What are the guideline sources, guidelines and references for Transfusion strategies in critical care ?
Guideline sources The following summarized guidelines for the evaluation and management of transfusion strategies in critical care are prepared by our editorial team based on guidelines from the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023), the European Society of Intensive Care Medicine (ESICM 2021; 2020), the Eastern Association for the Surgery of Trauma (EAST 2020), and the British Society for Haematology (BSH 2018). 1 2 3 4 5 Guidelines 1. Diagnostic investigations Coagulation and viscoelastic testing: As per ABC-T 2023 guidelines, initiate monitoring and measures to support coagulation immediately upon hospital admission of patients with traumatic hemorrhage. B Show 2 more As per ESICM 2021 guidelines, consider obtaining either viscoelastic testing or conventional coagulation testing to guide transfusions in the following patients: patients with massive or non-massive bleeding with cirrhosis, liver transplant, or critically ill patients with trauma C patients with massive bleeding due to trauma C patients with bleeding undergoing cardiac surgery C patients with non-massive bleeding patients undergoing ECMO. C https://web.pathway.md/diseases/recOIRnNtjIhwotI1 1/4 6/24/23, 4:08 PM Transfusion strategies in critical care Pathway As per EAST 2020 guidelines, consider using thromboelastography/rotational thromboelastometry-guided strategy in adult trauma or surgical patients or critically ill patients with ongoing hemorrhage and concern for coagulopathy, to reduce blood product transfusions. C As per BSH 2018 guidelines, recognize that normal viscoelastic hemostatic assay results confer a high negative predictive value for transfusion need in trauma patients, enabling the clinical team to monitor the patient closely without immediate activation of the major hemorrhage protocol. B Show 2 more 2. Medical management Tranexamic acid: As per ABC-T 2023 guidelines: Administer tranexamic acid in patients with trauma with bleeding or at risk of significant bleeding as soon as possible, if feasible, en route to the hospital and within 3 hours after injury at a loading dose of 1 g infused over 10 minutes, followed by an IV infusion of 1 g over 8 hours. A Do not wait for results from a viscoelastic assessment to administer tranexamic acid. D As per ESICM 2021 guidelines, administer early (< 3 hours from trauma) tranexamic acid in critically ill patients with bleeding or suspected bleeding due to trauma. A Show 6 more As per BSH 2018 guidelines, do not withhold tranexamic acid based on the thromboelastography or rotational thromboelastometry parameters. D 3. Therapeutic procedures Massive bleeding, transfusion strategies: As per ABC-T 2023 guidelines: Insufficient evidence to recommend in favor or against using pre-hospital blood products in patients with traumatic hemorrhage. Target Hgb levels of 70-90 g/L if RBC transfusion is necessary in patients with major bleeding due to trauma. B As per ESICM 2021 guidelines: Consider using high-ratio transfusion strategies (at least 1 unit plasma per 2 units of PRBCs) over low-ratio transfusion strategies in critically ill patients with massive bleeding due to trauma. C Insufficient evidence to support the use of fixed high-ratio transfusion strategies in critically ill patients with non-traumatic massive bleeding. I Massive bleeding, platelet transfusion: https://web.pathway.md/diseases/recOIRnNtjIhwotI1 2/4 6/24/23, 4:08 PM Transfusion strategies in critical care Pathway As per ABC-T 2023 guidelines, consider administering platelets to maintain a platelet count > 50 10 /L in patients with trauma with ongoing bleeding and > 100 10 /L in patients with TBI. C Show 2 more As per ESICM 2021 guidelines, insufficient evidence to support the use of cryopreserved or cold-stored platelets in patients with massive or non-massive bleeding. I Massive bleeding (plasma transfusion): Guide further use of FFP, if a fresh-frozen plasma-based coagulation resuscitation strategy is used in patients with traumatic hemorrhage, by standard laboratory coagulation screening parameters (proTT and/or aPTT > 1.5 times normal and/or viscoelastic evidence of a coagulation factor deficiency). B Avoid administering FFP to correct hypofibrinogenemia if fibrinogen concentrate and/or cryoprecipitate are available. D Massive bleeding, coagulation factor transfusion: As per ABC-T 2023 guidelines, initiate monitoring and measures to support coagulation immediately upon hospital admission of patients with traumatic hemorrhage. B Show 7 more As per ESICM 2021 guidelines: Insufficient evidence to support the use of PCC versus plasma alone in patients with massive bleeding. I Insufficient evidence to support the use of early empiric fibrinogen replacement in critically ill patients with massive bleeding due to trauma. I Non-massive bleeding (RBC transfusion): consider setting a restrictive (7 g/dL) RBC transfusion threshold in patients with non-massive gastrointestinal bleeding. C Show 2 more Non-massive bleeding (platelet transfusion): insufficient evidence to recommend a restrictive over a liberal platelet transfusion threshold in non-massively bleeding patients with thrombocytopenia. I Show 2 more Non-massive bleeding (plasma and fibrinogen transfusion): insufficient evidence to recommend a restrictive over a liberal plasma transfusion strategy in non-massively bleeding patients with or without coagulopathy. I Show 2 more Non-bleeding (RBC transfusion thresholds): consider using Hgb or hematocrit triggers rather than alternative triggers for RBC transfusion. C Show 6 more Updated evidence: REALITY In adult patients with myocardial infarction and anemia, a restrictive strategy was noninferior to a liberal strategy with respect to the composite outcome of death, stroke, recurrent myocardial https://web.pathway.md/diseases/recOIRnNtjIhwotI1 3/4 6/24/23, 4:08 PM Transfusion strategies in critical care Pathway infarction, or emergency revascularization prompted by ischemia at 30 days. Gregory Ducrocq et al. JAMA. 2021 Feb 9. Non-bleeding (RBC transfusion prevention): Avoid using PO or IV iron therapy, EPO, D or a combination of both, to prevent RBC transfusion. D Consider using small-volume blood collection tubes C and blood conservation devices versus conventional blood sampling systems to prevent RBC transfusion. C Non-bleeding (platelet transfusion): avoid administering platelet transfusion to treat thrombocytopenia unless the platelet count falls < 10 10 /L. D Show 3 more Non-bleeding (plasma transfusion): Avoid administering prophylactic plasma transfusion in patients with coagulopathy. D Avoid administering prophylactic plasma transfusion before invasive bedside procedures in patients with coagulopathy. D References 1. Nicola S Curry, Ross Davenport, Sue Pavord et al. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol. 2018 Sep;182 6 789 806. Open 2. Rolf Rossaint, Arash Afshari, Bertil Bouillon et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27 1 80. Open 3. Alexander P Vlaar, Simon Oczkowski, Sanne de Bruin et al. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2020 Apr;46 4 673 696. Open 4. Alexander P J Vlaar, Joanna C Dionne, Sanne de Bruin et al. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2021 Dec;47 12 1368 1392. Open 5. Nikolay Bugaev, John J Como, Guy Golani et al. Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020 Dec;89 6 999 1017. Open 6. Donat R Spahn, Bertil Bouillon, Vladimir Cerny et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23 1 98. 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