Table 3.
Transfusion algorithm trigger values. Table explaining individual transfusion trigger values in the respective trials included in the meta-analyses
| Reference (Author and year) | RBC | FFP | Platelets | Other | ||||
|---|---|---|---|---|---|---|---|---|
| Control group | Intervention group | Control group | Intervention group | Control group | Intervention group | Control group | Intervention group | |
| Shore-Lesserson 1999 [33] | Hct < 25% (during CPB <21%) | Hct < 25% (during CPB <21%) | PT >150% of control (2U FFP) | hTEG R > 20 mm (2U FFP) | PC < 100 · 103/μL (6U PC) | PC < 100 · 103/μL AND TEG MA < 45 mm (6U PC) | Fibrinogen <100 mg/dL 10U of cryo EACA 10 g if failure |
Fibrinogen <100 mg/dL 10U of cryo LY30 > 7.5% EACA 10 g |
| Nuttall 2001 [31] | N/A | N/A | Clinician’s discretion with or without CCT | POC PT > 16.6 s and/or POC APTT > 57 s | Clinician’s discretion with or without CCT | PC < 102 · 103/mm3 and/or TEG MA <48 mm (PC or DDAVP) | Clinician’s discretion with or without CCT | Fibrinogen <144 mg/dL – cryo |
| Royston 2001 [32] | N/A | N/A | Clinician’s discretion with or without CCT | R > 14 mm < 21 mm – 1 FFP R > 21 mm < 28 mm – 2 FFP R > 28 mm – 4 FFP |
Clinician’s discretion with or without CCT | MA < 48 mm – 1 platelet pool MA < 40 mm 2 platelet pools |
Clinician’s discretion with or without CCT | LY30 > 7.5% - Aprotinin |
| Avidan 2004 [29] | Hb < 8 g/dL | Hb < 8 g/dL | If still bleeding >100 mL/h after aprotinin + desmopressin AND INR or APTT ratio > 150% control – 4U FFP | Excessive bleeding + R > 10 min – 4U FFP | Persisting excessive bleeding OR PC < 50x109/L – 1 platelet pool | PFA-100® ADP channel > 120 s, epinephrine channel > 170 s treated with DDAVP 0.4 μg/kg – if bleeding persisted 1 platelet pool | Bleeding >100 mL/h within 24 h after surgery – Aprotinin (2 Mu) + desmopressin (0.4 μg/kg) | LY30 > 7.5% + bleeding >100 mL/h – aprotinin 2Mu PFA-100® ADP channel > 120 s, epinephrine channel > 170 s – DDAVP 0.4 μg/kg |
| Ak 2009 [28] | Htc < 25% (during CPB <18%) | Htc < 25% (during CPB <18%) | PT > 14 s or APTT > 150% normal | R > 14 mm <21 mm – 1 FFP R ≥ 21 mm <28 mm – 2 FFP R ≥ 28 mm – 4 FFP |
PC < 100 · 103/μL | 40 ≤ MA < 48 mm – 1U platelets MA < 40 mm 2U platelets |
Absence of visible clots + presence of generalized oozing-type bleeding in surgical field – TXA | LY30 > 7.5% - TXA |
| Westbrook 2009 [35] | Clinician’s discretion with CCT | Hb > 70 g/L | Clinician’s discretion with CCT | 11 min < R(H) ≤ 14 min – 1U FFP 14 min < R(H) ≤ 20 min – 2U FFP 200 min < R(H) – 4U FFP |
Clinician’s discretion with CCT | MA(H) ≤ 41 mm – 5U platelets | TXA according to clinician’s discretion with CCT | LY30 > 15% - TXA |
| Girdauskas 2010 [30] | Htc < 25% (Hb 8.5 g/dL) (during CPB Htc < 20% (Hb 6.8 g/dL)) or physiologic transfusion triggers | Htc < 25% (Hb 8.5 g/dL) (during CPB Htc < 20% (Hb 6.8 g/dL)) or physiologic transfusion triggers | PT > 60s or INR >1.5 – FFP 15 mL/kg body mass | HEPTEM CT > 260 s – FFP 15 mL/kg body mass | PC < 100 · 103/μL – 1 platelet concentrate | (A) HEPTEM MCF 35-45 mm – 1 platelet concentrate (B) FIBTEM MCF >8 mm and HEPTEM MCF <35 mm – 1 platelet concentrate |
Fibrinogen <1.2 mg/dL – 2 g fibrinogen α2-Antiplasmin <80% - 3 g TXA |
FIBTEM <8 mm – 2 g fibrinogen APTEM MCF/HEPTEM MCF >1.5 – 3 g TXA APTEM CT > 120 s – 3000 IU PPSB |
| Wang 2010 [37] | Hb <8 g/dL | Hb <8 g/dL | PT and aPTT > 150% control | R > 10 min | PC < 50x109/L | MA < 55 mm – 6-8U pooled platelets | Fibrinogen <1 g/dL – cryo | α-angle < 45° - cryo |
| Paniagua 2011 [36] | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Schaden 2012 [38] | Hb <8 g/dL | Hb <8 g/dL | Clinician’s discretion with or without CCT | EXTEM CT > 100 s – 4U FFP | Clinician’s discretion with or without CCT | EXTEM A10 < 45 mm and FIBTEM >12 mm – 1U platelets concentrate | TXA and fibrinogen according to clinician’s discretion with or without CCT | EXTEM A10 < 45 mm and FIBTEM A10 < 12 mm – 2 g fibrinogen Spindle shaped trace APTEM A10> > EXTEM A10 – 10 mg/kg TXA EXTEM LY30 > 10% - 10 mg/kg TXA |
| Weber 2012 [34] | Hb <8 g/dL (during CPB Hb <6 g/dL) or physiologic transfusion triggers | Hb <8 g/dL (during CPB Hb <6 g/dL) or physiologic transfusion triggers | Transfused ≥4U PRBCs without new lab results – 15 mL/kg FFP INR > 1.4 or aPTT > 50s – 20-30 IU/kg prothrombin complex concentrate or 15 mL/kg FFP |
EXTEM CT > 80s or HEPTEM >240 s – 20-30 IU/kg prothrombin complex concentrate or 15 mL/kg FFP | PC < 80000/μL | EXTEM A10 ≤ 40 mm and FIBTEM A10 > 10 mm or TRAP < 50 AU and/or ASPI <30 AU and/or ADP < 30 AU (second choice) | Fibrinogen pre-value < 200 mg/dL or currently <150 mg/dL – 25-50 mg/kg fibrinogen Suspected platelet dysfunction – 0.3 μg/kg desmopressin |
FIBTEM MCF = 0 mm – 25 mg/kg fibrinogen before protamine EXTEM A10 ≤ 40 mm and FIBTEM A10 ≤ 10 mm – 25-50 mg/kg fibrinogen TRAP < 50 AU and/or ASPI <30 AU and/or ADP < 30 AU – 0.3 μg/kg desmopressin (first choice) |
| Barinov 2015 [41] | N/A | N/A | Clinician’s discretion with CCT | N/A | Clinician’s discretion with CCT | N/A | Clinician’s discretion with CCT | N/A |
| Gonzalez 2015 [22] | First units of RBC administered according to clinician’s discretion only Hb < 10 g/dL |
First units of RBC administered according to clinician’s discretion only Hb < 10 g/dL |
First units of FFP administered according to clinician’s discretion only INR ≥ 1.5 – 2U FFP |
First units of FFP administered according to clinician’s discretion only ACT 111-139 s – 2U FFP ACT ≥ 140 s – 2U FFP, 10-pack cryo and 1U apheresis platelets ACT > 110 s – 2U FFP |
PC < 100 · 103/μL – 1U apheresis platelets | ACT ≥ 140 s – 2U FFP, 10-pack cryo and 1U apheresis platelets MA < 55 mm – 1U apheresis platelets |
Fibrinogen >150 mg/dL – 10-pack cryo Suspicion on fibrinolysis with D-dimer >0.5 μg/dL – 1 g TXA |
ACT ≥ 140 s – 2U FFP, 10-pack cryo and 1U apheresis platelets α-angle < 63° - 10-pack cryo LY30 ≥ 7.5% - 1 g TXA (after 61% of enrolment LY30 ≥ 3% - 1 g TXA) |
| De Pietri 2015 [39] | Hb <8 g/dL | Hb <8 g/dL | INR > 1.8 – 10 mL/kg ideal body weight | R > 40 min – 10 mL/kg ideal body weight | PC < 50 · 109/L – 1U PLT | MA < 30 mm – 1U apheresis platelets | ||
| Cao 2016 [40] | Hb < 70 g/L, Htc < 25% - 2U RBC | Hb < 70 g/L, Htc < 25% - 2U RBC | Clinican’s discretion | R > 8 min – FFP 15 mL/kg | PC < 50 · 109/L – 1U PLT | MA < 70 mm – 1U platelets | Fibrinogen < 0.0012 mg/L – fibrinogen 2 g | α-angle < 72° - fibrinogen 2 g |
Control group = groups managed without the use of either TEG or ROTEM. Intervention group = groups managed with the use of TEG or ROTEM. Htc haematocrit, Hb haemoglobin, PC platelet count, U units, PT prothrombin time, N/A not applicable, CCT conventional coagulation test, RBC red blood cell, FFP fresh frozen plasma, PLT platelets, INR international normalized ratio, ACT activated clotting time, MA maximal amplitude, TXA tranexamic acid, R reaction time, aPTT activated partial thromboplastin time, CPB cardiopulmonary bypass, hTEG heparinase-TEG, POC point of care