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Peer-reviewedCC BY-NC-SASaudi journal of anaesthesia

A physiology-based approach to ROTEM interpretation for bleeding management in cardiac surgery: A narrative review.

  • Nasser Elsuhbi1
  • Abdullah Tai1
  • Muneeb Alnouri1
  • Saud Alzahrani2
  1. 1Department of Cardiac Anesthesia, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia.
  2. 2Department of Anatomy, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
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Abstract

Perioperative bleeding after cardiac surgery is common, multifactorial, and resource intensive. Conventional coagulation tests are often delayed and do not describe clot development in whole blood, whereas rotational thromboelastometry (ROTEM) provides point-of-care information about clot initiation, clot firmness, residual heparin effect, and fibrinolysis. This narrative review summarizes guideline statements, randomized trials, systematic reviews, and clinically relevant mechanistic literature on viscoelastic testing in cardiac surgery. Literature was identified through targeted searches of PubMed-indexed and major cardiothoracic anesthesia sources, prioritizing patient blood management guidelines, studies of ROTEM- or thromboelastometry-guided transfusion algorithms, and evidence relevant to FIBTEM, HEPTEM, protamine, fibrinogen replacement, platelet contribution, and antifibrinolytic therapy. The review proposes a stepwise approach that begins with clinical context, evaluates EXTEM clotting time, integrates early EXTEM and FIBTEM clot amplitude, uses INTEM and HEPTEM to distinguish residual heparin from non-heparin causes of delayed clot initiation, screens for hyperfibrinolysis, and requires repeat testing after targeted intervention. The framework is intended to complement local transfusion protocols and patient blood management programs, support interdisciplinary communication, and reduce empiric transfusion.

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Cite

BibTeXRIS
BibTeX
@article{elsuhbi2026physiologybased,
  title = {{A physiology-based approach to ROTEM interpretation for bleeding management in cardiac surgery: A narrative review.}},
  author = {Nasser Elsuhbi and Abdullah Tai and Muneeb Alnouri and Saud Alzahrani},
  journal = {Saudi journal of anaesthesia},
  year = {2026},
  month = oct,
  doi = {10.4103/sja.sja_547_26},
  url = {https://europepmc.org/article/MED/42960355},
  note = {CC BY-NC-SA},
}
RIS
TY  - JOUR
TI  - A physiology-based approach to ROTEM interpretation for bleeding management in cardiac surgery: A narrative review.
AU  - Nasser Elsuhbi
AU  - Abdullah Tai
AU  - Muneeb Alnouri
AU  - Saud Alzahrani
PY  - 2026
DA  - 2026/10/01
JO  - Saudi journal of anaesthesia
DO  - 10.4103/sja.sja_547_26
UR  - https://europepmc.org/article/MED/42960355
AB  - Perioperative bleeding after cardiac surgery is common, multifactorial, and resource intensive. Conventional coagulation tests are often delayed and do not describe clot development in whole blood, whereas rotational thromboelastometry (ROTEM) provides point-of-care information about clot initiation, clot firmness, residual heparin effect, and fibrinolysis. This narrative review summarizes guideline statements, randomized trials, systematic reviews, and clinically relevant mechanistic literature on viscoelastic testing in cardiac surgery. Literature was identified through targeted searches of PubMed-indexed and major cardiothoracic anesthesia sources, prioritizing patient blood management guidelines, studies of ROTEM- or thromboelastometry-guided transfusion algorithms, and evidence relevant to FIBTEM, HEPTEM, protamine, fibrinogen replacement, platelet contribution, and antifibrinolytic therapy. The review proposes a stepwise approach that begins with clinical context, evaluates EXTEM clotting time, integrates early EXTEM and FIBTEM clot amplitude, uses INTEM and HEPTEM to distinguish residual heparin from non-heparin causes of delayed clot initiation, screens for hyperfibrinolysis, and requires repeat testing after targeted intervention. The framework is intended to complement local transfusion protocols and patient blood management programs, support interdisciplinary communication, and reduce empiric transfusion.
SN  - 1658-354X
SN  - 0975-3125
ER  -