Transfusion practice in the bleeding critically ill: An international online survey—The TRACE ‐2 survey

Abstract Background Over the last decade, multiple large randomized controlled trials have studied alternative transfusion strategies in critically ill patients, demonstrating the safety of restrictive transfusion strategies. Due to the lack of international guidelines specific for the intensive care unit (ICU), we hypothesized that a large heterogeneity in transfusion practice in this patient population exists. The aims of this study were to describe the current transfusion practices and identify the knowledge gaps. Methods An online, anonymous, worldwide survey among ICU physicians was performed evaluating red blood cell, platelet and plasma transfusion practices. Furthermore, the presence of a hospital- or ICU-specific transfusion guideline was asked. Only completed surveys were analysed. Results Nine hundred forty-seven respondents filled in the survey of which 725 could be analysed. Hospital transfusion protocol available in their ICU was reported by 53% of the respondents. Only 29% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin (Hb) threshold for the general ICU population was 7 g/dL (7–7). The highest reported variation in transfusion threshold was in patients on extracorporeal membrane oxygenation or with brain injury (8 g/dL (7.0–9.0)). Platelets were transfused at a median count of 20 × 109 cells/L IQR (10–25) in asymptomatic patients, but at a higher count prior to invasive procedures (p < 0.001). In patients with an international normalized ratio (INR) > 3, 43% and 57% of the respondents would consider plasma transfusion without any upcoming procedures or prior to a planned invasive procedure, respectively. Finally, doctors with base specialty in anaesthesiology transfused critically ill patients more liberally compared to internal medicine physicians. Conclusion Red blood cell transfusion practice for the general ICU population is restrictive, while for different subpopulations, higher Hb thresholds are applied. Furthermore, practice in plasma and platelet transfusion is heterogeneous, and local transfusion guidelines are lacking in the majority of the ICUs.

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A UK national survey of prophylactic platelet transfusion thresholds in non-bleeding, critically ill adults

10.1101/2020.09.02.20186700 ◽

2020 ◽

Author(s):

Akshay Shah ◽

Doug W Gould ◽

James C Doidge ◽

Paul Mouncey ◽

David A Harrison ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Platelet Transfusion ◽

Online Survey ◽

Percutaneous Tracheostomy ◽

Transfusion Practice ◽

Research Centre ◽

Current Guideline ◽

Transfusion Threshold ◽

Platelet Transfusions

Thrombocytopaenia is common in critically ill patients and associated with poor clinical outcomes. Current guideline recommendations for prophylactic platelet transfusions, to prevent bleeding in critically ill patients with thrombocytopaenia, are based on observational data. Recent studies conducted in non-critically ill patients have demonstrated harm associated with platelet transfusions and have also called into question the efficacy of platelet transfusion. To date, there are no well-conducted randomised controlled trials (RCTs) evaluating platelet transfusion in critically ill patients. To inform the design of such an RCT, we sought to characterise current clinical practice across four commonly encountered scenarios in non-bleeding critically ill adult patients with thrombocytopaenia. An online survey link was sent to Clinical Directors and contacts of all adult general ICUs participating in the Intensive Care National Audit and Research Centre Case Mix Programme national clinical audit (n=200). The survey collected data regarding the respondents place of work, training grade and their current individual practice and possible limits of equipoise for prescribing prophylactic platelet transfusions across four scenarios: prophylaxis but with no procedure planned (NPP); ultrasound guided insertion of a right internal jugular central venous catheter (JVI); percutaneous tracheostomy (PT); and surgery with a low bleeding risk (SLBR). After excluding nine responses with missing data on all four of the main questions, responses were received from 99 staff, covering 78 ICUs (39.0% of 200 ICUs invited to participate). While nearly all respondents (98.0%) indicated a platelet transfusion threshold of 30 x 10^9/L or less for patients with no planned procedure, thresholds for planned procedures varied widely and centred at medians of 40 x 10^9/L for JVI (range: 10 to 70), 50 x 10^9/L for SLBR (range: 10 to 100) and 70 x 10^9/L for PT (range: 20 to greater than 100). Current platelet transfusion practice in UK ICUs prior to invasive procedures with relatively low bleeding risks is highly variable. Well-designed studies are needed to determine the optimal platelet transfusion thresholds in critical care.

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Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

Pediatric Critical Care Medicine ◽

10.1097/pcc.0000000000001613 ◽

2018 ◽

Vol 19 (9) ◽

pp. 884-898 ◽

Cited By ~ 34

Author(s):

Stacey L. Valentine ◽

Melania M. Bembea ◽

Jennifer A. Muszynski ◽

Jill M. Cholette ◽

Allan Doctor ◽

...

Keyword(s):

Critical Care ◽

Critically Ill ◽

Transfusion Practice ◽

Critically Ill Children ◽

Pediatric Critical Care ◽

Consensus Recommendations ◽

Rbc Transfusion

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Blood product therapy in the ICU

10.1093/med/9780199600830.003.0267 ◽

2016 ◽

Author(s):

Lirong Qu ◽

Darrell J. Triulzi

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Large Body ◽

Invasive Procedure ◽

Transfusion Practice ◽

Transmission Risk ◽

Haemostatic Agents ◽

Circulatory Overload ◽

Red Cell Transfusion ◽

Transfusion Guidelines

Transfusions are among the most common medical procedures in the intensive care unit. Several randomized controlled trials (RCT) indicate that restrictive red cell transfusion practice using a haemoglobin of <7g/dL is safe in critically-ill patients. Although similar RCT are not available for plasma or platelet transfusion guidelines, a large body of observational studies suggest that plasma transfusion for an invasive procedure has not been shown to be of benefit in patients with INR <2.0. Similarly, in thrombocytopenic patients, the target platelet count for bleeding or for an invasive procedure is 50,000/µl. Viral transmission risk has become exceedingly low. Other risks such as transfusion-associated circulatory overload and, to a lesser extent, transfusion-related acute lung injury, are much more common. Storage of red cells does not seem to be associated with adverse clinical outcomes. Alternatives using haemostatic agents, salvaged blood, and adherence to evidence-based transfusion guidelines probably reduce the need for transfusion in critically-ill patients.

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Transfusion practice in the critically ill: Can we do better?*

Critical Care Medicine ◽

10.1097/01.ccm.0000151075.26901.2f ◽

2005 ◽

Vol 33 (1) ◽

pp. 232 ◽

Cited By ~ 6

Author(s):

Howard L. Corwin

Keyword(s):

Critically Ill ◽

Transfusion Practice

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Blood Transfusion Practice in Critically Ill Patients and Clinical Outcomes

Turkish Journal of Medical and Surgical Intensive Care ◽

10.33381/dcbybd.2019.2200 ◽

2019 ◽

Author(s):

Kamil Gönderen ◽

Aysun Gönderen

Keyword(s):

Blood Transfusion ◽

Clinical Outcomes ◽

Critically Ill ◽

Critically Ill Patients ◽

Transfusion Practice

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Predictors of nurses’ caring practice for critically ill patients in critical technological environments: A cross-sectional survey study

Belitung Nursing Journal ◽

10.33546/bnj.1794 ◽

2021 ◽

Author(s):

Yinglan Li ◽

Waraporn Kongsuwan

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Online Survey ◽

Demographic Data ◽

Linear Regression Analysis ◽

Guizhou Province ◽

Survey Study ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Professional Value

Background: Caring practice for critically ill patients refers to the actions/behaviors/performance of nurses while caring for critically ill adult patients in the intensive care unit (ICU). Although the caring practice is vital in ICUs and complex due to the multitude of availabletechnologies, research on ICU nurses’ caring practice and its predictive factors are lacking. Objective: This study aimed to explore the level of nurses’ caring practice for critically ill patients in critical technological environments in China and its predictors. Methods: This was a cross-sectional online survey study with 218 ICU nurses in 29 tertiary hospitals of Guizhou province, China, from 1st to 30th April 2020. Data were collected by using e-questionnaires made in the Questionnaire Star program, including the Demographic Data Questionnaire (DDQ), Practice of Technological Competency as Caring in Nursing Instrument (P-TCCNI), Influence of Technology Questionnaire (ITQ), and Nurses’ Professional Value Scale (NPVS). The questionnaires were content validated by three experts. Cronbach’s alpha coefficient was 0.96 for the P-TCCNI, 0.70 for the ITQ, and 0.95 for the NPVS. Links to the questionnaires were distributed by research assistants to WeChat groups including target participants. Statistical Package for the Social Science (SPSS) program version 26 (IBM Corporation, Armonk, NY, USA) was used for data analysis. Descriptive and inferential statistics were used to analyze the data. Multiple linear regression analysis using stepwise solution analysis was performed to identify unique predictors of nurses’ caring practice. Results: The level of nurses’ caring practice for critically ill patients was high (mean = 87.30, standard deviation = 13.73). The professional value was a significant predictor of nurses’ caring practice (β = 0.41, p = 0.00). Conclusion: ICU nurses exhibited a high level of caring practice. Professional value was a significant predictor of ICU nurses’ caring practice. Nursing administrators should understand the current situation of caring practice in critical technological environments and design strategies to maintain and improve ICU nurses’ professional value to increase the level of caring practice. Funding: This study was financially supported by a thesis grant from Thailand’s Education Hub for Southern Region of ASEAN Countries (TEH-AC) Scholarship through Prince of Songkla University, Thailand.

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Vancomycin Dosing Practices among Critical Care Pharmacists: A Survey of Society of Critical Care Medicine Pharmacists

Infectious Diseases Research and Treatment ◽

10.1177/1178633720952078 ◽

2020 ◽

Vol 13 ◽

pp. 117863372095207

Author(s):

Alexander H Flannery ◽

Drayton A Hammond ◽

Douglas R Oyler ◽

Chenghui Li ◽

Adrian Wong ◽

...

Keyword(s):

Critical Care ◽

Infectious Diseases ◽

Critically Ill ◽

Critically Ill Patients ◽

Online Survey ◽

Critical Care Medicine ◽

Guideline Recommendation ◽

Critically Ill Patient ◽

Critically Ill Adults ◽

Monitoring Protocols

Introduction: Critically ill patients and their pharmacokinetics present complexities often not considered by consensus guidelines from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Prior surveys have suggested discordance between certain guideline recommendations and reported infectious disease pharmacist practice. Vancomycin dosing practices, including institutional considerations, have not previously been well described in the critically ill patient population. Objectives: To evaluate critical care pharmacists’ self-reported vancomycin practices in comparison to the 2009 guideline recommendations and other best practices identified by the study investigators. Methods: An online survey developed by the Research and Scholarship Committee of the Clinical Pharmacy and Pharmacology (CPP) Section of the Society of Critical Care Medicine (SCCM) was sent to pharmacist members of the SCCM CPP Section practicing in adult intensive care units in the spring of 2017. This survey queried pharmacists’ self-reported practices regarding vancomycin dosing and monitoring in critically ill adults. Results: Three-hundred and sixty-four responses were received for an estimated response rate of 26%. Critical care pharmacists self-reported largely following the 2009 vancomycin dosing and monitoring guidelines. The largest deviations in guideline recommendation compliance involve consistent use of a loading dose, dosing weight in obese patients, and quality improvement efforts related to systematically monitoring vancomycin-associated nephrotoxicity. Variation exists regarding pharmacist protocols and other practices of vancomycin use in critically ill patients. Conclusion: Among critical care pharmacists, reported vancomycin practices are largely consistent with the 2009 guideline recommendations. Variations in vancomycin dosing and monitoring protocols are identified, and rationale for guideline non-adherence with loading doses elucidated.

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