Sanne de Bruin

68 Chapter 3 levels. For fibrinogen administration, no association was found between the primary specialty and the reported fibrinogen threshold. Effect of having transfusion guidelines during non-massive bleeding The effect of a hospital-wide and an ICU-specific transfusion protocol was assessed for bleeding critically ill patients. When a hospital-wide transfusion protocol was available, lower platelet transfusion thresholds were applied to patients with upper GI bleeding and in post-cardiothoracic surgery patients. A hospital-wide transfusion protocol did not affect the thresholds for RBC transfusion and fibrinogen administration (Additional file 3 table S3). The availability of an ICU-specific transfusion protocol only showed an effect on the RBC transfusion threshold in ECMO patients (Additional file 3 table S4). When this protocol was available, ECMO patients were transfused at lower Hb levels (p=0.026). Each boxplot represents the medians with first and third quartile. The upper and lower whiskers are estimates of the 10 th and 90 the percentile, respectively. Viscoelastic tests The majority of the respondents reported the use of viscoelastic tests to guide the blood product choice (RBC, plasma and platelet concentrates) during massive hem- orrhage (73%). However, only 23% reported using viscoelastic tests to guide the use of PCC and 19% to guide the use of fibrinogen. In the decision-making process for the administration of TXA during massive bleeding, 8% reported using viscoelastic tests to guide its use. This is significantly lower (p<0.001) than in non-massively bleeding patients, where 24% reported using viscoelastic tests prior toTXA administration. When deciding to transfuse non-massively bleeding ICU patients with plasma, 42% reported using viscoelastic tests. The use of viscoelastic tests during non-massive bleeding for administration of other blood products was not studied in this survey. Discussion This is the first international survey among ICU physicians assessing transfusion practic- es in bleeding critically ill patients. The main findings of this study were: (1) half of the respondents did not have an ICU specific transfusion protocol available at their ICU; (2) the presence of an MTP was correlated with the use of fixed transfusion ratios during massive bleeding; (3) a high variation in practice in the use of diagnostic tests, transfu- sion ratios, fibrinogen, TXA and PCC in the setting of hemorrhage; (4) during non-mas- sive bleeding, a high variability in platelet and RBC transfusion thresholds within and