From Hypercoagulability to Hypocoagulability: Dynamic ROTEM Phenotypes and Outcomes in Sepsis and Septic Shock

Background/Objectives: Sepsis is characterized by profound and dynamic alterations of haemostasis, ranging from hypercoagulability and fibrinolysis shutdown to mixed patterns, hypocoagulability, and overt disseminated intravascular coagulation. Conventional coagulation tests provide only a partial representation of these changes. Rotational thromboelastometry (ROTEM) offers a whole-blood, dynamic assessment of clot initiation, propagation, firmness, and lysis, potentially allowing for more accurate haemostatic phenotyping. Methods: A narrative review of the literature was performed using PubMed, Scopus, and EMBASE from database inception to August 2026. Studies addressing sepsis or septic shock and rotational thromboelastometry, thromboelastometry, viscoelastic testing, coagulation phenotypes, fibrinolysis, disseminated intravascular coagulation, and clinical outcomes were considered. Additional references were identified through manual screening of relevant articles and reviews. Results: The available evidence indicates that ROTEM can identify distinct haemostatic phenotypes in sepsis, including hypercoagulability, fibrinolysis shutdown, mixed hypo-hypercoagulable patterns, and hypocoagulability. Hypercoagulable profiles are frequently reported in early or less advanced sepsis, whereas hypocoagulability and reduced clot firmness are increasingly observed in septic shock and advanced coagulopathy. Impaired fibrinolysis and hypocoagulable profiles have been associated with greater organ dysfunction and mortality. Importantly, discordance between conventional coagulation tests and ROTEM is common, supporting the value of integrated whole-blood assessment. However, most studies are observational, heterogeneous, and based on single time-point measurements. Conclusions: ROTEM should be regarded primarily as a complementary tool for dynamic haemostatic phenotyping and risk stratification in sepsis and septic shock. Future prospective studies should determine whether serial ROTEM trajectories provide incremental prognostic value and can identify subgroups potentially amenable to phenotype-guided therapeutic strategies.