Blood Clot Consensus Recommendations on Bleeding Management during Cardiac Surgery in Low-Resource Settings using E-Delphi Methodology

India conducts around 240,000 adult cardiac surgeries annually, with bleeding and transfusions being common complications that can worsen outcomes. Implementing patient blood management strategies can reduce unnecessary transfusions and improve results. With emerging management options and point-of-care testing, the need for standardized bleeding management during cardiac surgery in India became evident. The Blood Clot (Indian Bleeding Management during Cardiac Surgery) Working Group convened 3 times (one in-person, two virtual) to discuss and vote on consensus-based recommendation statements derived from a Delphi process. The online Delphi platform enabled anonymous voting, providing real-time statistical insights during discussions. Using the accurate consensus reporting document methodology, 26 recommendations were finalized, covering pre-, intra-, and post-operative bleeding management. The recommendations included both Thrombelastography (TEG)/Rotational thromboelastometry (ROTEM) and non-TEG/ROTEM-based algorithms, along with specific guidance for managing bleeding in cyanotic congenital heart disease surgery. These consensus-based recommendations represent the first comprehensive, India-specific guidelines for managing bleeding during cardiac surgery, aiming to optimize practices and potentially set a new standard of care. This approach could also influence global practices in similar contexts.