Nationwide expert survey on transfusion and coagulation management strategies for bleeding critically ill patients in China

Abstract

This study aimed to investigate coagulation management strategies by experienced critical care physicians across China. The questionnaire was independently designed referencing current guidelines and literature, and refined through five rounds of multidisciplinary review, covering basic information, blood product supply, clinical practices, and laboratory support. The survey recruited 473 senior physicians from 473 Intensive Care Units (ICUs) at 431 tertiary hospitals across China. Many hospitals reported a shortage of blood products. Most physicians preferred a strategy of fixed ratio for transfusion in traumatic (350/473, 74.0 %) and non-traumatic (271/473, 57.29 %) massive hemorrhage. For patients with hemorrhage and coagulopathy, fresh frozen plasma (FFP) (421/473, 89.0 %), prothrombin complex concentrate (PCC) (274/473, 57.9 %), and cryoprecipitate (Cryo) (213/473, 45.0 %) were commonly used. In cases of massive hemorrhage, 39.7 % (188/473) of physicians would empirically administer PCC, and 77.6 % (367/473) would rely on the results of traditional laboratory tests. Human fibrinogen (FIB) concentrate (373/473, 78.9 %) and Cryo (380/473, 80.3 %) were commonly used to replenish fibrinogen. To raise plasma FIB levels, 1-2 g of FIB (352/473, 74.4 %) and 5-15 units (U) of Cryo (402/473, 84.99 %) were usually administered empirically; a FIB level above 2.0 g/L was the most commonly used standard for treatment termination (234/473, 49.5 %). Tranexamic acid (TXA) was commonly used to treat traumatic (338/473, 71.5 %) or non-traumatic (326/473, 68.9 %) intracranial hemorrhage. Significant variation was observed in the use of FFP (351/473, 74.2 %) and PCC (171/473, 36.2 %) to treat hemorrhage caused by vitamin K antagonists. Significant differences have been observed in blood product supply and treatment strategies used by ICU physicians for massive hemorrhage in critically ill patients, suggesting the need for treatment protocol standardization and further research. KEYPOINTS: This nationwide expert survey provides a comprehensive understanding of current clinical practices in blood product transfusion and coagulation management for critically ill patients with hemorrhage. Most hospitals encounter a shortage of blood products while treating massive hemorrhage. Blood product transfusion ratios, plasma transfusion strategies, and PLT transfusion indications are notably different when treating critically ill patients with massive versus non-massive hemorrhage. Practical variations exist regarding the threshold indications and dosing of PCC, FIB, Cryo, and TXA in the setting of hemorrhage. Discrepancy and knowledge gaps still exist in antithrombotic reversal strategy for vitamin K antagonists, novel oral anticoagulant (NOAC), and antiplatelet drug-induced hemorrhage.

Keywords: Coagulation management; Hemorrhage; Intensive care unit.