Navigating Critical Waters: The Importance of a Systematic Coagulation Algorithm in the Intensive Care Unit

Managing acute bleeding in the intensive care unit (ICU) remains a major challenge. Blood loss and also the transfusion of red blood cells (RBCs), plasma, and platelets are associated with adverse outcomes and high costs. A systematic approach guided by point-of-care testing and a coagulation factor–based hemostatic therapy enables rapid and effective bleeding control, optimizing the use of blood components tailored to individual patient needs.

The narrative review of Crochemore et al discusses bleeding management in critically ill ICU patients by outlining “The Ten Steps” approach to early goal-directed hemostatic therapy (EGDHT). The authors analyzed relevant publications, including systematic reviews, meta-analyses, trials, and case reports, emphasizing study methodology, patient populations, bleeding management, and clinical outcomes. Key findings include the effectiveness of EGDHT guided by viscoelastic testing in reducing allogeneic blood transfusions and improving outcomes for actively bleeding patients. Inappropriate use of allogeneic blood products to correct conventional coagulation tests is associated with adverse events and poor outcomes. Additionally, prospective trials highlight the role of goal-directed fibrinogen substitution in reducing bleeding and the use of allogeneic transfusions, potentially lowering mortality.

In the complex realm of intensive care, a well-structured coagulation algorithm is not just a guideline; it is also an indispensable navigation tool. While “The Ten Steps” framework provides a valuable structure for managing severe acute bleeding in the ICU, the ranking and sequencing of steps should be flexible and adaptable to the specific clinical situation. Surgical bleeding control (point 5), in particular, should be recognized as a potentially urgent and life-saving intervention that may need to take precedence in certain cases. Individualized patient care and interdisciplinary collaboration should be central to the approach. Thereby, thromboelastography (TEG) or rotational thromboelastometry (ROTEM)–guided coagulation management revolutionizes patient care by delivering personalized, real-time insights into a patient’s coagulation status. This approach enables swift decision-making in critical scenarios; it assists in monitoring anticoagulant therapy, diagnosing coagulation disorders, and advancing liver disease management. The principle of a well-structured coagulation algorithm is simple: first, coagulation is assessed with viscoelastic tests and conventional laboratory tests to detect any coagulopathy as soon as possible. Once a coagulopathy or coagulation factor deficiency is detected, the algorithm states what needs to be done to correct the coagulation situation in an individualized goal-directed manner. This avoids both overuse and underuse of these critical interventions, and minimizes unnecessary blood product use, reducing the risks of adverse events and ensuring that patients receive the appropriate care they need. The success of such coagulation algorithms guided by viscoelastic testing has been shown in trauma, cardiac surgery, liver transplantation, and burns. Accordingly, such algorithms are strongly recommended by the Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the European Society of Cardiology, endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC). In 2023, the ESAIC has updated their guidelines on the management of severe perioperative bleeding and the European guidelines on the management of major bleeding and coagulopathy after trauma were published in their sixth edition. Together, these guidelines cover all aspects of perioperative bleeding and trauma treatment from the prehospital period to the treatment in the emergency room, surgical and interventional procedures, and intensive care management. Such algorithms are also part of Patient Blood Management, which has been taken up by the World Health Organization (WHO).

It is not sufficient merely to have an algorithm on paper; it must be effectively implemented and put into clinical practice. The simple publication of a transfusion and coagulation guideline did not alter the use of allogeneic blood products. Only when combined with a monitoring and feedback system have they been shown to make a considerable difference and be associated with cost savings. The implementation process involves a systematic, multistage approach: recognizing the need and assembling a support team, tailoring evidence-based strategies while engaging stakeholders, addressing barriers, implementing changes incrementally with educational support, monitoring progress, evaluating clinical outcomes, and maintaining sustainability through evidence-based practices and a culture of continuous improvement.

The significance of a coagulation algorithm goes beyond just treatment. It also plays a vital role in education and training. New health care professionals entering the ICU are often overwhelmed by the complexity of critical care. Having a standardized algorithm not only simplifies the decision-making process but also aids in the education of new team members. It becomes a tool for fostering a culture of best practices, uniform treatment quality, and continuous improvement.

The implementation of a well-designed coagulation algorithm in the ICU is not just a recommendation; it is a necessity. It empowers health care providers to make informed, timely decisions, reduces the risk of complications, and ultimately is a crucial tool in our mission to improve the clinical outcomes and provide the best possible care to our critically ill patients. As we continue to advance in the field of critical care, let us not underestimate the value of this guiding light in the turbulent waters of coagulation management. It is, without a doubt, a crucial tool in our mission to save lives and provide the best possible care to our critically ill patients.