Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review

Abstract

This is a narrative review of the published evidence for bleeding management in critically ill patients in different clinical settings in the intensive care unit (ICU). We aimed to describe "The Ten Steps" approach to early goal-directed hemostatic therapy (EGDHT) using point-of-care testing (POCT), coagulation factor concentrates, and hemostatic drugs, according to the individual needs of each patient. We searched National Library of Medicine, MEDLINE for publications relevant to management of critical ill bleeding patients in different settings in the ICU. Bibliographies of included articles were also searched to identify additional relevant studies. English-language systematic reviews, meta-analyses, randomized trials, observational studies, and case reports were reviewed. Data related to study methodology, patient population, bleeding management strategy, and clinical outcomes were qualitatively evaluated. According to systematic reviews and meta-analyses, EGDHT guided by viscoelastic testing (VET) has been associated with a reduction in transfusion utilization, improved morbidity and outcome in patients with active bleeding. Furthermore, literature data showed an increased risk of severe adverse events and poor clinical outcomes with inappropriate prophylactic uses of blood components to correct altered conventional coagulation tests (CCTs). Finally, prospective, randomized, controlled trials point to the role of goal-directed fibrinogen substitution to reduce bleeding and the amount of red blood cell (RBC) transfusion with the potential to decrease mortality. In conclusion, severe acute bleeding management in the ICU is still a major challenge for intensive care physicians. The organized and sequential approach to the bleeding patient, guided by POCT allows for rapid and effective bleeding control, through the rational use of blood components and hemostatic drugs, since VET can identify specific coagulation disorders in real time, guiding hemostatic therapy with coagulation factor concentrates and hemostatic drugs with individual goals.

Graphical abstract

Figure 1.

Hemostasis. PAI-1 indicates plasminogen activator inhibitor type 1; TAFI, thrombin activatable fibrinolysis inhibitor; TF, tissue factor; TFPI, tissue factor pathway inhibitor; t-PA, tissue plasminogen activator; vWF, von Willebrand factor.

Figure 2.

Functional classification of the coagulation. aPTT indicates activated partial thromboplastin time; FDP, fibrin degradation products; INR, international normalized ratio; PT, prothrombin time; TF, tissue factor; VET, viscoelatic testing.

Figure 3.

EGDHT algorithm. 4F-PCC indicates four-factor prothrombin complex concentrate; ADPTEM, adenosine diphosphate; APTEM, aprotinin; ARATEM, arachidonic acid; ARU, aspirin reaction units; CT, clotting time; DDAVP, desmopressin; DOACS, direct oral anticoagulants; EGDHT, early goal-directed hemostatic therapy; EXTEM, extrinsic pathway; FIBTEM, fibrinogen test; HEPTEM, heparinase; INTEM, intrinsic pathway; IV, intravenous; ML, maximum lysis; PCC, prothrombin complex concentrate; PFT, platelet function test; POCT, point-of-care testing; PRU, P2Y12 reaction units; RBC, red blood cell; ROTEM, rotational thromboelastometry; TRAPTEM, thrombin-activating peptide.

Figure 4.

The Ten Steps. ABC indicates Ensure patient’s Airway, Breathing, and Circulation; CCTs, coagulation conventional tests; DIC, disseminated intravascular coagulation; DOACS, direct oral anticoagulants; EGDHT, early goal-directed hemostatic therapy; Hb, hemoglobin; LMWH, low-molecular-weight heparin; PPH, postpartum hemorrhage; RBC, red blood cell; TXA, tranexamic acid; VET, viscoelatic testing.

Figure 5.

Reverse treatment. aPTT indicates activated partial thromboplastin time; FDP, fibrin degradation products; INR, international normalized ratio; PT, prothrombin time; TF, tissue factor.