Document Type



Anaesthesiology (East Africa)


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.

Hemorrhage and thrombosis are frequent complications in the intensive care unit (ICU), compromising the clinical outcome of patients.1 Among them, the main cause of death in the world is thrombosis. However, there is concern about the risk of bleeding in patients who have pathological results from conventional coagulation tests (CCTs).2 For this reason, prophylactic transfusion of allogeneic blood components is still very frequent, even in the absence of bleeding. However, transfusion is associated with life-threatening adverse events.3 In this literature review, we aimed to describe critical aspects of the approach to patients with severe acute bleeding in the ICU, focusing on the importance of point-of-care testing (POCT) for early identification of coagulopathy to guide early goal-directed hemostatic therapy (EGDHT) using coagulation factor concentrates and hemostatic drugs.

Publication (Name of Journal)

Anesthesia & Analgesia



Creative Commons License

Creative Commons Attribution 4.0 International License
This work is licensed under a Creative Commons Attribution 4.0 International License.