The use of balanced transfusions and point-of-care viscoelastic testing such as rotational thromboelastometry (ROTEM) and thromboelastography (TEG) are primary strategies for resuscitation of coagulopathy in trauma and surgery. These methods utilize a rotating pin vs rotating cup to measure how whole blood forms and dissolves a clot. The use of these tests is becoming common practice in medical ICU patients with hemorrhages. Viscoelastic testing has been evaluated in patients with cirrhosis, postpartum hemorrhage, gastrointestinal hemorrhage, COVID-19, and, increasingly, sepsis-induced coagulopathy (SIC).1
SIC is a common ICU complication with poor clinical outcomes and high mortality. It involves a disruption in the balance between procoagulant and anticoagulant pathways, and diagnosis is difficult. Often, this leads to an early hypercoagulable state that transitions to a severe hypocoagulable state. Conventional coagulation testing may overdiagnose hypocoagulability while not addressing potential hypercoagulability and excess activation of fibrinolysis. Given the uncertainty of a patient’s clotting or bleeding potential, these tests offer a unique tool to prevent overutilization or underutilization of blood products.
While these tests have not been studied in a large cohort of patients with sepsis, Koami and colleagues showed that there is good sensitivity and prognostic value in sepsis when they are utilized.2 In fact, early in a patient’s admission, the presence of a hypercoagulable profile can help detect the presence of sepsis.In 2023, Bui-Thi and colleagues evaluated coagulation profiles in patients with sepsis and found that ROTEM can detect various forms of coagulopathy in sepsis.3 They observed that patients with septic shock had more hypocoagulability aligning with previous studies, showing hypocoagulability is associated with severity of disease. Boscolo and colleagues studied patients admitted to the ICU or emergency department and evaluated measurements of ROTEM and TEG between patients who survived or did not survive sepsis.4 They found INTEM (intrinsic factors) clotting time and clot formation time to be shorter in survivors, while EXTEM (extrinsic factors) maximum clot formation was lower in patients who did not survive (P < .05 for all).4 These tests may help guide at the bedside to initiate the need for massive transfusion and determine an early differential diagnosis of coagulopathy.
In cardiac surgery and trauma surgery, ROTEM and TEG decreased the use of blood products while decreasing mortality.1 SIC has an increased risk of thrombosis, so being judicious with blood product administration may be vital. This can be another indication that traditional coagulation workup, including prolonged prothrombin time and thrombocytopenia, can often misguide transfusion needs.
Important considerations of these tests include a potential for false negative tests in patients with hypocalcemia or hypothermia.1 This occurs because calcium is needed to activate clotting, and all blood samples are heated in the process.
Overall, it remains unclear whether ROTEM and TEG can be vastly applied to patients with SIC and how their utility can be used in common practice. TEG and ROTEM are used in trauma and on-pump surgeries, as they have shown to reduce use of transfused blood products. It does highlight the need for further clinical research for their application in patients with SIC.
References
1. Whitton TP, Healy WJ. Review of thromboelastography (TEG): medical and surgical applications. Ther Adv PulmCritCare Med. 2023;18. doi:10.1177/29768675231208426
2. Koami H, Sakamoto Y, Hirota Y, et al. Effect of hypofibrinolysis on clinical outcomes of patients with septic disseminated intravascular coagulation. Thromb Res. 2025;245:109235. doi:10.1016/j.thromres.2024.109235
3. Bui-Thi HD, Gia KT, Le Minh K. Coagulation profiles in patients with sepsis/septic shock identify mixed hypo-hypercoagulation patterns based on rotational thromboelastometry: a prospective observational study. Thromb Res. 2023;227:51-59. doi:10.1016/j.thromres.2023.05.010
4. Boscolo A, Spiezia L, De Cassai A, et al. Are thromboelastometric and thromboelastographic parameters associated with mortality in septic patients? A systematic review and meta-analysis. J Crit Care. 2021;61:5-13. Preprint. Posted online October 6, 2020. PMID: 33049490. doi: 10.1016/j.jcrc.2020.09.034