Variation in Blood Transfusion and Coagulation Management in Traumatic Brain Injury at the Intensive Care Unit: A Survey in 66 Neurotrauma Centers Participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study

Abstract

Our aim was to describe current approaches and to quantify variability between European intensive care units (ICUs) in patients with traumatic brain injury (TBI). Therefore, we conducted a provider profiling survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The ICU Questionnaire was sent to 68 centers from 20 countries across Europe and Israel. For this study, we used ICU questions focused on 1) hemoglobin target level (Hb-TL), 2) coagulation management, and 3) deep venous thromboembolism (DVT) prophylaxis. Seventy-eight participants, mostly intensivists and neurosurgeons of 66 centers, completed the ICU questionnaire. For ICU-patients, half of the centers (N = 34; 52%) had a defined Hb-TL in their protocol. For patients with TBI, 26 centers (41%) indicated an Hb-TL between 70 and 90 g/L and 38 centers (59%) above 90 g/L. To treat trauma-related hemostatic abnormalities, the use of fresh frozen plasma (N = 48; 73%) or platelets (N = 34; 52%) was most often reported, followed by the supplementation of vitamin K (N = 26; 39%). Most centers reported using DVT prophylaxis with anticoagulants frequently or always (N = 62; 94%). In the absence of hemorrhagic brain lesions, 14 centers (21%) delayed DVT prophylaxis until 72 h after trauma. If hemorrhagic brain lesions were present, the number of centers delaying DVT prophylaxis for 72 h increased to 29 (46%). Overall, a lack of consensus exists between European ICUs on blood transfusion and coagulation management. The results provide a baseline for the CENTER-TBI study, and the large between-center variation indicates multiple opportunities for comparative effectiveness research.

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis

“…GOSE Glasgow Outcome Scale extended, ICP intracranial pressure, MOR median odds ratio combinations of these different factors. As for monitoring and management variations among centers, heterogeneity was not unexpected: previous studies [19][20][21] and surveys [22][23][24] found profound dissimilarities between centers in monitoring and treatment policies similar to our study.…”

Current state of transfusion in traumatic brain injury and associated coagulopathy

“…Patients with isolated TBI receive plasma transfusions primarily to revers trauma‐induced or medically induced coagulopathy. In a provider‐profiling survey that included 66 centers from 20 European countries, fresh frozen plasma was transfused to treat hemostatic abnormalities in 73% of patients with TBI . A small retrospective study found that plasma transfusion before hospital admission reduced the average international normalized ratio (INR) upon admission from 3.1 to 1.9 in patients with TBI on warfarin, but the clinical outcomes for these patients were not reported .…”

“…In a provider-profiling survey that included 66 centers from 20 European countries, fresh frozen plasma was transfused to treat hemostatic abnormalities in 73% of patients with TBI. 56 A small retrospective study found that plasma transfusion before hospital admission reduced the average international normalized ratio (INR) upon admission from 3.1 to 1.9 in patients with TBI on warfarin, but the clinical outcomes for these patients were not reported. 57 The transfusion of fresh or lyophilized fresh frozen plasma (FFP) has been reported to reduce neurologic impairment and accelerate the recovery of Yorkshire swine subjected to TBI and controlled hemorrhagic shock as compared to those receiving normal saline.…”

“…In the same provider-profiling survey of 66 centers from 20 European countries, platelets were transfused to treat hemostatic abnormalities in 52% of patients. 56 There have been consistent reports that platelets undergo significant phenotypic changes over the course of TBI, but their causes are less understood than the causes of the consumptive coagulopathy and hyperfibrinolysis. 14,65 Platelets have moderately low counts and enhanced activation and express procoagulant activity in patients with TBI as well as in rats subjected to TBI.…”

Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: a European prospective, multicentre, longitudinal, cohort study

“…Provider Profiles of participating centres were established to characterize structures and processes of care in preparation for comparative effectiveness research. [5][6][7][8][9][10] We here aim to describe the contemporary landscape of TBI in Europe, with a focus on the patient case-mix, care pathways, and outcome in the Core study, and to explore generalizability by comparison to the Registry.…”