBI patients.

Transfusion d’érythrocytes chez les patients en état critique atteints de traumatisme cérébral : une enquête de pratique internationale des médecins

Résumé

Introduction

Le recours à des stratégies de transfusion restrictives a été préconisé chez les patients en état critique. Une incertitude considérable demeure toutefois quant aux seuils optimaux de transfusion pour les patients atteints de traumatisme cérébral (TCC) considérant que le cerveau lésé est susceptible de subir des lésions hypoxémiques. Nous avons tenté d’identifier les facteurs déterminants pour l’initiation d’une transfusion d’érythrocytes ansi que les seuils de transfusion considérés comme optimaux chez les patients adultes victimes de TCC modéré à grave.

Méthodologie

Nous avons développé un sondage électronique et auto-administré destiné aux intensivistes et aux neurochirurgiens canadiens, australiens et britanniques prenant soin de patients ayant subi un TCC. Le questionnaire a d’abord été élaboré par un groupe d’experts à l’aide d’un processus structuré (génération et réduction de domaines/items). Le questionnaire a ensuite été validé pour garantir sa sensibilité clinique, sa fiabilité et son contenu.

Résultats

Le taux de réponse était de 28,7% (218/760). Lorsqu’on a soumis aux répondants le cas hypothétique d’un jeune adulte ayant subi un TCC, nous avons observé un vaste éventail de pratiques transfusionnelles, 47% (intervalle de confiance [IC] 95%, 41 à 54%) des répondants étant en faveur d’une transfusion d’érythrocytes à partir d’un taux d’hémoglobine ≤ 70 g·L–1 dans la phase aiguë de soins, alors que 73% (IC 95%, 67 à 79%) utiliseraient ce seuil déclencheur dans la phase chronique des soins. Les traumatismes multiples, les données de monitorage neurologique, un choc hémorragique et une chirurgie programmée constituaient les principaux facteurs influençant le besoin perçu de transfusion. L’absence de données probantes cliniques et de recommandations était responsable de l’incertitude concernant les stratégies de transfusion d’érythrocytes chez cette population de patients.

Conclusion

Dans notre questionnaire portant sur les patients victimes de TCC en état critique, nous avons observé que les pratiques de transfusion étaient principalement influencées par l’acuité des soins, les caractéristiques des patients et le monitorage neurologique. L’équilibre clinique (equipoise) concernant la stratégie de transfusion optimale est probablement principalement attribuable à l’absence de données probantes cliniques claires ou de recommandations. Des études randomisées contrôlées sont nécessaires afin de déterminer quelles stratégies de transfusion seraient optimales pour les patients atteints de TCC.

Notes

Acknowledgements

The authors would like to thank Xavier Neveu MSc for his help with statistical analyses, and Caroline Léger PhD and Marjorie Daigle for their administrative help. This study was developed with the Canadian Critical Care Trials Group (CCCTG) and the Canadian Traumatic Brain Injury Research Consortium (CTRC). We want to thank the CCCTG and the CTRC Grants and Manuscripts Committees for critically reviewing the manuscript.

Conflicts of interest

The authors declare no conflict of interest.

Editorial responsibility

This submission was handled by Dr. Steven Backman, Associate Editor, Canadian Journal of Anesthesia.

Author contributions

Paule Lessard Bonaventure and Alexis F. Turgeon contributed to the study concept and design. Paule Lessard Bonaventure, Michèle Shemilt, Amélie Robitaille, and Alexis F. Turgeon contributed to the acquisition, analysis, and interpretation of data. Paule Lessard Bonaventure and Alexis F. Turgeon contributed to drafting the manuscript. Paule Lessard Bonaventure, Michèle Shemilt, and Alexis F. Turgeon contributed to the statistical analyses. All authors contributed to the critical revision of the manuscript. Alexis F. Turgeon contributed to the study supervision.

Funding

This work was funded by the CHU de Québec – Université Laval Foundation (Killimanjaro Fund) and by a Foundation Scheme Grant (354039) from the Canadian Institutes of Health Research (CIHR). Dr Lessard Bonaventure is the recipient of a training award from the CIHR. Drs. Lauzier, Moore, and Chassé are recipients of a research career award from the Fonds de Recherche du Québec - Santé (FRQS). Drs. Turgeon, Lauzier, and Moore are supported by the Traumatology Research Consortium of the FRQS. Dr. Turgeon is the chairholder of the Canada Research Chair in Critical Neurology and Trauma. The Canadian Traumatic Brain Injury Research Consortium is funded by a Team Grant from the CIHR, and the Canadian Critical Care Trials Group is funded by a Community Development Grant from the CIHR.

Supplementary material

12630_2019_1369_MOESM1_ESM.pdf (2.3 mb)
Supplementary material 1 (PDF 2391 kb)

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Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  • Paule Lessard Bonaventure
    • 1
    • 2
  • Francois Lauzier
    • 1
    • 3
    • 4
  • Ryan Zarychanski
    • 5
  • Amélie Boutin
    • 1
  • Michèle Shemilt
    • 1
  • Manoj Saxena
    • 6
  • Parjam Zolfagari
    • 7
  • Donald Griesdale
    • 8
  • David K. Menon
    • 7
  • Simon Stanworth
    • 9
  • Shane English
    • 10
    • 11
  • Michaël Chassé
    • 12
  • Dean A. Fergusson
    • 10
  • Lynne Moore
    • 1
    • 13
  • Andreas Kramer
    • 14
  • Amélie Robitaille
    • 1
  • John Myburgh
    • 6
  • Jamie Cooper
    • 6
    • 15
  • Peter Hutchinson
    • 7
  • Alexis F. Turgeon
    • 1
    • 3
    Email author
  • the Canadian Critical Care Trials Group and the Canadian Traumatic Brain Injury Research Consortium
  1. 1.CHU de Québec – Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care MedicineCHU de Québec-Université Laval (Hôpital de l’Enfant-Jésus)Québec CityCanada
  2. 2.Department of Surgery, Division of NeurosurgeryUniversité LavalQuébec CityCanada
  3. 3.Division of Critical Care Medicine, Department of Anesthesiology and Critical Care MedicineUniversité LavalQuébec CityCanada
  4. 4.Department of MedicineUniversité LavalQuébec CityCanada
  5. 5.Department of Internal Medicine, Sections of Critical Care Medicine, of Haematology and of Medical Oncology, Faculty of MedicineUniversity of ManitobaWinnipegCanada
  6. 6.The George Institute for Global HealthSydneyAustralia
  7. 7.Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals TrustCambridge UniversityCambridgeUK
  8. 8.Division of Critical Care Medicine, Department of Medicine, Vancouver General HospitalUniversity of British ColumbiaVancouverCanada
  9. 9.National Institute for Health Research (NIHR), Oxford Biomedical Research CentreOxford University Hospitals and the University of OxfordOxfordUK
  10. 10.Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
  11. 11.Department of Medicine (Critical Care)University of OttawaOttawaCanada
  12. 12.CHUM Research CenterUniversité de MontréalMontréalCanada
  13. 13.Department of Preventive and Social MedicineUniversité LavalQuébec CityCanada
  14. 14.Department of Critical Care MedicineFoothills Medical CenterCalgaryCanada
  15. 15.The Alfred HospitalMelbourneAustralia

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