Confidential Page 1 of 18 Survey on Clinically Relevant

Thank you for having accepted to participate in this research project. We all know when a patient is presenting with a clinically relevant bleeding episode, but it is difficult to have an operational definition that can be used for research. The goal of this survey is to understand what pediatric critical care providers consider a clinically relevant bleed. Some might define "clinically relevant" as an increased risk of worse outcome, others as the requirement for more support, or as increased costs, etc. For each of the following items, please indicate how you would qualify the clinical significance of the bleeding in the following scenarios. We do realize that it will sometimes be difficult for you to answers as the significance of bleeding might depend on the clinical context. Unfortunately, a survey does not allow to capture the complexity of real-life situations. If you do not feel comfortable with the wording of the questions, please feel free to move to the next question or to end the survey.

Thank you for having accepted to participate in this research project.

We all know when a patient is presenting with a clinically relevant bleeding episode, but it is difficult to have an operational definition that can be used for research. The goal of this survey is to understand what pediatric critical care providers consider a clinically relevant bleed. Some might define "clinically relevant" as an increased risk of worse outcome, others as the requirement for more support, or as increased costs, etc.

For each of the following items, please indicate how would you qualify the clinical significance of the bleeding in the following scenarios. We do realize that it will sometimes be difficult for you to answers as the significance of bleeding might depend on the clinical context. Unfortunately, a survey does not allow to capture the complexity of real-life situations.

If you do not feel comfortable with the wording of the questions, please feel free to move to the next question or to end the survey.

For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Intracranial extraparenchymal bleeding with signs of increased ICP or midline shift

Intracranial intra-parenchymal bleeding without signs of increased ICP

Intraorbital or intra-ocular bleeding with visual change

Bleeding in the spinal cord Bleeding from arterio-venous malformations

Bleeding ruptured aneurysms

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Bleeding leading to a drop in hemoglobin by > 20%

Bleeding leading to a drop in hemoglobin by 10 to 20%

Bleeding leading to a drop in hemoglobin by < 10%

Bleeding leading to a drop in hemoglobin by > 2 g/dL (20 g/L)

Bleeding leading to a drop in hemoglobin by 1 to 2 g/dL (10 to 20 g/L)

Bleeding leading to a drop in hemoglobin by < 1 g/dL (10 g/L)

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Bleeding leading to hypovolemia with signs of hypoperfusion

Bleeding leading to hypovolemia without signs of hypoperfusion

Bleeding leading to increase in lactate above 3 mmol/L (27 mg/dL)

Bleeding with normal lactate (< 3 mmol/L (27 mg/dL))

Bleeding leading to drop in SvO2 below 65%

Bleeding with normal SvO2 (above 70%)

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Bleeding associated with a drop in systolic blood pressure by > 20%

Bleeding associated with a drop in systolic blood pressure by 10 to 20%

Bleeding associated with a drop in systolic blood pressure by < 10%

Bleeding associated with an increase in heart rate by > 20%

Bleeding associated with an increase in heart rate by 10 to 20%

Bleeding associated with an increase in heart rate by < 10%

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Bleeding leading to a drop in by > 33% from baseline Bleeding leading to a drop in platelets by < 33% from baseline Bleeding leading to a increase in INR by > 0.5 from baseline

Bleeding leading to a increase in INR by < 0.5 from baseline

Bleeding leading to a drop in fibrinogen by > 35% from baseline

Bleeding leading to a drop in fibrinogen by < 35% from baseline

Bleeding leading to a increased time to thrombin generation

Bleeding leading to hyperfibrinolysis

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Bleeding leading to fluid replacement

Bleeding leading to red blood cell transfusion

Bleeding leading to plasma transfusion

Bleeding leading to transfusion

Bleeding leading to cryo or fibrinogen infusion

Bleeding leading to rFVIIa infusion Bleeding in which red blood cell transfusion fails to increase hemoglobin level

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When considering quantifiable bleeding, such as from < 1 ml/kg/hr a chest tube, what would be the volume that you > 1 ml/kg/hr would consider "definitively clinically relevant" > 2 ml/kg/hr (the duration of bleeding is the next question)? > 3 ml/kg/hr > 5 ml/kg/hr > 7 ml/kg/hr > 10 ml/kg/hr

How long must the patient be bleeding above the < 30 minutes previous threshold for you to consider it > 30 minutes "definitively clinically relevant"? > 1 hour > 2 hour > 4 hour > 6 hours

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Tamponade with symptoms (chest pain)

Tamponade with hemodynamic compromise

Asymptomatic Pulmonary intraparenchymal bleeding with respiratory distress Pulmonary intraparenchymal bleeding with increase in FiO2

Pulmonary intraparenchymal bleeding even without respiratory distress

Hemothorax with clinical repercussions (respiratory distress or cardiovascular compromise)

Hemothorax without clinical repercussions (asymptomatic)

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Bleeding not resolving within 6 hours

Bleeding resolving within 2 to 6 hours

Bleeding resolving in less than 2 hours

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Bleeding leading to hospital admission

Bleeding leading to pediatric critical care admission

Bleeding leading to prolonged surgical time for hemostasis

Bleeding requiring operative intervention

Bleeding requiring procedure (e.g. chest tube insertion)

Bleeding requiring requesting tests

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Post-op oro-pharyngeal bleeding with respiratory distress

Retroperitoneal bleeding Abdominal compartment syndrome due to bleeding

Moderate abdominal bleeding following trauma (as evaluated by ultrasound)

Minimal abdominal bleeding following trauma (as evaluated by ultrasound)

Bleeding in limbs with compartment syndrome

Intra-articular, with pain and/or decreased range of motion

Intra-articular, asymptomatic

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How would the following items influence the likelihood of clinically relevant bleeding? Decreas No Increase e the change s the likelihoo in the likelihoo d of likelihoo d of clinically d of clinically relevant clinically relevant bleeding relevant bleeding bleeding

Patient on anticoagulant Patient on anti-platelet therapy Patient with primary (e.g. hemophilia)

Patient with secondary coagulopathy (e.g. liver failure)

Patient with reduced platelet function

Patient with reduced fibrinogen function

Bleeding in the context of ongoing hemodynamic instability

Bleeding in the context of signs of impaired oxygen delivery

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Rectal bleeding, more than streaks of blood

Rectal streaks of blood Grossly blood-tinged urine Moderately blood-tinged urine Lightly blood-tinged urine Gross bleeding in endotracheal tube

Bleeding in endotracheal tube only during suctioning

Streaks of blood in endotracheal aspirates

Grossly blood-tinged naso- or oro-gastric aspirates

Moderately blood-tinged naso- or oro-gastric aspirates

Lightly blood-tinged naso- or oro-gastric aspirates

Streaks of blood in naso- or oro-gastric tube

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For each item, how would you qualify the clinical significance of the bleeding in the following scenarios? Not Somewh Definitiv clinically at ely relevant clinically clinically relevant relevant Skin > 2.5 cm in diameter

Skin hematoma < 2.5 cm in diameter

Coalescing petechia (only in connection with the relevance of bleeding, not the general clinical relevance of petechia per se)

Non-coalescing petechia (only in connection with the relevance of bleeding, not the general clinical relevance of petechia per se)

Nasal bleeding (epistaxis) lasting for > 20 minutes despite compression

Nasal bleeding (epistaxis) lasting for < 20 minutes (thanks to compression)

Blood in dressings requiring to be changed < each 2 hours

Blood in dressings requiring to be changed each 2 to 4 hours

Blood in dressings requiring to be changed each 4 to 6 hours

Blood in dressings requiring to be changed > each 6 hours

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For each of the following statements, please indicate if you agree or disagree. Strongly Agree Weakly Neutral/no Weakly Disagree Strongly agree agree opinion disagree disagree Bleeding less than 1 ml/kg/h for less than 6 hours is clinically irrelevant.

Minimal blood in dressings (dressings required to be changed no less than each 6 hours) is clinically irrelevant.

Non-coalescing petechia are clinically irrelevant bleeding.

Streaks of blood in ETT are clinically irrelevant bleeding.

Blood in ETT only during suctioning is clinically irrelevant bleeding.

Streaks of blood in oro- or nasogastric tube are clinically irrelevant bleeding.

Lightly blood-tinged urine is clinically irrelevant bleeding.

Bleeding with drop in Hb by < 10% is clinically irrelevant bleeding.

Bleeding with drop in Hb by < 1 g/dL (10 g/L) is clinically irrelevant bleeding.

When considering quantifiable bleeding, such as from < 0.5 ml/kg/hr a chest tube, what would be the volume that you < 1 ml/kg/hr would consider "not clinically relevant"? < 2 ml/kg/hr < 3 ml/kg/hr < 5 ml/kg/hr < 7 ml/kg/hr < 10 ml/kg/hr

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In your own words, how would you define "clinically relevant bleeding"? ______

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Finally, could you please provide us with some background information?

In which country do you practice? ______

What is your age? < 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 and more

What is your gender? Female Male

What is your profession? Pediatric Critical Care Physician Pediatric Critical Care Nurse Practitionner Other

Please specify your profession.

______

How many years have you been in critical care < 5 practice? (Please include fellowship training if 5-9 applicable) 10-14 15-19 20-24 25 and more

How many beds are there in your intensive care unit? < 5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40 and more

How many admissions were there in your intensive care < 300 unit in the last 12 months? 300-599 600-899 900-1199 1200-1499 1500-1799 1800-2099 2100-2399 2400 and more

Please provide us with any final comments:

______

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