ROTEM-Guided Transfusion and Hemostatic Therapy in Suspected Coagulopathy
ROTEM should be used in a goal-directed strategy to guide transfusion and hemostatic therapy in patients with suspected coagulopathy, as it improves survival and reduces blood product usage compared to conventional coagulation assays. 1
Benefits of ROTEM Over Conventional Tests
ROTEM provides several advantages in managing coagulopathy:
- Faster results than conventional coagulation assays
- Comprehensive assessment of all phases of coagulation
- Evaluation of clot formation, strength, and fibrinolysis
- Reduced mortality (24h: 13% vs. 5%; 30 days: 25% vs. 11%) 1
- Decreased use of blood products (plasma, platelets, and overall transfusions) 1, 2
- Fewer additional invasive hemostatic interventions 1, 2
Key ROTEM Parameters and Interpretation
ROTEM provides multiple test profiles that evaluate different aspects of coagulation:
| Test | Purpose | Clinical Application |
|---|---|---|
| EXTEM | Extrinsically activated test | Assesses overall clotting pathway |
| INTEM | Intrinsically activated test | Evaluates contact activation pathway |
| FIBTEM | Fibrin-based extrinsically activated test | Isolates fibrinogen contribution to clot strength |
| APTEM | Fibrinolysis inhibition test | Detects hyperfibrinolysis |
Important parameters to monitor include:
- Clotting Time (CT): Time to 2mm amplitude - reflects initiation of clotting
- Clot Formation Time (CFT): Time from 2mm to 20mm amplitude - reflects speed of clot formation
- Maximum Clot Firmness (MCF): Maximum amplitude - reflects maximum clot strength
- Clot Amplitude at 5/10/15 min (CA5, CA10, CA15): Early indicators of clot formation
- Lysis Index at 30 min (LI30): Percentage of clot remaining at 30 min - detects hyperfibrinolysis
ROTEM-Guided Transfusion Algorithm
Based on the evidence, here is a specific algorithm for guiding transfusion using ROTEM parameters:
1. Fibrinogen Replacement (Cryoprecipitate or Fibrinogen Concentrate)
- Indicated when: FIBTEM CA5 < 10 mm or FIBTEM MCF < 7 mm 1
- Dosing: For fibrinogen concentrate, 70 mg/kg can increase plasma concentration by approximately 125 mg/dL 3
2. Platelet Transfusion
- Indicated when: EXTEM CA5 - FIBTEM CA5 < 30 mm or EXTEM MCF - FIBTEM MCF < 45 mm 1
- This calculation isolates the platelet contribution to clot strength
3. Fresh Frozen Plasma (FFP)
- Indicated when: EXTEM CA5 > 40 mm plus EXTEM CT > 80 s or EXTEM MCF > 45 mm plus prolonged CT 1
- Addresses coagulation factor deficiencies
4. Antifibrinolytic Therapy (Tranexamic Acid)
- Indicated when: EXTEM LI30 < 85% or visible hyperfibrinolysis on EXTEM 1
- Addresses pathological fibrinolysis
Diagnostic Accuracy of ROTEM
ROTEM has demonstrated good sensitivity and specificity for detecting coagulopathy:
- CA15-EXTEM at 32 mm has 87% sensitivity and 100% specificity for detecting PT > 1.5 of control value 4
- CA10-FIBTEM at 5 mm has 91% sensitivity and 85% specificity for detecting fibrinogen < 1 g/L 4
Clinical Applications
ROTEM is particularly valuable in:
- Trauma patients: Significantly reduces progressive hemorrhagic injury, especially in traumatic brain injury 1, 5
- Cardiac surgery: Reduces unnecessary transfusions and guides targeted therapy 1, 6
- Postpartum hemorrhage: Helps identify coagulopathy early in obstetric patients 1
- Acquired fibrinogen deficiency: Guides fibrinogen replacement with products like FIBRYGA 3
Limitations and Pitfalls
When implementing ROTEM-guided transfusion, be aware of these limitations:
- Current ROTEM tests may be insensitive to mild fibrinolytic activation 1
- Requires trained users for proper interpretation 1
- Most evidence comes from cardiac surgery settings, with fewer studies in acute trauma 6, 7
- Should be used in conjunction with clinical assessment and conventional tests when necessary 1
Evidence Quality
The evidence supporting ROTEM-guided transfusion is of moderate quality:
- Most studies are observational with moderate risk of bias 5, 7
- Limited randomized controlled trials 6
- Trial sequential analysis indicates only 54% of required information size has been reached for mortality outcomes 6
Despite these limitations, the available evidence consistently supports that ROTEM-guided transfusion strategies reduce blood product usage and may improve patient outcomes in those with suspected coagulopathy.