Role of Thromboelastometry in Sepsis-Induced Coagulopathy: A Narrative Review

Sepsis-induced coagulopathy (SIC) represents an early, predominantly prothrombotic disturbance that is difficult to detect using conventional coagulation tests. This review aims to evaluate whether rotational thromboelastometry (ROTEM) provides added value in the diagnosis and phenotyping of SIC compared with standard laboratory parameters. We summarize current evidence on SIC pathophysiology and its relationship to disseminated intravascular coagulation (DIC), with particular focus on mechanisms driving hypercoagulability and fibrinolytic shutdown. The limitations of routine tests, platelet count, PT/INR, fibrinogen, and fibrin-related markers are examined, especially their inability to capture early dynamic changes in coagulation. We then outline the principles of ROTEM and review clinical studies assessing its application in sepsis. Available data consistently demonstrate increased clot firmness, frequently driven by elevated fibrinogen, along with impaired fibrinolysis. These patterns often precede overt SIC or DIC and are associated with worse clinical outcomes, including organ dysfunction and mortality. Finally, we discuss the implications of these findings for clinical management. While routine anticoagulation in unselected septic patients remains unsupported, integrating SIC criteria with ROTEM profiles may improve risk stratification and help identify prothrombotic phenotypes that could benefit from targeted therapies. Overall, ROTEM appears to be a valuable adjunct to conventional testing, with potential to refine diagnostic accuracy and guide future interventional strategies in septic coagulopathy.