Rotational thromboelastometry-guided transfusion in acute trauma: Less plasma, greater precision

Effective transfusion management is essential in trauma patients with active bleeding. In this study, we aimed to evaluate the association between point-of-care rotational thromboelastometry (ROTEM)-guided management, blood-component utilization, and clinical outcomes.

We conducted a retrospective comparative cohort study of 200 trauma patients with active bleeding admitted between October 2023 and March 2025. One-hundred patients received ROTEM-guided management and 100 were managed using conventional coagulation tests. Blood-component utilization during the first 24 h and clinical outcomes were analyzed using multivariable models adjusted for relevant baseline variables.

ROTEM-guided management was associated with lower fresh frozen plasma utilization (adjusted incidence rate ratio [aIRR] 0.36, 95% confidence interval [CI]: 0.24-0.55), higher cryoprecipitate utilization (aIRR 1.92, 95% CI: 1.40-2.66), and shorter intensive care unit (ICU) stay. Adjusted red blood cell (RBC) and platelet utilization did not differ between groups. Maximum clot firmness in the fibrin-based thromboelastometry assay correlated strongly with fibrinogen concentration, and clot formation time in the extrinsically activated thromboelastometry assay correlated inversely with platelet count. Differences in transfusion-related complications and in-hospital mortality were not statistically significant.

ROTEM-guided management was associated with lower plasma utilization, higher cryoprecipitate utilization, and shorter ICU stay. Given the retrospective, non-randomized design and low RBC exposure, these findings should not be interpreted as evidence that ROTEM reduced bleeding severity or RBC requirements, particularly in massive-transfusion populations. Prospective studies in trauma patients with massive hemorrhage are required to evaluate the utility of ROTEM in guiding specific hemostatic blood-product transfusions.