The precision of ROTEM EXTEM is decreased in hypocoagulable blood: a prospective observational study

BACKGROUND: The use of viscoelastic tests is becoming increasingly popular. There is a paucity of validation of the reproducibility of varying coagulation states. Therefore, we aimed to study the coefficient of variation (CV) for the ROTEM EXTEM parameters clotting time (CT), clot formation time (CFT), alpha-angle and maximum clot firmness (MCF) in blood with varying degrees of coagulation strength. The hypothesis was that CV increases in states of hypocoagulability. METHODS: Critically ill patients and patients subjected to neurosurgery at a university hospital during three separate periods were included. Each blood sample was tested in eight parallel channels, yielding the CVs for the tested variables. In 25 patients, the blood samples were analysed both at baseline and after dilution with albumin 5%, as well as after being spiked with fibrinogen, simulating weak and strong coagulation. RESULTS: In total, 225 unique blood samples were collected from 91 patients. All samples were analysed in eight parallel ROTEM channels, resulting in 1,800 measurements. In hypocoagulable samples, defined as those with values outside the normal reference range, the CV of CT was higher (median (interquartile range)) (6.3% (5.1–9.5)) than for normocoagulable samples (5.1% (3.6–7.5)), p < 0.001. CFT showed no difference (p = 0.14), while the CV of alpha-angle was higher in hypocoagulable samples (3.6% (2.5–4.6)) than in normocoagulable samples (1.1% (0.8–1.6), p < 0.001. The CV of MCF was higher in hypocoagulable samples (1.8% (1.3–2.6)) than in normocoagulable samples (1.2% (0.9–1.7)), p < 0.001. The CV ranges for the different variables were as follows: CT: 1.2%–37%, CFT: 1.7%–30%, alpha-angle: 0.0%–17% and MCF: 0.0%–8.1%. CONCLUSIONS: CVs for the EXTEM ROTEM parameters CT, alpha-angle, and MCF increased in hypocoagulable blood compared to blood with normal coagulation, confirming the hypothesis for CT, alpha-angle, and MCF but not for CFT. Furthermore, the CVs for CT and CFT were much higher than those for alpha-angle and MCF. The results demonstrate that EXTEM ROTEM results from patients with weak coagulation should be interpreted with the notion of limited precision and that procoagulative treatment, based only on ROTEM EXTEM, should be given with some caution. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12959-023-00468-5.