Normalized ROTEM but bleeding persists: think surgical source
When viscoelastic results improve but bleeding continues, the next question is not always more product. Reassess the surgical field, source control, timing, and physiology.
Clinical scenario
A 63-year-old man undergoes redo mitral valve surgery with CPB. After protamine, there is diffuse bleeding and low fibrin-based clot firmness. Fibrinogen replacement is given according to local protocol, temperature and calcium are corrected, and repeat ROTEM shows improved FIBTEM and acceptable EXTEM clot firmness. Lysis is not increased. Despite this, chest tube output remains brisk and the surgeon notes a persistent area of bleeding near the posterior atrioventricular groove.
The tests have improved — but the bleeding has not.
Reasoning goals
- Recognize that improved VET results do not exclude surgical bleeding.
- Distinguish diffuse coagulopathic oozing from persistent focal bleeding.
- Avoid reflexive additional product administration when the test pattern has corrected.
- Reassess the surgical field and source control.
- Continue physiology correction and monitoring.
- Use VET as a reassessment tool, not as proof that bleeding has stopped.
A. What changed after treatment?
- Fibrin-based clot firmness improved.
- Global clot strength is now acceptable.
- Lysis is not the dominant signal.
- Bleeding did not improve as expected.
B. Why this is not “more product” by default
- VET improvement means the measured coagulation pattern has improved.
- Persistent brisk or focal bleeding may reflect a surgical source.
- Additional products may not solve source bleeding and may add risk.
An improved test is not proof the bleeding has stopped
A corrected viscoelastic pattern tells you the measured coagulation has improved — it does not confirm haemostasis. When the test improves but bleeding persists, interpret the mismatch against the bleeding pattern and the surgical field rather than reaching for another product.
C. What surgical bleeding clues are present?
- Persistent localized bleeding.
- Brisk output despite a corrected clot pattern.
- Bleeding near a surgical site or high-risk dissection area.
- Mismatch between test improvement and clinical bleeding.
D. Action frame
- Communicate the mismatch: tests improved, bleeding persists.
- Inspect the surgical field again.
- Confirm source control.
- Continue correcting temperature, pH, calcium, and dilution.
- Repeat VET only if the bleeding pattern changes or after additional intervention.
- Avoid treating the screen instead of the patient.
Take-home message
A normalized or improved viscoelastic pattern does not rule out surgical bleeding. When the test improves but bleeding persists, source control moves back to the center of the decision.
Clinical content by Kozo Watanabe, MD View profile →
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