Transfusion threshold in severe TBI?

[Hamhock]

In the spirit (or dream) of multi-disciplinary CCM, I have choosen to post here, instead of the surgery forum.

In severe TBI, what Hgb are you all transfusing red blood cells in the ICU?

I am not referring to the initial resuscitation in the trauma bay or transfusion for hemorrhagic hypotension in polytrauma. In fact, let's limit this discussion to isolated severe TBI.

And let's say all other "goals" (eg CPP, paO2, etc) are met.

It's your call if the MRI or vasospastic TCDs matter to you and change your input.

Goal Hgb 10? Hgb 7?

Please let me know your primary training (surgery, EM, anesthesiology, IM, neuro, NSx) and what type of fellowship you completed (IM, surgery, NCC, anesthesiology). Did you have a neuro-specific unit during fellowship? Did your fellowship have separate units for neurotrauma and neurovascular ("medical neuro")?

Thanks, HH

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[deleted547339]

In the spirit (or dream) of multi-disciplinary CCM, I have choosen to post here, instead of the surgery forum.

In severe TBI, what Hgb are you all transfusing red blood cells in the ICU?

I am not referring to the initial resuscitation in the trauma bay or transfusion for hemorrhagic hypotension in polytrauma. In fact, let's limit this discussion to isolated severe TBI.

And let's say all other "goals" (eg CPP, paO2, etc) are met.

It's your call if the MRI or vasospastic TCDs matter to you and change your input.

Goal Hgb 10? Hgb 7?

Please let me know your primary training (surgery, EM, anesthesiology, IM, neuro, NSx) and what type of fellowship you completed (IM, surgery, NCC, anesthesiology). Did you have a neuro-specific unit during fellowship? Did your fellowship have separate units for neurotrauma and neurovascular ("medical neuro")?

Thanks, HH

I’m EM. Did plenty of neuro-trauma in fellowship.

I would argue that you should transfuse to 7 if HD stable, normal lactate, no signs of ischemia, etc. and that is my practice pattern.

My reason is this: we know for a fact that transfusions are damaging. We know that lower transfusion thresholds influence mortality. I’m not going to let a hypothetical, physiologic argument dissuade me from a scientifically demonstrated mortality improving outcome.

 

[CCM-MD]

CCM & IM here. Rotated through 2 Neuro-Trauma ICUs in fellowship. No separate unit for "medical neuro", everyone was lumped together in those 2 units. General consensus was goal Hb of >7 for most patients except those acutely bleeding or had high risk cardiac features (concomitant ACS or high risk ischemic heart disease).

 

[kemper6036]

Primary training in surgery. Fellowship in surgical critical care. Had rotation in neuro ICU and in trauma ICU which was where the majority of TBI were managed. Goal Hb>7. I don't think you'd find a lot of variation in this given the literature supporting 7 as opposed to 10. In my mind the only indication for 10 is active ACS and some ECMO

 

[Zedor]

Nsgy resident. Hg of 7