How to Interpret ROTEM in Bleeding Patients
A practical guide to ROTEM pattern recognition for perioperative bleeding — from CT and FIBTEM MCF to targeted treatment decisions for anesthesiologists.
Key points
- Fibrinogen is often the first clotting component to become critically depleted in major bleeding. Checking FIBTEM MCF before giving platelets helps guide targeted therapy.
- A prolonged CT with normal FIBTEM suggests factor deficiency — FFP or PCC may be appropriate; fibrinogen and platelet transfusion are unlikely to help in this pattern.
- EXTEM ML > 15% suggests active fibrinolysis. Tranexamic acid is typically the priority intervention, though treatment decisions should reflect clinical context and institutional protocols.
ROTEM gives you real-time viscoelastic data at the point of care. The challenge is not reading the numbers — it is knowing which channel answers which question, and translating patterns into treatment before the next result arrives.
What each parameter tells you
| Parameter | What it reflects | Channel |
|---|---|---|
| CT (clotting time) | Time to initial clot formation — primarily reflects coagulation factor activity | EXTEM, INTEM |
| CFT / α-angle | Speed of clot build-up — depends on fibrinogen and platelet contribution | EXTEM, FIBTEM |
| MCF (max clot firmness) | Strength of the fully formed clot — combined fibrinogen and platelet effect | EXTEM, FIBTEM |
| ML (max lysis) | Percentage of clot dissolved at 60 minutes — detects hyperfibrinolysis | EXTEM |
Key patterns and what to do
| Pattern | Key finding | Likely cause | Consider |
|---|---|---|---|
| Factor deficiency | EXTEM CT prolonged, FIBTEM MCF normal | Low coagulation factors | FFP or PCC |
| Fibrinogen depletion | FIBTEM MCF < 8–10 mm | Fibrinogen consumed or diluted | Fibrinogen concentrate or cryoprecipitate |
| Platelet issue | EXTEM MCF low, FIBTEM MCF normal | Platelet deficiency or dysfunction | Platelet transfusion |
| Hyperfibrinolysis | EXTEM ML > 15% | Active clot dissolution | Tranexamic acid |
| Mixed coagulopathy | Multiple channels abnormal | Combined deficiency | Target most depleted component first |
Fibrinogen first
In most major surgical bleeding, fibrinogen is often the first clotting component to fall critically low. Giving platelets before addressing fibrinogen may have limited effect. When FIBTEM MCF is low, consider fibrinogen supplementation first — then reassess.
Translating results into treatment
- Prolonged EXTEM CT — consider FFP or PCC; comparing INTEM CT may help distinguish intrinsic from extrinsic pathway deficiency
- FIBTEM MCF < 8 mm — fibrinogen concentrate may be appropriate; a dosing calculator based on patient weight and target MCF can help guide the dose
- Low EXTEM MCF with normal FIBTEM MCF — consider platelet transfusion; fibrinogen supplementation is unlikely to help when FIBTEM MCF is already within range
- EXTEM ML > 15% — tranexamic acid may be appropriate; consider repeating EXTEM after 30 minutes to assess response