Critically ill ECMO patients face high bleeding risks from anticoagulation and other factors. Although viscoelastic tests, like ROTEM, are widely used to assess hemostasis, evidence for their superiority over conventional coagulation tests (CCTs) is unclear. We assessed the prevalence of coagulopathy defined by ROTEM and CCT transfusion triggers, test concordance, and blood product use in bleeding ECMO patients.

This retrospective study included patients treated with ECMO at the Intensive Care Unit from April 1, 2020, to September 30, 2022, for whom ROTEM and CCTs were tested simultaneously to identify coagulopathy during bleeding. Coagulopathy and transfusion needs were assessed using the cut-offs from both methods.

Of 88 patients, 34 (39%) had Clauss fibrinogen <1.5 g/L, and 21 (24%) had INR ≥1.8. Low FIBTEM A10, low EXTEM A10, and prolonged EXTEM CT were identified in 49 (56%), 43 (49%), and 36 patients (41%). EXTEM CT and INR were poorly associated, particularly for patients on VV-ECMO. FIBTEM A10 and Clauss fibrinogen showed a stronger relationship regardless of circuit type. For plasma and fibrinogen transfusions, ROTEM-based thresholds were more frequently met than CCT thresholds. Patients with abnormal ROTEM received more plasma and fibrinogen than those without [26/36 (72%) versus 21/52 (40%) and 45/49 (92%) versus 13/39 (33%), all p-values <0.01].

Abnormal ROTEM results were more frequent, often discordant with CCTs, and were associated with more plasma and fibrinogen transfusions in bleeding patients on ECMO. Further prospective studies are required to assess the potential clinical utility of ROTEM in ECMO settings.