Sanne de Bruin

70 Chapter 3 thresholds in several guidelines 24,25 . The high variety in Hb thresholds in ECMO patients is not surprising, as this was reported earlier 15,26 . As long as no randomized studies are performed in patients receiving ECMO, the optimal Hb trigger in ECMO patients will remain a matter of debate, thus explaining the heterogeneity in the Hb thresholds applied to transfuse these patients. Despite limited evidence in the ICU, a large proportion of respondents were using vis- coelastic tests to guide the choice of blood products during massive bleeding (73.3%). But when deciding to administer fibrinogen or PCC, the number of respondents who use viscoelastic tests was lower: 19% and 23% respectively. In this survey, the use of viscoelastic tests during non-massive bleeding to guide platelet and plasma transfusion was not assessed. However, viscoelastic testing did play a role in the use of TXA during non-massive bleeding, as 24% of respondents used viscoelastic tests to assess wheth- er a patient would benefit from TXA administration. None of these indications have been studied yet in the ICU setting, but there may be potential to reduce the amount of transfusion and thereby the exposure to the potential harmful side effects of blood products 27 . In this survey, 78% would correct a VKA induced coagulopathy with PCC in massively bleeding patients. However, 61%of the respondents also reported that they considered using plasma for this indication, although no evidence is available to support this prac- tice. Multiple RCTs have shown the superiority of PCC versus plasma for VKA reversal in patients with major bleeding or for patients prior to urgent surgical procedures 28,29 . Since plasma transfusion has several disadvantages including slower infusion rate, risk of transfusion reactions and risk of fluid overload 30 , we expected a smaller number of respondents administering plasma for iatrogenic coagulopathy. Therefore, we con- clude that the use of plasma could be safely reduced by evidence-based transfusion guidelines. This study has several limitations. First, due to the nature of the design of the study, the survey reflects the perceived practice of respondents. Actual practice may still differ from the responses given in the survey. Second, as it is unknown who the non-respond- ers were, we cannot estimate the effect of this participation bias. Physicians with more interest in blood transfusion might be more likely to fill in this survey, and this group of physicians is likely to be more aware of the latest literature on transfusion practices. Third, to avoid a too long survey, we did not question the use of cryoprecipitate. Since themajority of the respondents works in countries where fibrinogen is used, we believe this did not influence our results. Fourth, themajority of our respondents are working in