Management of patients with acute hemorrhage requires addressing the source of bleeding, replenishing blood volume, and addressing any coagulopathy that may be present. Assessing coagulopathy and predicting blood requirements in real-time in patients experiencing ongoing bleeding can pose substantial challenges. In these patients, transfusion concepts based on ratios do not effectively address coagulopathy or reduce mortality. Moreover, ratio-based concepts do not stop bleeding; instead, they just give physicians more time to identify the bleeding source and plan management strategies. In clinical practice, standard laboratory coagulation tests (SLCT) are frequently used to assess various aspects of blood clotting. However, these tests may not always offer a comprehensive understanding of clinically significant coagulopathy and the severity of blood loss. Furthermore, the SLCT have a considerable turnaround time, which may not be ideal for making prompt clinical decisions. In recent years, there has been a growing interest in point-of-care viscoelastic assays like rotational thromboelastometry, which provide real-time, dynamic information about clot formation and dissolution.

• Bleeding
• Critical care
• Haemorrhage
• Intensive care unit
• Rotational thromboelastometry
• Viscoelastic tests

• Humans
• Child
• Adolescent
• Female
• Male
• Child, Preschool
• Erythrocyte Transfusion/statistics & numerical data
• Erythrocyte Transfusion/methods
• Resuscitation/methods
• Plasma
• Prospective Studies
• Wounds and Injuries/therapy
• Wounds and Injuries/mortality
• Wounds and Injuries/complications
• Injury Severity Score
• Blood Component Transfusion/statistics & numerical data
• Blood Component Transfusion/methods
• Treatment Outcome
• Prevalence

• Humans
• Treatment Outcome
• Blood Component Transfusion
• Plasma

• Massive hemorrhage
• massive transfusion
• massive transfusion protocol
• ratio of blood components

• Humans
• Hemostatics/therapeutic use
• Prospective Studies
• Goals
• Thrombelastography/methods
• Hemorrhage/chemically induced
• Hemorrhage/therapy
• Intensive Care Units
• Blood Coagulation Factors

• Morbidity
• Mortality
• Plasma transfusion
• Prognosis
• Subarachnoid hemorrhage

• Adult
• Humans
• Subarachnoid Hemorrhage
• Retrospective Studies
• Hospital Mortality
• Blood Component Transfusion
• Treatment Outcome
• Plasma
• Morbidity

• armed conflict
• austere
• burns
• critical care
• distributed maritime operations
• freeze-dried plasma
• maritime injury
• mass-casualty disaster
• prolonged casualty care
• whole blood

• Fresh frozen plasma
• Hepatocellular carcinoma
• Liver resection
• Transfusion

• Humans
• Carcinoma, Hepatocellular/surgery
• Blood Component Transfusion/adverse effects
• Retrospective Studies
• Liver Neoplasms/surgery
• Plasma
• Postoperative Complications/epidemiology
• Bacterial Infections

• Pregnancy
• Female
• Humans
• Postpartum Hemorrhage/diagnosis
• Postpartum Hemorrhage/prevention & control
• Oxytocics/adverse effects
• Cesarean Section/adverse effects
• Blood Transfusion

• Burn
• Fluid creep
• Glycocalyx
• Resuscitation
• Revised starling principle
• Syndecan shedding

• Humans
• Burns/therapy
• Burns/metabolism
• Endothelium, Vascular/metabolism
• Fluid Therapy
• Glycocalyx/physiology
• Resuscitation

• Pregnancy
• Female
• Humans
• Postpartum Hemorrhage/diagnosis
• Postpartum Hemorrhage/etiology
• Postpartum Hemorrhage/therapy
• Blood Transfusion/methods
• Blood Coagulation
• Blood Coagulation Disorders/diagnosis
• Blood Coagulation Disorders/etiology
• Blood Coagulation Disorders/therapy
• Hemostasis

• Blood products
• Cost
• Outcome
• Thromboelastometry
• Trauma

• fresh frozen plasma
• in-hospital mortality
• nationwide
• non-massive transfusion
• real-word data
• surgical patients

• damage control surgery
• exsanguination
• fluid load test
• hemorrhagic shock
• hypotensive resuscitation
• titrated-to-response anesthesia

• coagulation management
• coagulopathy
• multiple injury

• canine
• hemothorax
• pleural effusion
• vascular avulsion

• child
• critical care
• evidence-based
• guidelines
• intensive care
• intracranial hemorrhage
• pediatrics
• plasma
• platelet
• transfusion
• trauma
• traumatic brain injury

• Anemia/etiology
• Anemia/therapy
• Blood Component Transfusion
• Brain Injuries, Traumatic/complications
• Brain Injuries, Traumatic/therapy
• Child
• Critical Care
• Critical Illness/therapy
• Erythrocyte Transfusion
• Evidence-Based Medicine/methods
• Hemorrhage/etiology
• Hemorrhage/therapy
• Humans
• Infant, Newborn
• Intracranial Hemorrhages/etiology
• Intracranial Hemorrhages/therapy
• Plasma
• Platelet Transfusion

• R13 HL154544 NHLBI NIH HHS
• UL1 TR002384 NCATS NIH HHS

• Hemostasis
• Humans
• Injury Severity Score
• Thrombin/biosynthesis
• Thrombosis/etiology
• Wounds and Injuries/blood
• Wounds and Injuries/metabolism

• coagulopathy
• endotheliopathy
• hemorrhage
• macrocirculation
• microcirculation
• oxygen transport
• polytrauma
• resuscitation
• shock

• Acute Kidney Injury/epidemiology
• Acute Kidney Injury/etiology
• Acute Kidney Injury/prevention & control
• Adult
• Aged
• Blood Coagulation Factors/administration & dosage
• Blood Coagulation Factors/adverse effects
• Blood Transfusion/methods
• Female
• Hospital Mortality
• Humans
• Injury Severity Score
• Intensive Care Units/statistics & numerical data
• Length of Stay/statistics & numerical data
• Male
• Middle Aged
• Retrospective Studies
• Shock, Hemorrhagic/etiology
• Shock, Hemorrhagic/mortality
• Shock, Hemorrhagic/therapy
• Treatment Outcome
• Wounds and Injuries/complications
• Wounds and Injuries/mortality
• Wounds and Injuries/therapy

In a developing country like India, with limited resources and access to healthcare facilities, dealing with massive hemorrhage is a major challenge. This challenge gets compounded by pre-existing anemia, hemostatic disorders, and logistic issues of timely transfer of such patients from peripheral hospitals to centers with adequate resources and management expertise. Despite the awareness amongst healthcare providers regarding management modalities of bleeding patients, no uniform Patient Blood Management (PBM) or perioperative bleeding management protocols have been implemented in India, yet. In light of this, an interdisciplinary expert group came together, comprising of experts working in transfusion medicine, hematology, obstetrics, anesthesiology and intensive care, to review current practices in management of bleeding in Indian healthcare institutions and evaluating the feasibility of implementing uniform PBM guidelines. The specific intent was to perform a gap analysis between the ideal and the current status in terms of practices and resources. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management. Here, trauma, major surgery, postpartum hemorrhage, cardiac and liver surgery are the most common clinical settings associated with massive blood loss. Accordingly, PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.

• Bleeding
• blood transfusion
• coagulopathy
• hemorrhage
• hemostasis testing
• patient blood management
• patient safety
• point-of-care testing
• thromboelastometry

• Hemorrhage
• Obstetric
• Point-of-care testing
• Transfusion

Trauma is a leading cause of mortality, with major bleeding and trauma-induced coagulopathy (TIC) contributing to negative patient outcomes. Treatments for TIC include tranexamic acid (TXA), fresh frozen plasma (FFP), and coagulation factor concentrates (CFCs, e.g. prothrombin complex concentrates [PCCs] and fibrinogen concentrate [FCH]). Guidelines for TIC management vary across Europe and a clear definition of TIC is still lacking.

An advisory board involving European trauma experts was held on 02 February 2019, to discuss clinical experience in the management of trauma-related bleeding and recommendations from European guidelines, focusing on CFC use (mainly FCH). This review summarises the discussions, including TIC definitions, gaps in the guidelines that affect their implementation, and barriers to use of CFCs, with suggested solutions.

A definition of TIC, which incorporates clinical (e.g. severe bleeding) and laboratory parameters (e.g. low fibrinogen) is suggested. TIC should be treated immediately with TXA and FCH/red blood cells; subsequently, if fibrinogen ≤ 1.5 g/L (or equivalent by viscoelastic testing), treatment with FCH, then PCC (if bleeding continues) is suggested. Fibrinogen concentrate, and not FFP, should be administered as first-line therapy for TIC. Several initiatives may improve TIC management, with improved medical education of major importance; generation of new and stronger data, simplified clinical practice guidance, and improved access to viscoelastic testing are also critical factors.

Management of TIC is challenging. A standard definition of TIC, together with initiatives to facilitate effective CFC administration, may contribute to improved patient care and outcomes.

• Bleeding
• Coagulation factor concentrates
• Expert opinion
• Fibrinogen concentrate
• Trauma-induced coagulopathy

• fresh frozen plasma
• haemostasis management
• perioperative bleeding
• rotational thrombelastometry
• total hip replacement revision surgery

• Aged
• Arthroplasty, Replacement, Hip/adverse effects
• Arthroplasty, Replacement, Hip/methods
• Blood Coagulation Disorders/prevention & control
• Blood Loss, Surgical/prevention & control
• Blood Transfusion/statistics & numerical data
• Case-Control Studies
• Female
• Humans
• Male
• Middle Aged
• Prospective Studies
• Reoperation/adverse effects
• Reoperation/methods
• Thrombelastography/methods
• Thrombelastography/statistics & numerical data

This study aimed to evaluate the effect of plasma transfusion before urgent hemostasis initiation on in‐hospital mortality in hemodynamically unstable patients with severe trauma.

This retrospective observational study of patients admitted to hospital between January 2011 and January 2019 grouped patients according to whether plasma transfusion was initiated before (Before group) or after (After group) hemostasis initiation. Patients with severe trauma who were unable to wait for plasma transfusion and had started hemostasis before the plasma infusion were excluded. We used multivariable logistic regression analysis to determine the effect of plasma transfusion before the initiation of urgent hemostasis on in‐hospital mortality.

We included 47 and 73 patients in the Before and After groups, respectively. Blunt trauma was more common, and the D‐dimer levels and Injury Severity Score were significantly higher in the Before group than in the After group (median D‐dimer, 57.5 versus 38.1 μg/mL; P = 0.040; median Injury Severity Score, 50 versus 34; P < 0.001). Plasma given before hemostasis initiation was associated with significantly lower in‐hospital mortality (adjusted odds ratio, 0.27; 95% confidence interval, 0.078–0.900; P = 0.033) in contrast with the total plasma volume given in the first 6 or 24 h.

Plasma transfusion before hemostasis initiation could be an important factor for improving outcomes in hemodynamically unstable patients with blunt trauma, high D‐dimer levels, or a high Injury Severity Score.

• Blood component transfusion
• Injury Severity Score
• Trauma Severity Index
• hemostasis
• plasma volume

Aggressive crystalloid resuscitation increases morbidity and mortality in exsanguinating patients. Polytrauma patients with severe tissue injury and subsequent inflammatory response without major blood loss also need resuscitation. This study investigated crystalloid and blood product resuscitation in non-exsanguinating polytrauma patients and studied possible adverse outcomes.

A 6.5-year prospective cohort study included consecutive trauma patients admitted to a Level 1 Trauma Center intensive care unit (ICU) who survived 48 hours. Demographics, physiologic and resuscitation parameters in first 24 hours, Denver Multiple Organ Failure scores, adult respiratory distress syndrome (ARDS) data and infectious complications were prospectively collected. Patients were divided in 5 L crystalloid volume subgroups (0–5, 5–10, 10–15 and >15 L) to make clinically relevant comparisons. Data are presented as median (IQR); p value <0.05 was considered significant.

367 patients (70% men) were included with median age of 46 (28–61) years, median Injury Severity Score was 29 (22–35) and 95% sustained blunt injuries. 17% developed multiple organ dysfunction syndrome (MODS), 4% ARDS and 14% died. Increasing injury severity, acidosis and coagulopathy were associated with more crystalloid administration. Increasing crystalloid volumes were associated with more blood products, increased ventilator days, ICU length of stay, hospital length of stay, MODS, infectious complications and mortality rates. Urgent laparotomy was found to be the most important independent predictor for crystalloid resuscitation in multinominal regression analysis. Further, fresh frozen plasma (FFP) <8 hours was less likely to be administered in patients >5 L compared with the group 0–5 L. With increasing crystalloid volume, the adjusted odds of MODS, ARDS and infectious complications increased 3–4-fold, although not statistically significant. Mortality increased 6-fold in patients who received >15 L crystalloids (p=0.03).

Polytrauma patients received large amounts of crystalloids with few FFPs <24 hours. In patients with <10 L crystalloids, <24-hour mortality and MODS rates were not influenced by crystalloid resuscitation. Mortality increased 6-fold in patients who received >15 L crystalloids ≤24 hours. Efforts should be made to balance resuscitation with modest crystalloids and sufficient amount of FFPs.

Level 3.

Population-based cohort study.

• multiple trauma
• resuscitation

• Coagulopathy management
• Fresh frozen plasma
• Plasma transfusion
• Plasma usage

• massive transfusion
• prehospital
• prehospital focused assessment of trauma (pFAST)
• trauma

• Bleeding
• a5-FIBTEM
• cardiac surgery
• coagulopathy
• fibrinogen concentrate
• postpartum hemorrhage
• ratio
• rotem
• trauma
• trauma-induced coagulopathy

• Adult
• Blood Transfusion/statistics & numerical data
• Female
• Hemorrhage/therapy
• Humans
• Infections/etiology
• Injury Severity Score
• Male
• Risk Factors
• Wounds and Injuries/surgery

• R01 HL119248 NHLBI NIH HHS

• blood product management
• coagulation testing
• deformity
• diagnostic technique
• pediatric surgery
• rotational thrombelastometry
• scoliosis surgery

• Adult
• Aged
• Area Under Curve
• Blood Transfusion
• Coagulation Protein Disorders/diagnosis
• Coagulation Protein Disorders/etiology
• Coagulation Protein Disorders/therapy
• Female
• Humans
• Injury Severity Score
• Male
• Middle Aged
• Plasma
• ROC Curve
• Reaction Time
• Retrospective Studies
• Sensitivity and Specificity
• Thrombelastography/methods
• Wounds and Injuries/complications
• Wounds and Injuries/therapy

• Hematologic disease
• Plasma transfusion
• Transfusion support

• INR
• bleeding, transfusion
• cardiac surgery
• coagulation
• plasma

Dengue is a public health problem, and noncompliance with World Health Organization (WHO) recommendations for blood transfusion components is frequently reported. Moreover, economic impact studies of the WHO recommendations on the use of blood transfusion are scarce.

We compared the cost and hospitalization time in a prospective observational study, by following hospitalised patients and analysing their medical records from 2010 and March 2016 to December 2017. We divided the patients into two groups: transfused (with or without WHO criteria for transfusion) and not transfused (with or without WHO criteria for transfusion). Generalised linear modelling was performed to identify the variable that could increase the costs and hospital stay.

Among 323 patients, 52 were transfused, of whom 52% without criteria (n = 27), and 271 were not transfused, of which 4.4% (n = 12) with criteria. Hospitalisation costs were 41% higher in the transfused group without criteria than in those with criteria (median US$ 674.3 vs US$ 478 p = 0.293). Patients who were not transfused but met the WHO criteria for transfusion (n = 12) had longer mean hospitalisation time than did those who were not transfused (3.8±3.4 days versus 3.6±3.1 days; p = 0.022). The GLM analysis using hospital stay and costs as the dependent variable explained approximately 33.4% (R² = 0.334) of the hospitalisation time and 79.3% (R² = 0.793) of costs. Receiving a transfusion increased the hospitalization time by 1.29 days (p = 0.0007; IRR = 1.29), and the costs were 5.1 times higher than those without receiving blood components (IRR = 5.1; p< 0.001; median US$ 504.4 vs US$ 170.7). In contrast, patients who were transfused according to WHO criteria had a reduction in costs of approximately 96% (IRR = 0.044; p<0.001; β = -3.12) compared to that for those who were not transfused according to WHO criteria (without criteria).

Transfusion without following WHO recommendations increased the time and cost of hospitalisation.

• Adolescent
• Adult
• Aged
• Blood Transfusion/economics
• Blood Transfusion/methods
• Brazil
• Child
• Child, Preschool
• Dengue/blood
• Dengue/economics
• Female
• Hospital Costs
• Hospitalization/economics
• Humans
• Length of Stay
• Male
• Middle Aged
• Prospective Studies
• Public Health/economics

• Fundação de Apoio ao Desenvolvimento do Ensino, Ciência e Tecnologia do Estado de Mato Grosso do Sul

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.

• Algorithms
• Bleeding management
• Health care costs
• Impedance aggregometry
• Patient blood management
• Thromboelastometry

• Blunt trauma
• Crystalloid administration
• Length of hospital stay
• Pediatric

• Trauma
• acute care surgery
• blood products transfusion
• hemorrhagic shock
• prehospital medicine

• Coagulopathy
• Emergency medicine
• Haemostasis
• Practice guideline
• Trauma

• Blood Coagulation/drug effects
• Blood Coagulation/physiology
• Encephalocele/prevention & control
• Europe
• Evidence-Based Medicine/methods
• Evidence-Based Medicine/trends
• Guidelines as Topic
• Hemorrhage/drug therapy
• Humans
• Respiration, Artificial/methods
• Wounds and Injuries/complications
• Wounds and Injuries/drug therapy

• N/A CSL Behring GmbH
• N/A Octapharma AG
• N/A LFB Biomédicaments

• Acute traumatic coagulopathy (ATC)
• Hemostasis
• Hemostatic resuscitation
• Massive transfusion
• Thromboelastograhy
• Thromboelastometry
• Trauma-induced coagulopathy (TIC)
• Viscoelastic testing