The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products – A systematic review and meta-analysis

Abstract

BackgroundManagement of the critically bleeding patient can be encountered in many medical and surgical settings. Common for these patients is a high risk of dying from exsanguination secondary to developing coagulopathy. The purpose of this meta-analysis was to systematically review and assess randomised controlled trials (RCTs) performed on patients in acute need for blood transfusions due to bleeding to evaluate the effect of viscoelastic haemostatic assay (VHA) guidance on bleeding, transfusion requirements and mortality.MethodsPubMed and EMBASE were searched for RCTs that 1) randomised patients into receiving transfusions based on either a VHA-guided (thromboelastography [TEG] or rotational thromboelastometry [ROTEM]) algorithm (intervention group) or at the clinician’s discretion and/or based on conventional coagulation tests (control group) and 2) adequately reported on the outcomes bleeding and/or transfusions and/or mortality. Data on bleeding, transfusions and mortality were extracted from each trial and included in a meta-analysis.ResultsFifteen RCTs (n = 1238 patients) were included. Nine trials referred to cardiothoracic patients, one to liver transplantation, one to surgical excision of burn wounds and one to trauma. One trial was conducted with cirrhotic patients, one with patients undergoing scoliosis surgery while one trial randomised treatment in post-partum females presenting with bleeding. The amount of transfused red blood cells (RBCs), fresh frozen plasma (FFP) and bleeding volume was found to be significantly reduced in the VHA-guided groups, whereas no significant difference was found for platelet transfusion requirements or mortality.

Thromboelastography‐Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial

“…The meta‐analysis demonstrated no difference in survival between the groups with an odds ratio of 0.60 (95% confidence interval [CI], 0.34‐1.07; P = 0.08). The amount of transfused fresh frozen plasma (FFP) was significantly reduced in the VHA‐guided groups (a standardized mean difference of −1.98 [95% CI, −3.41 to −0.54]; P = 0.007), whereas no significant difference was found for PLT transfusion requirements . In one study in patients with cirrhosis and significant coagulopathy before invasive procedures (60 patients were randomly allocated to TEG‐guided transfusion strategy or standard of care [SOC] in a 1:1 ratio), all subjects in the SOC group received blood product transfusions versus 5 in the TEG group (100% versus 16.7%; P < 0.0001).…”

“…(5,6) TEG is considered to be a more reliable test to assess coagulation than traditional tests (INR, PLTs) to guide transfusions in patients undergoing cardiac, trauma, and abdominal surgery and liver transplantation, and in patients with cirrhosis and significant coagulopathy undergoing invasive procedures. (7)(8)(9)(10)(11)(12)(13)(14)(15) A recently published systematic review and metaanalysis assessed the randomized controlled trials performed on patients in acute need of blood transfusions due to bleeding (not limited to liver disease patients), to evaluate the effect of VHA guidance on bleeding, transfusion requirements, and mortality. Fifteen randomized controlled trials with a total of 1,238 patients were included in this analysis.…”

Rotational thromboelastometry thresholds for patients at risk for massive transfusion

“…19 Our primary aim was to determine optimal thresholds for blood component therapy in patients at risk for MT. Viscoelastic assays illustrate multiple, different hemostatic indices but not all are used clinically.…”

Does rotational thromboelastometry accurately predict coagulation status in patients with lupus anticoagulant?

“…As such, ROTEM has seen increasing utilization in operating rooms, emergency rooms, and intensive care units. Clinicians can use the information it provides to rapidly correct coagulopathy by implementing goal‐directed therapies, which ultimately reduce overall transfusion requirements …”