coagulation

ROTEM Coagulation Guide

Interpret rotational thromboelastometry (ROTEM) results and guide targeted coagulation therapy. Separate fibrinogen deficiency from platelet dysfunction for goal-directed hemostatic resuscitation.

Based on: ESC 2022 · ESAIC

Input

Measurement Mode

Baseline assessment. Measures all 6 parameters: EXTEM CT, INTEM CT, HEPTEM CT, EXTEM A5, FIBTEM A5, EXTEM ML.

Clot InitiationEXTEM CT · INTEM CT / HEPTEM CT

EXTEM CT(sec)

Extrinsic pathway clotting time (reflects coagulation factor activity)

≥ 71 sec (prepare FFP)

INTEM CT(sec)

Intrinsic pathway CT (heparin-sensitive; compare with HEPTEM CT to detect heparin effect)

ratio > 1.10 (prepare protamine)

HEPTEM CT(sec)

CT with heparinase (neutralises heparin; reflects true factor activity)

Clot FirmnessFIBTEM A5 · EXTEM A5

EXTEM A5(mm)

Amplitude at 5 min — extrinsic (platelets + fibrinogen clot firmness)

29–35 mm (prepare platelets)

FIBTEM A5(mm)

Amplitude at 5 min — fibrin only (platelet contribution blocked; reflects fibrinogen)

7–12 mm (prepare fibrinogen)

FibrinolysisEXTEM ML

EXTEM ML(%)

Maximum lysis — extrinsic (percentage clot dissolved from peak; higher = more fibrinolysis)

≥ 13.5% (prepare TXA)

Overview

Rotational thromboelastometry (ROTEM) provides multi-channel viscoelastic assessment of whole blood haemostasis. By comparing EXTEM (total clot strength) with FIBTEM (fibrinogen-only channel, platelets blocked), ROTEM directly separates platelet dysfunction from fibrinogen deficiency — a key advantage over single-channel assays and conventional coagulation tests.

Evidence Summary

Evidence Snapshot

Multiple studies show that ROTEM-guided goal-directed haemostatic therapy reduces allogeneic blood transfusion. Importantly, this reduction occurs without increasing mortality or thromboembolic complications. Evidence is strongest in cardiac surgery and major trauma.

Key Study

A 2016 Cochrane meta-analysis (Afshari et al.) evaluated viscoelastic-guided transfusion strategies. Compared with conventional care, ROTEM/TEG-based algorithms significantly reduced red blood cell transfusion.

Guideline Position

The ESA/ESAIC 2023 guideline recommends viscoelastic testing for perioperative bleeding management. ROTEM-guided haemostatic therapy is supported as a Class I recommendation in appropriate clinical settings.