From the Guidelines
To use ROTEM effectively, it is crucial to interpret its results with caution due to the limitations in study design and risk of bias in published studies, as highlighted by the systematic review of viscoelastic testing in obstetrics 1. When utilizing ROTEM, ensure access to a ROTEM analyzer and appropriate reagents. Begin by collecting a fresh blood sample in a citrated tube. Within 4 hours of collection, pipette the blood into the ROTEM cup, add the specific reagent for the test, and place the cup in the analyzer. The machine will automatically warm the sample and begin the analysis. Results are displayed in real-time, showing clot formation, strength, and breakdown. Key parameters to interpret include clotting time, clot formation time, maximum clot firmness, and alpha angle to assess different aspects of hemostasis. Despite its potential, the current evidence base for ROTEM in obstetrics is limited, with only two RCTs and most studies having methodological limitations 1. Therefore, its use should be guided by the need for precise management of coagulopathies, particularly in settings where targeted blood product administration and monitoring of hemostatic therapy are critical 1. Some studies suggest benefits of using ROTEM to guide fibrinogen concentrate infusion in postpartum hemorrhage 1, but more evidence is required to support its utility in obstetric conditions. Given the lack of strong evidence, it is essential to weigh the potential benefits of ROTEM against its limitations and consider it as part of a comprehensive approach to managing coagulation disorders 1. In clinical practice, the decision to use ROTEM should be based on individual patient needs and the availability of high-quality evidence to support its use in specific clinical scenarios 1.
From the Research
Using ROTEM
To use ROTEM (Rotational Thromboelastometry) effectively, it is essential to understand its application in monitoring coagulation status, especially in severely bleeding patients 2. The main advantage of ROTEM is its ability to detect fibrinolysis, which is crucial for providing aimed therapy.
Activation and Interpretation
ROTEM can be used with reagents for activation, either through the extrinsic or intrinsic pathway of coagulation, to get fast results 2. However, in some cases, patients may be bleeding despite normal values of activated ROTEM methods (EXTEM, INTEM), highlighting the importance of nonactivated methods (NATEM) for detecting fibrinolysis 2.
Clinical Applications
ROTEM has been integrated into damage control resuscitation in trauma casualties, providing a fast, reliable, and robust means of identifying transfusion requirements 3. It offers information on clot initiation strength and breakdown, which is vital for targeted use of blood products. Studies have shown that ROTEM-guided trauma resuscitation can reduce the rate of transfusion and blood loss, although its impact on mortality is still under evaluation 3, 4.
Transfusion Practices
The use of ROTEM can significantly optimize transfusion practices, especially in scenarios like lung transplantation, where it has been shown to decrease perioperative blood loss and the consumption of blood products 5. In combat casualties, ROTEM measurements can help tailor the type and quantity of blood products transfused, improving adherence to damage control resuscitation practices 4.
Limitations and Future Directions
While ROTEM is a valuable tool in guiding resuscitation, its utility in certain patient groups, such as those with traumatic lower extremity fractures, may be limited 6. Further research is needed to fully evaluate the benefits and limitations of ROTEM in various clinical settings and to establish clear guidelines for its use.
Key Points for Use
- ROTEM is useful for monitoring coagulation status and detecting fibrinolysis in bleeding patients.
- Both activated and nonactivated ROTEM methods have their advantages and should be used appropriately based on the patient's condition.
- ROTEM can guide transfusion practices and reduce blood loss and product consumption in certain surgical procedures and trauma cases.
- Its application should be considered on a case-by-case basis, taking into account the specific clinical scenario and the availability of resources.