Point-of-care viscoelastic hemostatic testing in cardiac surgery patients: a systematic review and meta-analysis

  • Carly LodewyksEmail author
  • Jeffrey Heinrichs
  • Hilary P. Grocott
  • Keyvan Karkouti
  • Grace Romund
  • Rakesh C. Arora
  • Navdeep Tangri
  • Rasheda Rabbani
  • Ahmed Abou-Setta
  • Ryan Zarychanski
Review Article/Brief Review



Thromboelastography and rotational thromboelastometry are point-of-care (POC) viscoelastic tests used to help guide blood product administration. It is unclear whether these tests improve clinical or transfusion-related outcomes. The objective of this study was to appraise data from randomized trials evaluating the benefit of POC testing in cardiac surgery patients. Primary outcomes were the proportion of patients transfused with blood products and all-cause mortality.


Medline (Ovid), EMBASE (Ovid), CENTRAL (the Cochrane Library-Wiley), Web of Science, Biosis, Scopus, and CINAHL databases, as well as clinical trial registries and conference proceedings were queried from inception to February 2018.

Principal findings

We identified 1,917 records, 11 of which were included in our analysis (8,294 patients). Point-of-care testing was not associated with a difference in the proportion of patients transfused with any blood product (risk ratio [RR], 0.90; 95% confidence interval [CI], 0.79 to 1.02; I2 = 51%; four trials, 7,623 patients), or all-cause mortality (RR, 0.73; 95% CI, 0.47 to 1.13; I2 = 5%; six trials, 7,931 patients). Nevertheless, POC testing was weakly associated with a decrease in the proportion of patients receiving red blood cells (RBC) (RR, 0.91; 95% CI, 0.85 to 0.96; I2 = 0%; seven trials, 8,029 patients), and heterogeneous reductions in frozen plasma (FP) (RR, 0.58; 95% CI, 0.34 to 0.99; I2 = 87%; six trials, 7,989 patients) and platelets (RR, 0.66; 95% CI, 0.49 to 0.90; I2 = 65%; seven trials, 8,029 patients). Meta-analysis of the number of units of RBCs and FP was not possible due to heterogeneity in reporting, however POC testing significantly reduced the units of platelets transfused (standard mean difference, -0.09; 95% CI, -0.18 to 0.00; four trials, 7,643 patients).


Our review indicates that in cardiac surgery patients, POC viscoelastic hemostatic testing is not associated with a reduction in the proportion of patients receiving any blood product or all-cause mortality. However, viscoelastic testing is weakly associated with a reduction in proportion of patients transfused with specific blood products. Presently, the benefits associated with viscoelastic testing in cardiac surgery patients are insufficiently robust to recommend routine implementation of this technology.

Trial registration

PROSPERO (CRD4201706577). Registered 11 May 2017.

Tests hémostatiques viscoélastiques au point de service des patients subissant une chirurgie cardiaque : revue systématique de la littérature et méta-analyse



La thromboélastographie et la thromboélastométrie rotative sont des tests de la viscosité sanguine au point de service du patient et qui peuvent servir de guide à l’administration de produits sanguins. On ne sait pas avec certitude si ces tests améliorent l’évolution clinique ou les résultats liés à la transfusion. L’objectif de cette étude était d’évaluer les données provenant d’essais randomisés ayant étudié les bénéfices des tests de viscosité sanguine au point de service des patients subissant une chirurgie cardiaque. Les critères d’évaluation principaux ont été le pourcentage de patients recevant des transfusions de produits sanguins et la mortalité toutes causes confondues.


les bases de données MEDLINE (Ovid), EMBASE (Ovid), CENTRAL (la Cochrane Library-Wiley), Web of Science, Biosis, Scopus et CINAHL, ainsi que les registres d’essais cliniques et les comptes rendus de congrès ont été passés au crible depuis leur création jusqu’en février 2018.

Constatations principales

Nous avons identifié 1 917 rapports, dont 11 qui ont été inclus dans notre analyse (8 294 patients). Les tests de viscosité au point de service n’ont été associés à aucune différence en termes de pourcentages de patients recevant des transfusions de différents produits sanguins (rapport de risque [RR], 0,90; intervalle de confiance [IC] à 95 % : 0,79 à 1,02; I2 = 51 %; quatre essais, 7 623 patients) ou la mortalité toutes causes (RR, 0,73; IC à 95 % : 0,47 à 1,13; I2 = 5 %; six essais, 7 931 patients). Néanmoins, les tests de viscosité au point de service du patient ont été faiblement associés à une diminution du pourcentage de patients recevant des globules rouges (RR, 0,91; IC à 95 % : 0,85 à 0,96; I2 = 0 %; sept essais, 8 029 patients) et à des réductions hétérogènes de plasma congelé (RR, 0,58; IC à 95 % : 0,34 à 0,99; I2 = 87 %; six essais, 7 989 patients) et de plaquettes (RR, 0,66; IC à 95 % : 0,49 à 0,90; I2 = 65 %; sept essais, 8 029 patients). Une méta-analyse du nombre d’unités de globules rouges et de plasma congelé n’a pas été possible en raison de l’hétérogénéité des rapports; cependant, les tests de viscosité au point de service du patient ont significativement réduit le nombre d’unités de plaquettes transfusées (différence des moyennes standard, -0,09; IC à 95 % : -0,18 à 0,00; quatre essais, 7 643 patients).


Notre analyse indique que chez les patients subissant une chirurgie cardiaque, les tests de viscosité sanguine au point de service du patient ne sont pas associés à une réduction du pourcentage de patients recevant un produit sanguin ou à une réduction de la mortalité toutes causes confondues. Cependant, les tests de viscosité sont faiblement associés à une réduction du pourcentage de patients transfusés avec des produits sanguins spécifiques. Actuellement, les avantages associés aux tests de la viscosité sanguine chez les patients de chirurgie cardiaque ne sont pas suffisamment robustes pour recommander la mise en œuvre systématique de cette technologie.

Enregistrement de l’essai clinique

PROSPERO (CRD4201706577). Enregistré le 11 mai 2017.



Rakesh C. Arora has received an unrestricted educational grant from Pfizer Canada Inc. and an honorarium from Mallickrodt Pharmaceuticals. Keyvan Karkouti has received research support from TEM International Gmbh. Ryan Zarychanski receives salary and operating support from the Canadian Institutes of Health Research.

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Steven Backman, Associate Editor, Canadian Journal of Anesthesia.

Author contributions

Carly Lodewyks coordinated all aspects of the review, assisted with the literature search, screened relevant material, extracted and analyzed data, and prepared the final manuscript; Jeffrey Heinrichs assisted with screening relevant material, and extracting data in duplicate; two cardiac anesthesiologists (Hilary P. Grocott and Keyvan Karkouti) and one hematologist/critical care physician (Ryan Zarychanski) provided content expertise and methodological advice; one librarian with expertise in systematic review search methodology designed and executed the literature search strategies (Grace Romund); one clinician/researcher with expertise in conducting systematic reviews provided technical and methodological advice (Ahmed Abou-Setta); one senior biostatistician (Rasheda Rabbani) provided methodological expertise on statistical analysis; two clinician/researchers assisted with project planning and manuscript preparation (Rakesh C. Arora and Navdeep Tangri).

Sources of support

We did not obtain any specific funding for this systematic review.

Supplementary material

12630_2018_1217_MOESM1_ESM.pdf (57 kb)
Supplementary material 1 (PDF 56 kb)


  1. 1.
    Despotis GJ, Avidan MS, Hogue CW Jr. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001; 72: S1821-31.CrossRefGoogle Scholar
  2. 2.
    Nuttall GA, Oliver WC, Santrach PJ, et al. Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001; 94: 773-81.CrossRefGoogle Scholar
  3. 3.
    Dyke C, Aronson S, Dietrich W, et al. Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg 2014; 147(1458-63): e1.Google Scholar
  4. 4.
    Bennett-Guerrero E, Zhao Y, O’Brien SM, et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA 2010; 304: 1568-75.CrossRefGoogle Scholar
  5. 5.
    Patel NN, Avlonitis VS, Jones HE, Reeves BC, Sterne JA, Murphy GJ. Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis. Lancet Haematol 2015; 2: e543-53.CrossRefGoogle Scholar
  6. 6.
    Zbrozek A, Magee G. Cost of bleeding in trauma and complex cardiac surgery. Clin Ther 2015; 37: 1966-74.CrossRefGoogle Scholar
  7. 7.
    Benes J, Zatloukal J, Kletecka J. Viscoelastic methods of blood clotting assessment - a multidisciplinary review. Front Med (Lausanne) 2015; 2: 62.Google Scholar
  8. 8.
    Weber CF, Goerlinger K, Meininger D, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-47.CrossRefGoogle Scholar
  9. 9.
    Karkouti K, Callum J, Wijeysundera DN, et al. Point-of-Care hemostatic testing in cardiac surgery: a stepped-wedge clustered randomized controlled trial. Circulation 2016; 134: 1152-62.CrossRefGoogle Scholar
  10. 10.
    Anderson L, Quasim I, Soutar R, Steven M, Macfie A, Korte W. An audit of red cell and blood product use after the institution of thromboelastometry in a cardiac intensive care unit. Transfus Med 2006; 16: 31-9.CrossRefGoogle Scholar
  11. 11.
    Fassl J, Matt P, Eckstein F, et al. Transfusion of allogeneic blood products in proximal aortic surgery with hypothermic circulatory arrest: effect of thromboelastometry-guided transfusion management. J Cardiothorac Vasc Anesth 2013; 27: 1181-8.CrossRefGoogle Scholar
  12. 12.
    Gorlinger K, Dirkmann D, Hanke AA, et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology 2011; 115: 1179-91.PubMedGoogle Scholar
  13. 13.
    Westbrook AJ, Olsen J, Bailey M, Bates J, Scully M, Salamonsen RF. Protocol based on thromboelastograph (TEG) out-performs physician preference using laboratory coagulation tests to guide blood replacement during and after cardiac surgery: a pilot study. Heart Lung Circ 2009; 18: 277-88.CrossRefGoogle Scholar
  14. 14.
    Girdauskas E, Kempfert J, Kuntze T, et al. Thromboelastometrically guided transfusion protocol during aortic surgery with circulatory arrest: a prospective, randomized trial. J Thorac Cardiovasc Surg 2010; 140(1117-24): e2.Google Scholar
  15. 15.
    Higgins JP, Lasserson T, Chandler J, Tovey D, Churchill R. Methodological Expectations of Cochrane Intervention Reviews (MECIR) - Standards for the conduct of new Cochrane Intervention Reviews 2012, Version 2; 2013. Available from URL: (accessed August 2018).
  16. 16.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151: 264-9.CrossRefGoogle Scholar
  17. 17.
    Higgins JP, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928.CrossRefGoogle Scholar
  18. 18.
    Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1. The Cochrane Collaboration; 2011. Available from URL: (accessed August 2018).
  19. 19.
    Chong SW, Collins NF, Wu CY, Liskaser GM, Peyton PJ. The relationship between study findings and publication outcome in anesthesia research: a retrospective observational study examining publication bias. Can J Anesth 2016; 63: 682-90.CrossRefGoogle Scholar
  20. 20.
    Jones PM. Publication bias in the anesthesiology literature: shifting the focus from the “positive” to the “truth”. Can J Anesth 2016; 63: 658-63.CrossRefGoogle Scholar
  21. 21.
    Ak K, Isbir C, Tetik S, et al. Thromboelastography-based transfusion algorithm reduces blood product use after elective CABG: a prospective randomized study. J Cardiol Surg 2009; 24: 404-10.CrossRefGoogle Scholar
  22. 22.
    Paniagua P, Koller T, Requena T, Gil J, Campos JM, Galan J. Randomized controled trial to evaluate postoperative coagulation management with bed-side trombelastometry (Rotem) compared with a transfusion protocol based on laboratory meausurments in bleeding patients after cardiac surgery: preliminary data. Eur J Anaesthesiol 2011. Available from URL: (accessed August 2018).
  23. 23.
    Royston D, von Kier S. Reduced haemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. Br J Anaesth 2001; 86: 575-8.CrossRefGoogle Scholar
  24. 24.
    Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F, Ergin MA. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 1999; 88: 312-9.PubMedGoogle Scholar
  25. 25.
    Avidan MS, Alcock EL, Da Fonseca J, et al. Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery. Br J Anaesth 2004; 92: 178-86.CrossRefGoogle Scholar
  26. 26.
    Kultufan Turan S, Aydinli B, Ayik I, et al. The role of rotational thromboelastography on decision of blood transfusion in open heart surgery. GKD Anest Yoj Bak Dem Ders 2006; 12: 154-9.Google Scholar
  27. 27.
    Wikkelso A, Wetterslev J, Moller AM, Afshari A. Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) to monitor haemostatic treatment in bleeding patients: a systematic review with meta-analysis and trial sequential analysis. Anaesthesia 2017; 72: 519-31.CrossRefGoogle Scholar
  28. 28.
    Serraino GF, Murphy GJ. Routine use of viscoelastic blood tests for diagnosis and treatment of coagulopathic bleeding in cardiac surgery: updated systematic review and meta-analysis. Br J Anaesth 2017; 118: 823-33.CrossRefGoogle Scholar
  29. 29.
    Deppe AC, Weber C, Zimmermann J, et al. Point-of-care thromboelastography/thromboelastometry-based coagulation management in cardiac surgery: a meta-analysis of 8332 patients. J Surg Res 2016; 203: 424-33.CrossRefGoogle Scholar
  30. 30.
    Fahrendorff M, Oliveri RS, Johansson PI. The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products - a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2017; 25: 39.CrossRefGoogle Scholar
  31. 31.
    Whiting P, Al M, Westwood M, et al. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2015; 19: 1-228.CrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  • Carly Lodewyks
    • 1
    • 2
    • 8
    Email author
  • Jeffrey Heinrichs
    • 3
  • Hilary P. Grocott
    • 3
  • Keyvan Karkouti
    • 4
  • Grace Romund
    • 5
  • Rakesh C. Arora
    • 1
    • 7
  • Navdeep Tangri
    • 2
    • 7
  • Rasheda Rabbani
    • 2
    • 6
  • Ahmed Abou-Setta
    • 2
    • 6
  • Ryan Zarychanski
    • 2
    • 6
    • 7
  1. 1.Department of Surgery, Section of Cardiac Surgery, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  2. 2.Department of Community Health Sciences, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  3. 3.Department of Anesthesia and Perioperative Medicine, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  4. 4.Department of Anesthesia, Institute of Health Policy, Management, and Evaluation, and Peter Munk Cardiac CentreUniversity of TorontoTorontoCanada
  5. 5.Neil John Maclean Library, University of ManitobaWinnipegCanada
  6. 6.George & Fay Yee Center for Healthcare InnovationUniversity of Manitoba/Winnipeg Regional Health AuthorityWinnipegCanada
  7. 7.Department of Internal Medicine, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  8. 8.WinnipegCanada

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