Transfusion Algorithm Research Articles

Viscoelastic haemostatic assays to guide therapy in elective surgery: an updated systematic review and meta-analysis.

Patients undergoing major surgery frequently experience major uncontrolled bleeding. The aim of this systematic review and meta-analysis was to evaluate the clinical efficacy of using viscoelastic haemostatic assays to manage peri-operative bleeding in elective surgery. We searched PubMed/MEDLINE and Embase databases for randomised controlled trials according to pre-determined criteria. The primary outcomes were blood product requirements; duration of stay in the operating theatre or ICU; and surgical reintervention rate. We included 20 randomised controlled trials. The overall risk of bias was low to moderate. Twelve studies used thromboelastography-based transfusion algorithms, while eight used thromboelastometry. Viscoelastic haemostatic assay-guided therapy was associated with a statistically significant reduction in transfusion of red blood cells (standardised mean difference (95%CI) 0.16 (-0.29 to 0.02)), platelets (standardised mean difference (95%CI) -0.33 (-0.56 to -0.10)) and fresh frozen plasma (standardised mean difference (95%CI) -0.64 (-1.01 to -0.28)). There was no evidence of an effect of viscoelastic haemostatic assay-guided therapy on surgical reintervention (relative risk (95%CI) 1.09 (0.70-1.69)). Viscoelastic haemostatic assay-guided therapy was associated with lower blood loss and shorter ICU duration of stay. There was no evidence of any effect on total duration of stay and all-cause mortality. Viscoelastic haemostatic assay-guided therapy may reduce peri-operative blood product transfusion requirements and blood loss during major elective surgery, with no discernible effect on patient-centred outcomes. The overall quality of evidence was modest.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2022 Part II: Cardiac Transplantation

These highlights focus on the research that has been published in the year 2022 and is divided into preoperative, intraoperative, and postoperative sections. The preoperative section includes research pertaining to the assessment and optimization of candidates for HTX, donor optimization and the use of extended donors, organ protection systems, and donation after circulatory death (DCD) allografts, recipient factors including cannabis use, sex, race, and comorbidities such as obesity, diabetes mellitus, and peripartum cardiomyopathy, the effects of the 2018 heart allocation policy change on waitlist and postoperative mortality, updates on HTX in patients with Covid-19, in pediatric patients, and those who require a bridge to transplant. The intraoperative section includes the use of a multidisciplinary team, a proposed transfusion algorithm, bench surgery on the allograft, and size matching. The postoperative section focuses on the research pertaining to the development and management of tricuspid regurgitation, echocardiography, arrhythmia management, and finally xenotransplantation.

The Adherence to an Intraoperative Blood Product Transfusion Algorithm Is Associated With Reduced Blood Product Transfusions in Cardiac Surgical Patients Undergoing Coronary Artery Bypass Grafts and Aortic and/or Valve Replacement Surgery: A Single-Center, Observational Study

Objective(s)To demonstrate the value of a viscoelastic-based intraoperative transfusion algorithm to reduce blood product administration in adult cardiac surgical patients. DesignProspective observational. SettingQuaternary academic teaching hospital. ParticipantsCardiac surgical patients. InterventionsViscoelastic-based intraoperative transfusion algorithm. Measurements and Main ResultsWe compared intraoperative blood product transfusion rates in 184 cardiac surgical patients to 236 historical controls after implementing a viscoelastic-based algorithm. We found a 43.9% reduction in RBC units transfused (1.98 units ±2.24 vs 0.55 ±1.36; p=0.008). We found a reduction in transfusion of 23.8% for FFP (0.84 units ±1.4 vs 0.64 ±1.38; p=ns), 33.4% for platelets (0.90 units ±1.39 vs 0.60 ±131; p=ns), and 15.8% for cryoprecipitate (0.19 units ±0.54 vs 0.16 ±0.50; p=ns). There was no statistically significant difference in time to extubation (8.0 hours [4.0, 21.0] vs 8.0 [4.0, 22.3], reoperation for bleeding (15 (12.3%) vs 10 (10.6%), ICU LOS (51.0 hours [28.0, 100.5] vs. 53.5 [33.3, 99.0]) or hospital length of stay (9.0 days [6.0, 15.0] vs. 10.0 [7.0, 17.0]). Deviation from algorithm adherence was 32.7% (48/147). PRBC, FFP, platelets, cryoprecipitate and cell saver were significantly reduced in the Algorithm Compliant Cohort compared with Historical Controls while times to extubation, ICU and hospital lengths of stay did not reach significance. ConclusionsFollowing implementation of a viscoelastic-based algorithm, patients received fewer PRBC, FFP, platelets, cryoprecipitate and cell saver. Algorithm Compliant patients received fewer transfusions; however, reductions in times to extubation, ICU and hospital lengths of stay were not statistically significant compared with historical controls.

Comparison of Two Viscoelastic Testing Devices in a Parturient Population

Background: Viscoelastic hemostatic assays (VHAs) have become an integral diagnostic tool in guiding hemostatic therapy, offering new opportunities in personalized hemostatic resuscitation. This study aims to assess the interchangeability of ClotPro® and ROTEM® delta in the unique context of parturient women. Methods: Blood samples from 217 parturient women were collected at three timepoints. A total of 631 data sets were eligible for our final analysis. The clotting times were analyzed via extrinsic and intrinsic assays, and the clot firmness parameters A5, A10, and MCF were analyzed via extrinsic, intrinsic, and fibrin polymerization assays. In parallel, the standard laboratory coagulation statuses were obtained. Device comparison was assessed using regression and Bland–Altman plots. The best cutoff calculations were used to determine the VHA values corresponding to the established standard laboratory cutoffs. Results: The clotting times in the extrinsic and intrinsic assays showed notable differences between the devices, while the extrinsic and intrinsic clot firmness results demonstrated interchangeability. The fibrinogen assays revealed higher values in ClotPro® compared to ROTEM®. An ROC analysis identified VHA parameters with high predictive values for coagulopathy exclusion and yet low specificity. Conclusions: In the obstetric setting, the ROTEM® and ClotPro® parameters demonstrate a significant variability. Device- and indication-specific transfusion algorithms are essential for the accurate interpretation of measurements and adequate hemostatic therapy.

ERAS Cardiac Society turnkey order set for patient blood management: Proceedings from the AATS ERAS Conclave 2023

ObjectivesThere are multiple published guidelines on comprehensive patient blood management (PBM), centered on the 3 pillars of PBM: managing preoperative anemia, minimizing blood loss, and tolerating intraoperative/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based PBM for cardiac surgery patients. MethodsSubject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for PBM. Orders derived from consistent class I, class IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence are presented in italic type. ResultsPreoperatively, there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin and to discontinue dual antiplatelet therapy if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed-upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion. ConclusionsThe benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Using recommendations from existing guidelines, we have created a TKO to facilitate the implementation of PBM.

Viscoelastic testing: Critical appraisal of new methodologies and current literature.

United States Food and Drug Administration (FDA)-approved viscoelastic testing (VET) methodologies have significantly changed in the last 10 years, with the availability of cartridge-based VET. Some of these cartridge-based methodologies use harmonic resonance-based clot detection. While VET has always allowed for the evaluation of real-time clot formation, cartridge-based VET provides increased ease of use as well as greater portability and robustness of results in out-of-laboratory environments. Here we review the use of VET in a variety of clinical contexts, including cardiac surgery, trauma, liver transplant, obstetrics, and hypercoagulable states such as COVID-19. As of now, high quality randomized trial evidence for new generation VET (TEG 6s, HemoSonics Quantra, ROTEM sigma) is limited. Nevertheless, the use of VET-guided transfusion algorithms appears to result in reduced blood usage without worsening of patient outcomes. Future work comparing the new generation VET instruments and continuing to validate clinically important cut-offs will help move the field of point-of-care coagulation monitoring forward and increase the quality of transfusion management in bleeding patients.

Viscoelastometry to Manage Bleeding in Liver Disease.

A state of "re-balanced haemostasis" describes complex coagulation changes that arise in patients with liver disease. Changes include alterations in procoagulant and anticoagulant proteins, platelets and von Willebrand factor, as well as the fibrinolytic system. Various circumstances including infection, trauma, or surgery may disrupt this balance and predispose an individual to bleeding or thrombosis. The prothrombin time, international normalised ratio, and activated partial thromboplastin time are conventional coagulation screening tests that are routinely employed by clinicians to investigate unexplained bleeding, monitor anticoagulation, and inform preoperative assessments of bleeding risk. These standard coagulation tests assess quantitative defects in procoagulant clotting factors and are insensitive to levels of natural anticoagulants, which together with procoagulant factors, are often perturbed in liver disease. Therefore, the prolongation of clotting times measured by these tests often does not reflect the multifaceted alterations of haemostasis in these patients. Viscoelastic testing (VET) provides a more encompassing assessment of clotting function by recording real-time viscoelastic changes in whole blood and includes parameters that provide information on coagulation factor function, platelet contribution to clot formation, as well as fibrinolysis. To date, VET has been employed to predict and inform transfusion support in obstetric, trauma, and cardiac surgical fields, and its use in patients undergoing liver transplantation is well established. The ability of VET to accurately predict bleeding risk and precisely guide transfusion algorithms for patients with liver disease undergoing other invasive procedures or experiencing bleeding complications has been the topic of research over the last decade. This review is a critical summary of this data and provides a detailed snapshot of the position of VET as a clinical tool in patients with liver disease.

354 Decreasing Blood Transfusions with a Multidisciplinary Intra-Operative Algorithm in Open Craniosynostosis Surgery

INTRODUCTION: Blood transfusions are common in craniosynostosis surgery. Lack of an intra-operative transfusion protocol is a known risk factor for increased transfusion in these surgeries. METHODS: Quality improvement methodology was used (Institute for Healthcare Improvement model). A multidisciplinary team proceeded with a survey of anesthesiology teams to evaluate readiness for change; creation of an intra-operative algorithm (guiding decision making, timing of measuring hemoglobin, administration of fluid resuscitation, and indications for blood transfusion); and integration of the algorithm into the surgery time out. No modifications were made regarding the type of general anesthesia and surgical technique (1 neurosurgeon, 2 plastic surgeons). Data collected: use of the intra-operative algorithm, administration of blood products, lowest hemoglobin recorded during admission, and other relevant surgical details. Minimally invasive surgeries were excluded. RESULTS: Eighty-two surgeries were included in three cohorts: baseline (2018, n = 6), project initiation (2019-2020, n = 44), and post-intervention (2021-2022, n = 32). After implementation, the algorithm was used in all cases. Transfusions given in stable patients with a hemoglobin >7.5 g/dL decreased from a baseline of 40.0% to 0% (p < 0.01). This improvement was demonstrated with a centerline shift on a statistical process control chart (Aggregate Point Rule). Overall transfusion rate decreased from a baseline of 100% to 59.4% post-intervention (p = 0.07). Those receiving a transfusion did not require more than 1 unit of packed red blood cells. No transfusions were required beyond post-operative day 1. CONCLUSIONS: Implementation of a multidisciplinary intra-operative transfusion algorithm for open craniosynostosis surgery led to meaningful decrease in blood transfusions. This was achieved without changing surgical technique or introducing complex adjuncts.

Rotational Thromboelastometry–Guided Use of Synthetic Blood Products in Cardiac Transplant Patients: A Retrospective Before-After Study

Viscoelastic hemostatic assays, such as rotational thromboelastometry (ROTEM), are used increasingly in cardiac surgery to guide transfusion decisions. After separation from cardiopulmonary bypass (CPB), achieving hemostasis rapidly is the main goal before chest closure. The authors hypothesized that introducing a ROTEM-guided factor- concentrate transfusion algorithm would reduce the duration from CPB separation to chest closure during cardiac transplantation. A retrospective cohort study of 21 patients before and 28 patients after implementation of the ROTEM-guided transfusion algorithm who underwent cardiac transplantation. This single-center study was conducted at Saint Paul's Hospital, Vancouver, British Columbia, Canada. Using a ROTEM-guided factor-concentrate transfusion algorithm for cardiac transplant recipients. The primary outcome was the duration from CPB separation to chest closure analyzed using Mann-Whitney U tests. The secondary outcomes included the volume of postoperative chest tube drainage, packed red blood cell (pRBC) transfusion requirements within 24 hours of surgery, the incidence of adverse events, and the length of stay before and after introducing a ROTEM-guided factor-concentrate transfusion algorithm. After adjusting for confounders using multivariate linear regression analysis, using a ROTEM-guided factor-concentrate transfusion algorithm resulted in a significant decrease in time from CPB separation to skin closure of 39.4 minutes (-73.1 to 123.5 min, p=0.016). For the secondary outcomes, the use of ROTEM-guided transfusion showed reductions in pRBC transfusion within 24 hours of surgery (-1.3 units, -2.7 to 0.1 units; p=0.077) and chest tube bleeding (-0.44 mL, -0.96 to +0.083 mL; p=0.097); however, neither was statistically significant after adjustment.The median hospital length of stay in the study group was lower by 3 days (13 days v 16) days; p=0.048). The introduction of a ROTEM-guided factor-concentrate transfusion algorithm was associated with a significant reduction in time to chest closure after separation from CPB. Although it reduced the total hospital length of stay, there were no differences in mortality, major complications, or intensive care unit length of stay.

“TEG” talks: technology worth spreading?

“TEG” talks: technology worth spreading?

Guiding fibrinogen replacement by rotational thromboelastometry in liver transplantation: bridging the evidence gaps

Rotational thromboelastometry (ROTEM) and thromboelastography (TEG) are viscoelastic assays of blood coagulation that can be performed as point-of-care (POC) tests at the bedside or during surgical procedures [1]. Both methods monitor clot formation, firmness, and stability in whole blood under low shear stress; however, they utilize different technologies to detect clot properties. ROTEM and TEG are commonly used in transfusion algorithms to guide the administration of hemostatic products in trauma, postpartum hemorrhage, liver transplantation, and cardiac surgery [1,2].

A comparison of the ClotPro system with rotational thromboelastometry in cardiac surgery: a prospective observational study

Viscoelastic coagulation tests have been increasingly used for hemostasis management in cardiac surgery. The ClotPro system is a novel viscoelastic device based on principles of rotational thromboelastometry. We aimed to compare ClotPro with ROTEM and plasma coagulation assays in cardiopulmonary bypass (CPB) patients. Blood samples were collected from 25 CPB patients at (1) baseline, (2) start of CPB, (3) end of CPB, and (4) end of surgery. The EX-test, IN-test, HI-test, FIB-test parameters on ClotPro were compared with corresponding ROTEM assay (EXTEM, INTEM, HEPTEM, and FIBTEM). Standard plasma coagulation assays and endogenous thrombin generation (TG) were simultaneously evaluated. Pearson correlation analyses showed moderate correlations between clotting times (CTs) (r = 0.63–0.67; p < 0.001, respectively), and strong correlations with maximal clot firmness (MCF) (r = 0.93–0.98; p < 0.001, respectively) between ClotPro and ROTEM. EX-test and IN-test MCF parameters were interchangeable with acceptable percentage errors (EX-test MCF: 7.3%, IN-test MCF: 8.3%), but FIB-test MCF (27.0%) and CT results were not (EX-test CT: 44.7%, IN-test CT: 31.4%). The correlations of PT/INR or peak TG with EX-test CTs were higher than with EXTEM CTs (PT/INR: r = 0.80 and 0.41, peak TG: 0.43 and 0.18, respectively). FIB-test MCF has strong correlation with plasma fibrinogen and factor XIII level (r = 0.84 and 0.66, respectively). ROC analyses showed that ClotPro was capable of emulating well-established ROTEM thresholds (area under curves: 0.83–1.00). ClotPro demonstrated strong correlations in MCF parameters of ROTEM in CPB patients. It may be reasonable to modify ROTEM-based transfusion algorithm pertaining to MCF parameters to establish cut-off values for ClotPro device.

A Cohort Study in Intensive Care Units: Health Decisions Related to Blood Transfusion during the COVID-19 Pandemic.

Critically ill polytrauma patients with hemorrhage require a rapid assessment to initiate hemostatic resuscitation in the shortest possible time with the activation of a massive transfusion or a critical hemorrhage management protocol. The hospital reality experienced during the COVID-19 pandemic in all countries was critical, as it was in Spain; according to the data published daily by the Ministry of Health on its website, during the period of this study, the occupancy rate of intensive care units (ICUs) by patients diagnosed with the novel coronavirus disease (COVID-19) rose to 23.09% in Spain, even reaching 45.23% at the end of January 2021. We aimed to analyze the changes observed during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic period regarding the effectiveness of Spanish ICUs in terms of mortality reduction. We present a cross-sectional study that compares two cohorts of patients admitted to ICUs across all autonomous communities of Spain with a diagnosis of polytrauma. Results: Only age was slightly higher at admission during the first wave of the pandemic (47.74 ± 18.65 vs. 41.42 ± 18.82 years, p = 0.014). The transfusion rate during the pandemic increased by 10.4% compared to the previous stage (p = 0.058). Regarding hemostatic components, the use of tranexamic acid increased from 1.8% to 10.7% and fibrinogen concentrates from 0.9% to 1.9%. In the case of prothrombin complex concentrates, although there was a slight increase in their use, there were no significant differences during the pandemic compared to the previous period. Conclusion: Mortality showed no difference before and during the pandemic, despite the observed change in the transfusion policy. In summary, the immediate and global implementation of patient blood management (PBM) based on clinical transfusion algorithms should be mandatory in all hospitals in our country.

Prediction of platelet counts with ROTEM-sigma in cardiac surgery.

Excessive bleeding is common after cardiac surgery. According to transfusion algorithms based on ROTEM results (TEM International Inc., Munich, Germany), platelet transfusion is recommended when FIBTEM amplitude is normal and EXTEM amplitude is reduced. The aim of this study was to evaluate whether ROTEM (TEM International Inc.) parameters may predict accurately platelet counts in cardiac surgery patients, and to determine which of these parameters is the most useful for predicting platelet counts. In this retrospective single center study data from 83 patients who underwent cardiac surgery were reviewed. We analyzed the results of patients for whom ROTEM (TEM International Inc.) and conventional laboratory tests were performed simultaneously. The derived ROTEM (TEM International Inc.) parameter PLTEM was used to estimate platelet count; PLTEM is calculated by subtracting FIBTEM from EXTEM. Correlation between ROTEM (TEM International Inc.) variables and platelet counts were determined. Logistic regression analyses were performed to predict platelet counts. ROTEM A5 values show a high linear correlation with MCF values. PLTEM has a strong linear correlation with platelet counts. According to our results for PLTEM A5<32 mm the probability of platelet count <150×109/L is 100%, for PLTEM A5<27 mm the probability of platelet count <100×109/L is nearly 80%, and for PLTEM A5<22 the probability of platelet count <75×109/L is 70%. This study demonstrates the reliability of considering early ROTEM (TEM International Inc.) results and the feasibility of using PLTEM A5 to predict platelet counts and so, improve our ability to decide the need of platelet transfusion in cardiac surgery patients.

The Use of a Viscoelastic-Based Transfusion Algorithm Significantly Reduces Non–red Blood Cell Transfusion in Patients Undergoing Left Ventricular Assist Device Placement or Heart Transplantation: A Single-Center Observational Study

Does point-of-care viscoelastic testing in patients undergoing left ventricular assist device implantation or orthotopic heart transplantation reduce non-red blood cell transfusion or improve postoperative outcomes? A retrospective observational study. At a single-center tertiary university hospital. Patients undergoing left ventricular assist device placement or heart transplantation INTERVENTIONS: The authors implemented a TEG-based transfusion algorithm to reduce non-red cell transfusion rates compared with historical controls. From May 15, 2019, through March 20, 2020, 68 patients underwent left ventricular assist device placement or heart transplantation. Algorithm adherence was 49.2%. After adjusting for relevant variables, platelet (odds ratio [OR] 0.58 [0.39-0.84]; p=0.004) and cryoprecipitate (OR 0.37 [0.19-0.72]; p=0.004) transfusion rates and time to extubation (OR -14.1 [-25.8 to -2.3]; p=0.020) were significantly reduced compared with historical controls. After adjusting for relevant clinical variables, there was a statistically significant reduction in plasma (median [interquartile range] 0.16 [0.07-0.36], p < 0.001), platelets (0.06 [0.02-0.21], p < 0.001), and cryoprecipitate (0.06 [0.01-0.47], p=0.007) transfusion rates and time to extubation (-16.95 [-27.20 to -6.71], p=0.002) compared with historical controls. The authors report a statistically significant reduction in transfusion of platelets and cryoprecipitate and time to extubation after adjusting for relevant clinical variables compared with historical controls and a significant reduction in the transfusion of plasma, platelets, and cryoprecipitate and time to extubation in those patients for whom the transfusion algorithm was followed. Their results suggest the importance of implementing transfusion algorithms for patients undergoing heart transplantation and left ventricular assist device placement and of accounting for adherence.

Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

To present the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. Not applicable. Critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. None. A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement, two recommendations, and three expert consensus statements. Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.

Thromboelastography for monitoring resuscitation during acute hemorrhage.

1 in 10 were helped (PRBC transfusion avoided) 1 in 5 were helped (FFP transfusion avoided) 1 in 11 were helped (platelet transfusion avoided) 10% lower chance of requiring PRBC transfusion 20% lower chance of requiring FFP transfusion 9% lower chance of requiring platelet transfusion Severe bleeding and coagulopathy contribute to high morbidity and mortality in patients undergoing surgery. While conventional coagulation testing is commonly used to guide transfusion, these assays do not reveal the complexities of hemostatic derangements and were not designed to predict bleeding or guide coagulation management. Point-of-care thromboelastography (TEG) and rotational thromboelastometry (ROTEM) assays measure fibrinolysis and were developed partly for the purpose of guiding hemostatic resuscitation.1 TEG/ROTEM are currently used in many trauma centers to guide acute resuscitation, within minutes of a patient's arrival to the emergency department (ED). We examined the evidence pertaining to the benefit and safety of these assays for ED patients with acute hemorrhage. The systematic review and meta-analysis2 included 17 randomized controlled trials with 1,493 subjects, most of whom were adults undergoing elective cardiac surgery. The sample size of the 16 trials ranged from 28 to 224 per trial (median of 96 subjects per trial). The trials compared TEG- or ROTEM-guided transfusion strategies to care guided by clinical judgment or conventional testing. The systematic review's primary outcome was overall mortality; secondary outcomes included the proportion of patients requiring transfusion of packed red blood cells (PRBCs), platelets, and plasma, the amount of blood products transfused, rate of surgical reintervention, hospital length of stay, and complications from bleeding or transfusion.2 All-cause mortality was lower with TEG/ROTEM (7.4% control vs. 3.9% with TEG/ROTEM, relative risk [RR] = 0.5, 95% CI = 0.3–0.9, absolute risk difference [ARD] = 3.6%, number needed to treat [NNT] = 28, low-quality evidence, eight trials, n = 717). The proportion of patients receiving transfusion of PRBCs was lower in patients assigned to TEG/ROTEM (RR = 0.9, 95% CI = 0.8 to 0.9, ARD = 10%, NNT = 10, low-quality evidence, 10 trials, n = 832). Similarly, the need for plasma (RR = 0.6, 95% CI = 0.3 to 0.9, ARD = 20%, NNT = 5, low-quality evidence, 8 trials, n = 761), and platelets (RR = 0.7, 95% CI = 0.6 to 0.9, ARD = 9%, NNT = 11, low-quality evidence, 10 trials, n = 832) was also lower. The systematic review found no difference in rate of surgical reintervention to control bleeding. Some trials reported the amount of blood products used in each group as a continuous variable. However, because of the variability of the blood product measures (some trials reported them in units, others in milliliters, or mL/kg) and methods of summarizing data (medians and quartiles vs. means and standard deviation) as well as the significant heterogeneity between these trials, the systematic review did not summarize these data.2 Adverse outcomes and complications were inconsistently reported, thereby making estimates unreliable. Given the many limitations of the data, the authors of this systematic review offer guarded support for their findings and rate the quality of evidence as low. In addition, due to the wide array of transfusion algorithms and varied thresholds for administering blood products in each trial, there was significant clinical and statistical heterogeneity among the trials.2 Furthermore, no trial used a 1:1:1 hemorrhage transfusion strategy of red blood cells, plasma, and platelets, an approach currently favored by many experts.5, 6 Mortality data were missing or incompletely reported in many trials. In addition, statistical significance was lost for mortality when comparing fixed-effect and random-effect models, thereby suggesting that the results were unreliable. Therefore, we have not reported mortality outcomes in the summary table. Methodologic weaknesses were rife throughout the included trials. Only two of the 17 trials (12%) were appropriately blinded and had low risk of bias. Additionally, the data set was too heterogenous and biased to allow for meaningful appraisal of most outcomes. Finally, 91% of study participants were adults undergoing elective cardiac surgery. Data from these participants are not generalizable to other clinical settings of hemorrhage management, such as the ED or intensive care units. It may be premature to extrapolate the findings to acute trauma resuscitations or spontaneously bleeding medical patients, until trials are conducted in these specific populations. Severely injured patients or those with gastrointestinal bleeding, for example, may arrive in the ED already coagulopathic, with ongoing blood loss that continues until source control of bleeding is accomplished. In the two randomized trials comparing TEG/ROTEM-guided strategies to conventional management in acute care environments, no meaningful benefits were seen.3, 4 In summary, TEG/ROTEM-guided hemostatic resuscitation requires further study. While early, low-quality data from elective surgical settings suggest a possible benefit, more high-grade evidence from ED-relevant resuscitations is needed. Therefore, we have assigned a color recommendation of yellow (unclear if benefits, more data needed).

BLOOD AND COAGULATION PRODUCT DISPOSAL IN THE MODERN ERA - A SURVEY AND REVIEW OF CURRENT PRACTICE

Introduction Perioperative transfusion is associated with reduced with reduced survival1 and increased morbidity and mortality2 Several studies report poor adoption of guidelines and wide variation in clinical practice3. However, the influence of simple practical factors is disregarded, as for instance which blood products are available in which time for the transfusing physician? We hypothesize that local practical issues are a relevant cofounder of transfusion decisions. Methods With kind endorsement of EACTAIC, the link to a web-based survey was sent via newsletter to all EACTAIC-Members via the monthly newsletter in November 2020. Results The Newsletter was opened by 429 active members. We collected 66 survey responses, with 51 complete surveys, resulting in a response rate of 11.9% 72% of participants report having a local algorithm for the use of blood products and coagulation factors. Several factors were reported as having an influence on the local transfusion algorithm (Figure 1) and on transfusion practice (Figure 2). 86% of respondents report ROTEM®/TEG® available, 76% haemoglobin tests, 24% quick measurements and 22% Thrombocyte function tests. 6% of the respondents have no point of care test available. A majority of respondents report the possibility to receive more than 10 labile blood products delivered at once (64%). Packed red blood cells are available with a median time delay of 10-15 minutes (Figure 3). For platelets, a median time between ordering and delivery of 15-20 minutes was reported (Figure 4). Discussion The data of our survey reveals wide variability in the logistics of perioperative transfusion and significant subjective influence of these logistic factors. The time to delivery of labile blood products was the most mentioned factor. To our knowledge, this is the first study to evaluate logistic factors with influence on transfusion practice. The principal limitation of our survey is the low response rate. In many situations, the transfusing physician has the consequences of a delayed or omitted transfusion directly in sight, while the consequences of unnecessary transfusions remain diffuse. Those subjective benefits of transfusion might lead to a risk-aversive behavior, as is known from economy and sociology 4. In combination with (perceived) long delivery times, this might be a contributing factor for transfusion incidence. The adaption of institutional processes therefore bear potential benefits for better adherence to transfusion guidelines. In conclusion, transfusion logistics show wide variation across different institutions and are a significant subjective contributor to the individual transfusion behaviour.

TEG® and ROTEM® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit.

The concentration of the majority of hemostatic proteins differs considerably in early life, especially in neonates compared to adulthood. Knowledge of the concept of developmental hemostasis is an essential prerequisite for the proper interpretation of conventional coagulation tests (CCT) and is critical to ensure the optimal diagnosis and treatment of hemorrhagic and thrombotic diseases in neonatal age. Viscoelastic tests (VETs) provide a point-of-care, real-time, global, and dynamic assessment of the mechanical properties of the coagulation system with the examination of both cellular and plasma protein contributions to the initiation, formation, and lysis of clots. In this work, we provide a narrative review of the basic principles of VETs and summarize current evidence regarding the two most studied point-of-care VETs, thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), in the field of neonatal care. A literature analysis shows that viscoelastic hemostatic monitoring appears to be a useful additive technique to CCT, allowing targeted therapy to be delivered quickly. These tools may allow researchers to determine the neonatal coagulation profile and detect neonatal patients at risk for postoperative bleeding, coagulation abnormalities in neonatal sepsis, and other bleeding events in a timely manner, guiding transfusion therapies using the goal-oriented transfusion algorithm. However, diagnosis and treatment algorithms incorporating VETs for neonatal patients in a variety of clinical situations should be developed and applied to improve clinical outcomes. Further studies should be performed to make routinary diagnostic and therapeutic application possible for the neonatal population.

Effects of rotational thromboelastometry-guided transfusion management in patients undergoing surgical intervention for postpartum hemorrhage: An observational study.

Postpartum hemorrhage (PPH) can be associated with coagulopathy, which may be difficult to rapidly assess and may exacerbate blood loss. Rotational thromboelastometry (ROTEM) at the point of care can guide clinician choice of blood products and has been shown in some settings to reduce transfusions and improve outcomes. This hospital-based observational study aims to measure effects of a ROTEM-guided transfusion protocol on transfusion practice and clinical outcomes in patients with PPH managed in the operating theater. We compared a retrospective cohort of 450 consecutive patients with PPH treated in the operating theater before the introduction of a ROTEM-guided transfusion algorithm in June 2016, with 450 patients treated after its introduction. Multivariate regression was used to evaluate the effect of ROTEM introduction on the primary outcome, patients requiring a packed red blood cell (PRBC) transfusion and adjusting for demographic and obstetric confounders. Secondary outcomes included other blood product transfusions, hysterectomy, and intensive care unit admission. A total of 90 (20%) of patients treated prior to ROTEM introduction received a PRBC transfusion, compared with 102 (22.7%) of those treated after ROTEM introduction (95% confidence interval [CI] 1.0-2.0, p= .04). There was no difference in PRBC transfusion in patients undergoing caesarean section (95% CI 0.5-1.8, p= .99). There was a trend toward increased use of cryoprecipitate and reduced use of platelets and fresh frozen plasma after ROTEM introduction. In our institution, the introduction of ROTEM-guided transfusion did not reduce PRBC transfusion in patients with PPH treated in the operating theater.