Sanne de Bruin

69 Transfusion practice in the bleeding critically ill; an international online survey – The TRACE-2 Survey between different subpopulations; and (5) plasma was still often administered for VKA induced coagulopathy during massive bleeding. In general, this survey showed that the majority of the respondents did not use fixed transfusion ratios in the ICU – only 46% would consider this during massive bleeding. The 1:1:1 ratio was most commonly reported (33%). The use of this ratio is controversial as no beneficial effect on mortality in trauma patients was observed in a large RCT 16 . In addition, the potential harmof a high FFP ratio in an ICU setting was reported in a retro- spective study, where a high plasma:RBC ratio was associated with increased mortality in patients in general surgery and medicine 17 . Tranexamic acid use in the ICU differed significantly across all subpopulations. Overall, trauma and obstetric patients most often received TXA in the ICU during bleeding as compared to the general ICU population. We speculate that the rationale behind this is that both obstetric and trauma patients have relatively fewer comorbidities compared to the other subpopulations and the benefit of early TXA administration was proven in these patients in a non-ICU setting: the CRASH-2 Trial 18 showed reduced mortality in trauma patients in the emergency room and in the WOMAN-trial, early TXA adminis- tration in women with post-partumhemorrhage decreasedmortality due to bleeding 19 . In contrast, a recent study showed that in patients with upper GI bleeding, the use of high dose TXA did not result in a reduction in mortality 20 . In this survey, half of the re- spondents reported that they would administer TXA always or most of the time during massive upper GI bleeding. However, it should be mentioned that the abovementioned study was published after closing this survey. Therefore, the results on the use of TXA in this specific patient group may already be obsolete. In the general ICU populations and several subpopulations, including septic, obstetric, trauma and patients with upper GI bleeding, a relatively restrictive RBC transfusion strategy was reported, with a median Hb threshold of 7-7.5 g/dL. This is in accordance with several large RCT’s comparing liberal and restrictive transfusion strategies 12,13 . The highest Hb thresholds in this survey were reported for bleeding patients after car- diothoracic surgery 8[7.9-9] g/dL and bleeding patients supported with ECMO 8[7-9] g/dL. This is in contrast to multiple RCTs showing that a liberal transfusion strategy was not superior to a restrictive transfusion strategy after cardiothoracic surgery 11,22,23 . In our previous survey, there were also significantly higher Hb thresholds reported in patients with acute coronary syndrome compared to the general ICU population (9[8- 9.7] g/dL versus 7[7-7.5] g/dL) 15 . Physicians might associate cardiothoracic surgery with an increased risk of coronary syndrome, which is an indication to consider higher Hb 3