Rotational Thromboelastometry ( ROTEM ) Versus Conventional Coagulation Tests in Cirrhosis: Can We Reduce Plasma Transfusion Without ROTEM ?

Background Periprocedural rotational thromboelastometry (ROTEM) could reduce transfusions while maintaining low bleeding risks in cirrhosis. However, it is unclear whether the benefits arise from higher transfusion thresholds, or ROTEM's ability to detect rebalanced hemostasis. Method This cohort study assessed the correlation between CCTs and ROTEM by analyzing blood samples from cirrhotic patients scheduled for elective endoscopy. Additionally, anticoagulant protein levels were measured to assess whether ROTEM shares the same limitations as CCTs. Result The study included 133 patients, 57% male, with a mean age of 62 years. High correlations were observed between prothrombin time ratio (PT‐R) and EXTEM‐CT ( r = 0.73, p < 0.01), platelet count and EXTEM‐MCF ( r = 0.7, p < 0.01), fibrinogen and FIBTEM‐MCF ( r = 0.78, p < 0.01), and fibrinogen and EXTEM‐MCF ( r = 0.72, p < 0.01). Only 41.7% of patients with PT‐ R > 1.5 had EXTEM‐CT exceeding the transfusion threshold (> 110 s), while all patients with PT‐ R > 1.8 showed prolonged EXTEM‐CT. A platelet count ≤ 40.5 × 10 9 /L was associated with impaired EXTEM‐MCF (< 40 mm). Patients with EXTEM‐CT > 110 s had significantly lower protein C and antithrombin levels. Endoscopy revealed esophageal varices in 68 (52%) patients, with 23 (34%) requiring band ligation. No bleeding occurred within 2 weeks. Conclusion ROTEM correlates strongly with CCTs and does not overcome their limitations in detecting rebalanced hemostasis. Prophylactic transfusions based solely on abnormal ROTEM or CCTs should be avoided. However, increasing transfusion thresholds to PT‐ R > 1.8 and platelet count < 40 × 10 9 /L during active bleeding may help reduce unnecessary transfusions.