Kvisselgaard A D, Wolthers S A, Wikkelsø A, Holst L B, Drivenes B, Afshari A
Department of Anesthesia and Intensive Care, Copenhagen University Hospital-Herlev, Copenhagen, Denmark.
Prehospital Centre Zealand, Naestved, Denmark.
Acta Anaesthesiol Scand. 2025 Jan;69(1):e14558. doi: 10.1111/aas.14558.
Bleeding patients face significant morbidity and mortality due to impaired haemostasis. Haemostatic resuscitation has evolved, yet the optimal approach remains unclear. The primary objective was to assess the benefits and risks of transfusion guided by TEG/ROTEM versus standard of care in bleeding patients in an updated review.
This systematic review of randomised controlled trials with meta-analyses and trial sequential analysis was conducted according to Cochrane Collaboration methodology, PRISMA and GRADE guidelines. A literature search was conducted in five major databases. Both paediatric and adult patients were included. The primary outcome was mortality, and secondary outcomes were the administration of blood products, blood loss, surgical reintervention, and dialysis-dependent renal injury.
This systematic review included 31 randomised trials (n = 2756), with most patients undergoing elective cardiac surgery. TEG-/ROTEM-guided algorithms reduced the amount of transfused fresh frozen plasma (RR 0.5, 95% CI 0.32-0.72, I: 94%), platelets (RR 0.7, 95% CI 0.55-0.91, I: 57%), the risk for surgical reintervention (RR 0.65, 95% CI 0.47-0.94, I: 0%), and bleeding with a standard mean difference of -0.31 (95% CI -0.55 to -0.08, I: 75%). No statistically significant difference was demonstrated for mortality (RR 0.76, 95% CI 0.57-1.00, I: 5%). According to GRADE methodology, the certainty of the evidence was very low for all outcomes. Trial sequential analysis of mortality analysis indicated that 54% of the optimal information size was reached with an alpha-boundary RR of 0.81 (95% CI 0.63-1.03).
TEG-/ROTEM-guided transfusion algorithms may reduce the risk of mortality, bleeding volume, and the need for fresh frozen plasma and platelets, but the evidence is very uncertain. Further, the results were primarily based on the adult population undergoing elective cardiac surgery.
出血患者由于止血功能受损面临显著的发病率和死亡率。止血复苏方法不断发展，但最佳方法仍不明确。本更新综述的主要目的是评估在出血患者中，血栓弹力图（TEG）/旋转血栓弹力图（ROTEM）指导下输血与标准治疗的益处和风险。
根据Cochrane协作网方法、PRISMA和GRADE指南，对随机对照试验进行系统综述并进行荟萃分析和试验序贯分析。在五个主要数据库中进行文献检索。纳入儿科和成年患者。主要结局是死亡率，次要结局包括血液制品的输注、失血量、手术再次干预以及依赖透析的肾损伤。
本系统综述纳入31项随机试验（n = 2756），大多数患者接受择期心脏手术。TEG/ROTEM指导的算法减少了新鲜冰冻血浆的输注量（风险比[RR] 0.5，95%置信区间[CI] 0.32 - 0.72，异质性[I²]：94%）、血小板输注量（RR 0.7，95% CI 0.55 - 0.91，I²：57%）、手术再次干预风险（RR 0.65，95% CI 0.47 - 0.94，I²：0%），以及出血情况，标准均差为 -0.31（95% CI -0.55至 -0.08，I²：75%）。死亡率方面未显示出统计学显著差异（RR 0.76，95% CI 0.57 - 1.00，I²：5%）。根据GRADE方法，所有结局的证据确定性都非常低。死亡率分析的试验序贯分析表明，当α边界RR为0.81（95% CI 0.63 - 1.03）时，达到了最佳信息量的54%。
TEG/ROTEM指导的输血算法可能降低死亡率、出血量以及新鲜冰冻血浆和血小板的需求，但证据非常不确定。此外，结果主要基于接受择期心脏手术的成年人群。
