Survey No. ______

Survey of transfusion practices in critically ill patients
with traumatic brain injury

Please answer the following 23 questions in the way that best reflects your clinical practice. If you do not find an ideal answer among the available options for a particular question, please choose the answer that most closely reflects your opinion. Your answers will be kept confidential.

1)What year did you complete postgraduate training (i.e. residency or fellowship)?

______

2)What is your specialty? (If you have more than one specialty, choose the one that you primarilypractice.)

  1. Neurosurgery
  2. General surgery
  3. Internal medicine
  4. Anesthesia
  5. Neurology
  6. Emergency Medicine
  7. Other (please state)______

3)Within your specialty, which of the following best defines your subspecialty interest?

  1. Trauma
  2. A subspecialty other than trauma
  3. No particular subspecialty

4)Are you board certified in adult critical care (surgery, medicine, anesthesia, or emergency medicine)?

  1. Yes
  2. No

5)Please indicate which, if any, of the following administrative responsibilities you have (circle all that apply)

  1. Physician in charge of the general surgery service that cares for trauma patients (i.e. “Chief of Trauma”)
  2. Physician in charge of the neurosurgery service that cares for trauma patients (i.e. “Chief of Neurosurgery”)
  3. Physician in charge of the intensive care unit that cares for trauma patients (i.e. “Surgical ICU Director”)
  4. Physician in charge of the neurointensive care unit that cares for head-injured patients (i.e. “Neurosurgical ICU Director”)
  5. None of the above administrative responsibilities

6)In your estimation, approximately how many patients with traumatic brain injury required craniotomy or intracerebral pressure monitoring at your hospital over the past year? If you work at more than one institution, please estimate the number at the hospital which admits the largest number of brain trauma patients. This includes both those with isolated brain injuriesand patients with injuries to multiple organ systems. (circle one)

  1. ≤ 12 (approximately 1 per month or less)
  2. 13-25 (approximately 1-2 per month)
  3. 26-50 (approximately 3-4 per month)
  4. 51-100 (approximately 1-2 per week)
  5. >100 (more than 2 per week)

7)Approximately how many weeks during the last 12 monthsdid you attend as the primary physician or consultant in the inpatient management of ICU patients with traumatic brain injury?

______

8)When a patient with anisolated traumatic brain injurywhorequires craniotomy or ICP monitoring is admitted to the ICU at your hospital, which service is most likely to have primary responsibility for patient care during the majority of the patient’s ICU admission? (circle one)

  1. General Surgery (including Trauma Surgery)
  2. Neurosurgery
  3. Dedicated neurosurgical intensive care unit service staffed by medicine, anesthesia, or emergency medicine critical care-trained physicians
  4. Medical intensive care unit service
  5. Neurology
  6. Other (please describe)______

9)When a multiply injured patient with traumatic brain injurythat requires craniotomy or ICP monitoring is admitted to the ICU at your hospital, which service is most likely to have primary responsibility for patient care during the majority of the patient’s ICU admission? (circle one)

  1. General Surgery (including Trauma Surgery)
  2. Neurosurgery
  3. Dedicated neurosurgical intensive care unit service staffed by medicine, anesthesia, or emergency medicine critical care-trained physicians
  4. Medical intensive care unit service
  5. Neurology
  6. Other (please describe) ______

10)For a critically ill, multiply injured patient without traumatic brain injury, below what hemoglobin threshold would you generally administer a transfusion of packed red blood cells? Assume that the patient is a young, previously healthy adult who is euvolemic and does not have evidence of active bleeding or infection. Even if you do not routinely care for these patients, your best answer is still appreciated. (circle one)

  1. Hemoglobin = 5.0 g/dl (Hematocrit = 15%)
  2. Hemoglobin = 6.0 g/dl (Hematocrit = 18%)
  3. Hemoglobin = 7.0 g/dl (Hematocrit = 21%)
  4. Hemoglobin = 8.0 g/dl (Hematocrit = 24%)
  5. Hemoglobin = 9.0 g/dl (Hematocrit = 27%)
  6. Hemoglobin = 10.0 g/dl (Hematocrit = 30%)
  7. Hemoglobin = 11.0 g/dl (Hematocrit = 33%)
  8. Hemoglobin = 12.0 g/dl (Hematocrit = 36%)

11)For a critically ill, multiply injured patient with traumatic brain injury, below what hemoglobin threshold would you generally administer a transfusion of packed red blood cells? Assume that the patient is a young, previously healthy adult who is euvolemic, does not have evidence of active bleeding or infection, and has a normal ICP. (circle one)

  1. Hemoglobin = 5.0 g/dl (Hematocrit = 15%)
  2. Hemoglobin = 6.0 g/dl (Hematocrit = 18%)
  3. Hemoglobin = 7.0 g/dl (Hematocrit = 21%)
  4. Hemoglobin = 8.0 g/dl (Hematocrit = 24%)
  5. Hemoglobin = 9.0 g/dl (Hematocrit = 27%)
  6. Hemoglobin = 10.0 g/dl (Hematocrit = 30%)
  7. Hemoglobin = 11.0 g/dl (Hematocrit = 33%)
  8. Hemoglobin = 12.0 g/dl (Hematocrit = 36%)

12)For the patient in question 11, which category of physician is most likely to decide whether a transfusion should be given? (circle one)

  1. Neurosurgery junior resident
  2. Neurosurgery senior or chief resident
  3. Neurosurgery attending
  4. General trauma surgery junior resident
  5. General trauma surgery senior or chief resident
  6. General trauma surgery attending
  7. Non-surgeon intensive care resident (medicine, anesthesia or emergency medicine)
  8. Non-surgeon intensive care attending (medicine, anesthesia or emergency medicine)
  9. Other (please describe) ______

13)At your institution, how often do you feel there is general agreement between physicians from different services (anesthesia or medical intensivists, neurosurgery, general/trauma surgery) on a transfusion threshold for critically ill patients with severe traumatic brain injury (i.e. require craniotomy or ICP monitoring)?

  1. Usually agree
  2. Sometimes agree
  3. Infrequently agree

Please answer the followingquestions (14-21) below using the following case scenario:

A 25 year old man was admitted to the ICU aftera motor vehicle crash. He is now post injury day 3. His head CT scan demonstrates multiple small cerebral contusions (unchanged from admission). His other injuries include multiple rib fractures and a liver laceration without evidence of ongoing bleeding. He is intubated and mechanically ventilated. His GCS is stable at 6T (E1, M4, V1T) and his intracranial pressure is 12 mm Hg. His blood pressure is stable at 135/65 and his heart rate is 95. He does not have any evidence of an infection. His hemoglobin is 7.4 g/dl (hematocrit 22%).

14)Would you administer a blood transfusion to this patient?

  1. Yes
  2. No

15)If you would administer blood to this patient, how many units of packed red blood cells would you give the patient at this time? (circle one)

  1. 1
  2. 2
  3. 3
  4. 4 or more

16)If you would administer blood to this patient, do you believe that blood transfusion in this general setting is associated with better neurologic outcomes than no transfusion? (circle one)

  1. Yes
  2. No

17)Would you routinely use additional information beyond what is presented in the scenario above to determine whether or not to administer a blood transfusion in this situation?

  1. Yes
  2. No

18)If you would routinely use additional information to determine whether or not to administer blood, what additional information would you use in this patient with normal ICP? (if you answered “yes” to question 17, circle all that apply)

  1. Peripheral arterial oxygen saturation (SaO2)
  2. Pulmonary artery mixed venous oxygen saturation (SvO2)
  3. Jugular bulb venous oxygen saturation (SjO2)
  4. Brain tissue pO2 (LICOX)
  5. Other (please describe) ______

19)Below what hemoglobin threshold would you administer a transfusion of packed red blood cells to this patient? (circle one)

  1. Hemoglobin = 5.0 g/dl (Hematocrit = 15%)
  2. Hemoglobin = 6.0 g/dl (Hematocrit = 18%)
  3. Hemoglobin = 7.0 g/dl (Hematocrit = 21%)
  4. Hemoglobin = 8.0 g/dl (Hematocrit = 24%)
  5. Hemoglobin = 9.0 g/dl (Hematocrit = 27%)
  6. Hemoglobin = 10.0 g/dl (Hematocrit = 30%)
  7. Hemoglobin = 11.0 g/dl (Hematocrit = 33%)
  8. Hemoglobin = 12.0 g/dl (Hematocrit = 36%)

20)If you were taking care of the same patient but instead his ICP were 27 mm Hg and it remained that high despite efforts to control it, below what hemoglobin threshold would you administer a transfusion of packed red blood cells? (circle one)

  1. Hemoglobin = 5.0 g/dl (Hematocrit = 15%)
  2. Hemoglobin = 6.0 g/dl (Hematocrit = 18%)
  3. Hemoglobin = 7.0 g/dl (Hematocrit = 21%)
  4. Hemoglobin = 8.0 g/dl (Hematocrit = 24%)
  5. Hemoglobin = 9.0 g/dl (Hematocrit = 27%)
  6. Hemoglobin = 10.0 g/dl (Hematocrit = 30%)
  7. Hemoglobin = 11.0 g/dl (Hematocrit = 33%)
  8. Hemoglobin = 12.0 g/dl (Hematocrit = 36%)

21)Now assume this patient’s ICP is not elevated but that he is about to undergo general anesthesia for two hours for tracheostomy and gastrostomy tube placement. The anticipated blood loss for these procedures is minimal (<50 ml). Below what hemoglobin threshold would you administer a transfusion of packed red blood cells? (circle one)

  1. Hemoglobin = 5.0 g/dl (Hematocrit = 15%)
  2. Hemoglobin = 6.0 g/dl (Hematocrit = 18%)
  3. Hemoglobin = 7.0 g/dl (Hematocrit = 21%)
  4. Hemoglobin = 8.0 g/dl (Hematocrit = 24%)
  5. Hemoglobin = 9.0 g/dl (Hematocrit = 27%)
  6. Hemoglobin = 10.0 g/dl (Hematocrit = 30%)
  7. Hemoglobin = 11.0 g/dl (Hematocrit = 33%)
  8. Hemoglobin = 12.0 g/dl (Hematocrit = 36%)

22)Some physicians believe that occult secondary brain injury is an important problem in head-injured patients because even careful monitoring of these patients has practical limitations. However, other physicians think that secondary injury is not a problem because monitoring can prevent its occurrence. Do you think occult secondary brain injury (despite diligent monitoring) is an important problem in your clinical practice?

  1. Yes
  2. No
  3. Don’t know

23)Some physicians believe that blood transfusions have harmful immunomodulatory effects that result in increased risk for infection and/or organ failure. However, other physicians do not believe such effects occur. Do you believe that red cell transfusions have clinically significant immunomodulatory effects in critically ill patients?

  1. Yes
  2. No
  3. Don’t know

Thank you for your participation in this survey. If you have any comments concerning this topic or the survey content, please include them in the space provided below. Your time is greatly appreciated. Return this using the enclosed self addressed, postage paid envelope.

Comments:

Matthew J. Sena, MDGarth H. Utter, MD MSc

Assistant ProfessorAssistant Professor

Department of SurgeryDepartment of Surgery

U.C.DavisMedicalCenterU.C.DavisMedicalCenter

(916) 734-1767(916) 734-1768

Felix D. Battistella, MDJ. Paul Muizelaar, MD PhD

Professor & Chief of TraumaProfessor and Chair

Department of SurgeryDepartment of Neurological Surgery

U.C.DavisMedicalCenterU.C.DavisMedicalCenter

(916) 734-4771(916) 734-3071