Rapid Update and Revision of: Thromboelastography or Rotational Thromboelastometry Guided Algorithms in Bleeding Patients—An Updated Systematic Review With Meta‐Analysis and Trial Sequential Analysis

Background Bleeding patients face significant morbidity and mortality due to impaired hemostasis. Hemostatic 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. Methods This systematic review of randomized 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 pediatric 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. Results This systematic review included 35 randomized trials ( n = 3096), primarily elective cardiac surgery. TEG‐/ROTEM‐guided algorithms led to a statistically significant reduction in mortality (RR = 0.76, 95% CI 0.63–0.92) I 2 : 0%. Furthermore, a significant reduction in transfused fresh frozen plasma (RR = 0.52, 95% CI 0.35–0.76) I 2 : 94%, platelets (RR = 0.69, 95% CI 0.55–0.87) I 2 : 60%, the risk for surgical reintervention (RR = 0.63, 95% CI 0.45–0.88) I 2 : 0%, and bleeding with a standard mean difference of −0.31 (95% CI, −0.51 to −0.11) I 2 : 72% was found. According to GRADE methodology, the certainty of the evidence was very low for all outcomes. Trial sequential analysis of mortality analysis indicated that 64% of the optimal information size was reached with a crossed alpha‐boundary. Conclusions TEG‐/ROTEM‐guided transfusion algorithms may reduce the risk of mortality, bleeding volume, and the need for fresh frozen plasma, platelets, and surgical reintervention, but the evidence is very uncertain. Furthermore, the results were primarily based on the adult population undergoing elective cardiac surgery. Editorial Comment This updated systematic review presents a synthesis of evidence for how thromboelastography or rotational thromboelastometry has been implemented in study conditions to guide tranfusion in bleeding patients. The certainty for the evidence is very limited.