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ROTEM algorithms August 2018
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ROTEM 1 - PPH 3 litres
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Severe fibrinogen deficiency. Fibtem A5 = 2mm - give fib conc 5g or 3 adult doses cryo.
Extem CT 113s - Should correct with fibrinogen.
Extem A5 = 21mm - consider 1 dose platelets.
No fibrinolysis but give TXA 1g as per WOMAN trial.
ROTEM 2 - PPH > 2litres
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Fibtem A5 >10, Extem CT <80, Extem A5 > 35. Normal ROTEM no products needed. Consider TXA 1g.
ROTEM 3 - Anaphylaxis to suxamethonium & bleeding FDIU
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Severe fibrinolysis can be triggered by severe shock or hypotension. If bleeding give TXA 1g
ROTEM 4 - Major oncology surgery 2L blood loss
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Fibtem A5 = 18mm, Extem CT = 45s, Ex A5 = 50mm. Nothing needed. Cancer is a prothrombotic state and patients often retain good haemostatic reserve in the face of significant blood loss.
ROTEM 5 - Abruption & Bleeding
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Fibrinolysis and severe fibrinogen deficiency - give TXA 1g, Fibtem A5 = 5mm give fib conc 4g or cryo 2-3adult doses. Ex CT 98s - should correct with fibrinogen. Ex A5 = 26mm, due to fib def, no platelets needed
ROTEM 6 - Baseline before accreta surgery
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Normal ROTEM but note that her Fibtem A5 is only 12mm, and EX A5 only 36mm - these are actually low for 3rd trimester. Accreta patients often bleed rapidly at delivery anticipate the need to correct fibrinogen early if any major bleeding occurs.
ROTEM 7 - Bleeding after termination of pregnancy
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Severe fibrinogen deficiency and mild late fibrinolysis. Give TXA 1g - ML 13%, Fibtem A5 = 6mm give Fib conc 3-4g or 2 doses cryo. Ext A5 28mm - b/c low fibrinogen no need for plts. Ext CT normal - no FFP/PTX
ROTEM 8 - PPH
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Severe fib deficiency and late systemic hyperfibrinolysis. Give TXA 1g. Fib A5 = 2mm. Give 5g Fib conc or 2-3 doses cryo. Ex A5 = 30mm - no plts needed. Ex CT 109s - should correct with fibrinogen.
ROTEM 9 - PPH 2-3litres
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Normal ROTEM. This is the most common finding even with 2-3 litre blood loss - most women have very good haemostatic reserve in the 3rd trimester.
ROTEM 10 - Obstetric patient prior to CS - what do they have?
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This patient has HELLP syndrome! Plt count 20-30. High fibtem A5 = 19mm helps compensate. You would expect Ex A5 of >40 but here it is only 28mm.
ROTEM 11 - Uterine inversion PPH
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Severe fib deficiency Fib A5 = 3mm give 4-5g Fib conc or 2-3 doses cryo. Ex A5=20mm give plts. Ex CT 97s should correct with fibrinogen. No evidence fibrinolysis but strongly consider TXA 1g anyway!
ROTEM 12 - Abruption
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Isolated fibrinogen deficiency. Fibtem A5 = 7mm give fib conc 3g or cryo 2 doses. Ex A5=35mm no plts needed. Ex CT=61s no FFP/PTX. Note Ex ML=23% but Fib ML = 0% - this is probably clot retraction not true fibrinolysis.
ROTEM 13 - PPH 2.6Litres
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Normal ROTEM - once again even with high blood loss most parturients retain normal haemostatic reserve - consider TXA 1g (preferably early) however.
ROTEM 14 - Large PPH
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Normal ROTEM - no blood products needed - this is the most common ROTEM result.
ROTEM 15 - Cirrhosis upper GI bleed
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Almost no haemostatic capacity - every aspect of haemostasis is deficient. Fibrinolysis - give TXA 1g. Fib A5=0mm Give 5-6g fib conc or 3 doses cryo. Ex A5=11mm give platelets (1or2doses). Ex CT=117s - consider Prothrombinex 10u/kg
ROTEM 16 - Elective AAA post cross clamp release
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Jesus! Severe multifactorial coagulopathy. Give TXA 1-2g. Give Fib conc 5-6g or 3 doses cryo. Give platelets. Check HEPTEM do they need protamine? Consider FFP/PTX - perhaps give the rest and recheck ROTEM first.
ROTEM 17 - Ruptured uterus aortic occlusion applied
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Pretty normal ROTEM but massive ongoing bleeding be proactive to prevent coagulopathy. Fibtem A5 =12mm low normal give some fibrinogen. Give TXA 1g. No plts or FFP needed
ROTEM 18 - Large pelvic cancer resection 1.5litre blood loss
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Normal ROTEM - no treatment needed. Cancer patients are often prothrombotic.
ROTEM 19 - Abruption and fetal death
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Isolated severe fibrinogen deficiency.
Consider TXA 1g early. Fib A5 = 5mm give fib conc 4g or cryo 2-3doses. Ex A5=27mm due to fibrinogen no plts needed. Ex CT=77s no FFP/PTX needed.
ROTEM 20 - Post CABG arrival in ICU
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Hyperfibrinolysis - treat with TXA. No evidence heparin effect, no need for plts, fibrinogen or FFP
ROTEM 21 - Abruption and Fetal Death
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Severe fibrinogen deficiency causing low fibtem A5 and mildly prolonged Extem CT
ROTEM 22 - MVA
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Fibtem A5 = 4mm give 4-5g fib conc. Extem CT = 88s due to low fibrinogen no FFP needed. Extem A5 = 26mm consider platelets soon.
ROTEM 1 - PPH 3 litres
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Severe fibrinogen deficiency. Fibtem A5 = 2mm - give fib conc 5g or 3 adult doses cryo.
Extem CT 113s - Should correct with fibrinogen.
Extem A5 = 21mm - consider 1 dose platelets.
No fibrinolysis but give TXA 1g as per WOMAN trial.
ROTEM 2 - PPH > 2litres
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Fibtem A5 >10, Extem CT <80, Extem A5 > 35. Normal ROTEM no products needed. Consider TXA 1g.
ROTEM 3 - Anaphylaxis to suxamethonium & bleeding FDIU
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Severe fibrinolysis can be triggered by severe shock or hypotension. If bleeding give TXA 1g
ROTEM 4 - Major oncology surgery 2L blood loss
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Fibtem A5 = 18mm, Extem CT = 45s, Ex A5 = 50mm. Nothing needed. Cancer is a prothrombotic state and patients often retain good haemostatic reserve in the face of significant blood loss.
ROTEM 5 - Abruption & Bleeding
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Fibrinolysis and severe fibrinogen deficiency - give TXA 1g, Fibtem A5 = 5mm give fib conc 4g or cryo 2-3adult doses. Ex CT 98s - should correct with fibrinogen. Ex A5 = 26mm, due to fib def, no platelets needed
ROTEM 6 - Baseline before accreta surgery
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Normal ROTEM but note that her Fibtem A5 is only 12mm, and EX A5 only 36mm - these are actually low for 3rd trimester. Accreta patients often bleed rapidly at delivery anticipate the need to correct fibrinogen early if any major bleeding occurs.
ROTEM 7 - Bleeding after termination of pregnancy
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Severe fibrinogen deficiency and mild late fibrinolysis. Give TXA 1g - ML 13%, Fibtem A5 = 6mm give Fib conc 3-4g or 2 doses cryo. Ext A5 28mm - b/c low fibrinogen no need for plts. Ext CT normal - no FFP/PTX
ROTEM 8 - PPH
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Severe fib deficiency and late systemic hyperfibrinolysis. Give TXA 1g. Fib A5 = 2mm. Give 5g Fib conc or 2-3 doses cryo. Ex A5 = 30mm - no plts needed. Ex CT 109s - should correct with fibrinogen.
ROTEM 9 - PPH 2-3litres
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Normal ROTEM. This is the most common finding even with 2-3 litre blood loss - most women have very good haemostatic reserve in the 3rd trimester.
ROTEM 10 - Obstetric patient prior to CS - what do they have?
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This patient has HELLP syndrome! Plt count 20-30. High fibtem A5 = 19mm helps compensate. You would expect Ex A5 of >40 but here it is only 28mm.
ROTEM 11 - Uterine inversion PPH
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Severe fib deficiency Fib A5 = 3mm give 4-5g Fib conc or 2-3 doses cryo. Ex A5=20mm give plts. Ex CT 97s should correct with fibrinogen. No evidence fibrinolysis but strongly consider TXA 1g anyway!
ROTEM 12 - Abruption
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Isolated fibrinogen deficiency. Fibtem A5 = 7mm give fib conc 3g or cryo 2 doses. Ex A5=35mm no plts needed. Ex CT=61s no FFP/PTX. Note Ex ML=23% but Fib ML = 0% - this is probably clot retraction not true fibrinolysis.
ROTEM 13 - PPH 2.6Litres
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Normal ROTEM - once again even with high blood loss most parturients retain normal haemostatic reserve - consider TXA 1g (preferably early) however.
ROTEM 14 - Large PPH
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Normal ROTEM - no blood products needed - this is the most common ROTEM result.
ROTEM 15 - Cirrhosis upper GI bleed
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Almost no haemostatic capacity - every aspect of haemostasis is deficient. Fibrinolysis - give TXA 1g. Fib A5=0mm Give 5-6g fib conc or 3 doses cryo. Ex A5=11mm give platelets (1or2doses). Ex CT=117s - consider Prothrombinex 10u/kg
ROTEM 16 - Elective AAA post cross clamp release
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Jesus! Severe multifactorial coagulopathy. Give TXA 1-2g. Give Fib conc 5-6g or 3 doses cryo. Give platelets. Check HEPTEM do they need protamine? Consider FFP/PTX - perhaps give the rest and recheck ROTEM first.
ROTEM 17 - Ruptured uterus aortic occlusion applied
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Pretty normal ROTEM but massive ongoing bleeding be proactive to prevent coagulopathy. Fibtem A5 =12mm low normal give some fibrinogen. Give TXA 1g. No plts or FFP needed
ROTEM 18 - Large pelvic cancer resection 1.5litre blood loss
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Normal ROTEM - no treatment needed. Cancer patients are often prothrombotic.
ROTEM 19 - Abruption and fetal death
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Isolated severe fibrinogen deficiency.
Consider TXA 1g early. Fib A5 = 5mm give fib conc 4g or cryo 2-3doses. Ex A5=27mm due to fibrinogen no plts needed. Ex CT=77s no FFP/PTX needed.
ROTEM 20 - Post CABG arrival in ICU
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Hyperfibrinolysis - treat with TXA. No evidence heparin effect, no need for plts, fibrinogen or FFP
ROTEM 21 - Abruption and Fetal Death
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Severe fibrinogen deficiency causing low fibtem A5 and mildly prolonged Extem CT
ROTEM 22 - MVA
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Fibtem A5 = 4mm give 4-5g fib conc. Extem CT = 88s due to low fibrinogen no FFP needed. Extem A5 = 26mm consider platelets soon.