Bleeding during veno-venous ECMO cannot reliably be predicted by rotational thrombelastometry (ROTEM™)

Area of Science:

• Critical Care Medicine
• Hematology
• Cardiopulmonary Support

Background:

• Veno-venous extracorporeal membrane oxygenation (vvECMO) is crucial for respiratory support but is associated with significant bleeding complications in over a third of patients.
• Routine coagulation tests often fail to identify mechanisms of bleeding, such as acquired von Willebrand syndrome, during vvECMO.
• Predicting and managing bleeding is a critical challenge in patients requiring vvECMO.

Purpose of the Study:

• To evaluate the utility of rotational Thrombelastography (ROTEM™) in predicting specific bleeding events in patients undergoing vvECMO.
• To determine if ROTEM™ provides additional predictive value beyond standard coagulation tests for bleeding risk during vvECMO.

Main Methods:

• A retrospective analysis of 534 ROTEM™ assays from 57 patients over 574 days was conducted.
• Patients were categorized into three groups based on bleeding severity using the Freiburg ECMO bleeding assessment.
• ROTEM™ results were compared with basic and comprehensive laboratory coagulation tests across bleeding severity groups and time points.

Main Results:

• Of 57 patients, 25% had no bleeding, 39% had mild bleeding, and 36% had relevant clinical bleeding. No fatal bleeding or bleeding shock occurred.
• The only significant difference observed was in the clotting time (CT) of the InTEM analysis across bleeding groups.
• ROTEM™ analysis, particularly ExTEM, FibTEM, and ApTEM, showed worsening CT and reduced clot firmness over time, but these changes did not reliably predict bleeding events.

Conclusions:

• Rotational Thrombelastography (ROTEM™) does not offer additional predictive information for bleeding events compared to standard laboratory coagulation tests in patients on vvECMO.
• Specific ROTEM™ results cannot be used to reliably predict the occurrence or severity of bleeding during vvECMO therapy.
• Current standard coagulation assessments remain the primary tool for evaluating bleeding risk in the vvECMO population.