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Con: Viscoelastic Testing Should Not Be Used Routinely but Selectively in Cardiac Surgery
Matthew Cameron1, Taysir Awad2
1Department of Anesthesia, McGill University, Montreal, Canada; Department of Anesthesia, Jewish General Hospital, Canada.
Insights
Viscoelastic testing (VET) is beneficial in cardiac surgery when used selectively for active bleeding, not routinely preoperatively. Evidence supports VET within blood management algorithms for evident bleeding, not for all patients.
Area of Science:
- Cardiovascular Surgery
- Hemostasis and Thrombosis
- Transfusion Medicine
Background:
- Viscoelastic testing (VET) is increasingly utilized in cardiac surgery for bleeding management.
- Current evidence supporting VET primarily focuses on patients with active bleeding.
- Preoperative VET lacks reliability in predicting bleeding or transfusion needs.
Purpose of the Study:
- To evaluate the efficacy and appropriate application of VET in cardiac surgery.
- To differentiate the benefits of VET in active bleeding versus routine preoperative screening.
- To inform evidence-based guidelines regarding VET use in cardiac surgery.
Main Methods:
- Review of randomized trials and meta-analyses on VET in cardiac surgery.
- Analysis of evidence regarding preoperative VET versus VET in clinically evident bleeding.
- Assessment of current expert guidelines on VET utilization.
Main Results:
- VET improves outcomes when integrated into blood management algorithms for active bleeding.
- Routine preoperative VET does not reliably predict bleeding or transfusion requirements.
- Indiscriminate VET may lead to unnecessary blood product administration and increased costs.
Conclusions:
- Selective VET for suspected coagulopathy in cardiac surgery preserves benefits and minimizes harm.
- Established clinical predictors and standard labs are effective for bleeding risk assessment.
- Routine preoperative VET for all cardiac surgery patients is discouraged by expert guidelines.
Abstract:
Viscoelastic testing (VET) has become an important tool in cardiac surgery, particularly within bleeding management algorithms. However, evidence supporting its benefits largely pertains to patients with active bleeding rather than its use in all cases. VET does not reliably predict bleeding or transfusion requirements when performed preoperatively, and its indiscriminate application may lead to unnecessary blood product administration and increased costs. Randomized trials and meta-analyses consistently show that VET improves outcomes when integrated into structured blood management algorithms after bleeding is clinically evident. Established clinical predictors and standard laboratory tests remain effective for assessing bleeding risk, and recent expert guidelines explicitly discourage routine VET for all cardiac surgery patients. Selective use of VET in patients with suspected coagulopathy preserves its clinical benefits, minimizes harm, and aligns with evidence-based practice.
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