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Hershkop, M.; Rafiee, B.; Friedman, M.T. The Application of Viscoelastic Testing in Patient Blood Management. Encyclopedia. Available online: https://encyclopedia.pub/entry/58718 (accessed on 14 December 2025).
Hershkop M, Rafiee B, Friedman MT. The Application of Viscoelastic Testing in Patient Blood Management. Encyclopedia. Available at: https://encyclopedia.pub/entry/58718. Accessed December 14, 2025.
Hershkop, Mordechai, Behnam Rafiee, Mark T. Friedman. "The Application of Viscoelastic Testing in Patient Blood Management" Encyclopedia, https://encyclopedia.pub/entry/58718 (accessed December 14, 2025).
Hershkop, M., Rafiee, B., & Friedman, M.T. (2025, August 05). The Application of Viscoelastic Testing in Patient Blood Management. In Encyclopedia. https://encyclopedia.pub/entry/58718
Hershkop, Mordechai, et al. "The Application of Viscoelastic Testing in Patient Blood Management." Encyclopedia. Web. 05 August, 2025.
Peer Reviewed
The Application of Viscoelastic Testing in Patient Blood Management
This is a peer-reviewed entry published in Encyclopedia Journal, full entry can be found at 10.3390/encyclopedia5030110
Patient blood management (PBM) is a multidisciplinary approach aimed at improving patient outcomes through targeted anemia treatment that minimizes allogeneic blood transfusions, employs blood conservation techniques, and avoids inappropriate use of blood product transfusions. Viscoelastic testing (VET) techniques, such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), have led to significant advancements in PBM. These techniques offer real-time whole-blood assessment of hemostatic function. This provides the clinician with a more complete hemostasis perspective compared to that provided by conventional coagulation tests (CCTs), such as the prothrombin time (PT) and the activated partial thromboplastin time (aPTT), which only assess plasma-based coagulation. VET does this by mapping the complex processes of clot formation, stability, and breakdown (i.e., fibrinolysis). As a result of real-time whole-blood coagulation assessment during hemorrhage, hemostasis can be achieved through targeted transfusion therapy. This approach helps fulfill an objective of PBM by helping to reduce unnecessary transfusions. However, challenges remain that limit broader adoption of VET, particularly in hospital settings. Of these, standardization and the high cost of the devices are those that are faced the most. This discussion highlights the potential of VET application in PBM to guide blood-clotting therapies and improve outcomes in patients with coagulopathies from various causes that result in hemorrhage. Another aim of this discussion is to highlight the limitations of implementing these technologies so that appropriate measures can be taken toward their wider integration into clinical use.
coagulation hemostasis patient blood management (PBM) point-of-care testing (POCT) Quantra rotational thromboelastometry (ROTEM) thromboelastography (TEG) viscoelastic testing (VET)
The World Health Organization (WHO) notes that PBM is a patient-centered approach that addresses anemia, coagulopathy, and blood loss in both surgical and nonsurgical patients as risk factors for adverse medical outcomes. Furthermore, the WHO includes minimization of blood loss and optimization of coagulation as one of three PBM pillars (along with detection and management of anemia and iron deficiency and leveraging and optimizing patient-specific physiological tolerance of anemia as the other two pillars) [1]. While timely blood transfusions certainly can be life-saving, unnecessary or excessive transfusions, which occur due to outdated clinical practices (e.g., transfusion of two units of red blood cells [RBCs] when a single unit would be sufficient), lack of clinical education in the use of blood products, and the use of outdated transfusion indication guidelines, among other contributing factors, increase risks to patients. Risks include volume overload (i.e., transfusion-associated circulatory overload [TACO]), immunological reactions (e.g., alloimmunization, hemolytic transfusion reactions, transfusion-related acute lung injury [TRALI]), transmissible diseases (e.g., viral hepatitis [hepatitis B virus, hepatitis C virus], human immunodeficiency virus [HIV], parasites [such as babesiosis and malaria]), allergic reactions, iron overload (i.e., excessive transfusion of RBCs), and transfusion-associated graft-versus-host disease (TA-GVHD).
VET represents a significant development in coagulation evaluation, offering dynamic, real-time assessment of clot formation, stability, and breakdown (fibrinolysis) [2][3]. Whereas CCTs, such as the PT and aPTT, among others, are performed using only the plasma portion of blood, VET analyzes whole-blood (WB) clot formation, enabling the clinician to understand the interaction of plasma coagulation factors with cellular blood components (i.e., RBCs and platelets) under conditions similar to physiological ones [4][5]. Although VET technologies were developed as early as 1948 with the invention of thromboelastography (TEG) by Hartert, they remained largely underutilized until the 1980s when improvements in device reliability and accessibility led to their broader adoption in clinical patient care [3][6]. Nevertheless, even in the present time, many institutions outside of major academic centers do not have VET analyzers [5].
VET has a wide range of utilities encompassing various clinical conditions [5]. The technology has revolutionized transfusion management in cardiac and liver transplantation surgery by minimizing the unnecessary use of blood products, thereby avoiding related complications [7][8][9]. In trauma, it may make the identification and correction of coagulopathies more efficient, potentially improving survival [10][11]. In obstetrics, it provides critical insights into hypercoagulable states during pregnancy and may aid in the management of severe postpartum hemorrhage [12][13][14]. Additionally, its use in oncology and critical care has allowed for individualized therapies in heterogeneous patient populations [15].
Nevertheless, there are several controversies concerning this modality. The main issues are the cost-effectiveness of VET compared to CCTs and the standardization of devices and protocols [16]. Several studies challenge the generalizability of findings from different clinical settings and patient groups. However, consensus emphasizes its revolutionary role in improving patient outcomes and healthcare spending.
This entry collates current evidence regarding VET, its utility in the clinical environment by discipline, its limitations, and points to future possibilities. The critical analysis is meant to guide the integration of VET into the broader patient management strategies. The main conclusion is that, although challenges remain, the adoption of VET represents an essential shift in hemostasis diagnostics and management [4]. Hence, better-targeted therapies and improved patient outcomes are in prospect as adaptation becomes more widespread.

References

  1. World Health Organization. Patient Blood Management: A Global Strategy to Optimize the Care of Patients Who Need Transfusion; WHO: Geneva, Switzerland, 2021; Available online: https://www.who.int/publications/i/item/9789240035744 (accessed on 25 June 2025).
  2. Mooney, C.; Byrne, M.; Kapuya, P.; Pentony, L.; De la Salle, B.; Cambridge, T.; Foley, D. Point of care testing in general haematology. Br. J. Haematol. 2019, 187, 296–306.
  3. Carll, T.; Wool, G.D.; Carll, T. Basic principles of viscoelastic testing. Transfusion. 2020, 60, S1–S9.
  4. Gonzalez, E.; Moore, E.E.; Moore, H.B.; Chapman, M.P.; Chin, T.L.; Ghasabyan, A.; Wohlauer, M.V.; Barnett, C.C.; Bensard, D.D.; Biffl, W.L.; et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: A pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann. Surg. 2016, 263, 1051–1059.
  5. Azvolinsky, A. Thromboelastography: Measuring blood coagulation in real time. ASH Clinical News, 2018. Available online: https://ashpublications.org/ashclinicalnews/news/6430/Thromboelastography-Measuring-Blood-Coagulation-in (accessed on 25 June 2025).
  6. Nogami, K. The utility of thromboelastography in inherited and acquired bleeding disorders. Br. J. Haematol. 2016, 174, 503–514.
  7. Girdauskas, E.; Kempfert, J.; Kuntze, T.; Borger, M.A.; Enders, J.; Fassl, J.; Falk, V.; Mohr, F.-W. Thromboelastometrically guided transfusion protocol during aortic surgery with circulatory arrest: A prospective, randomized trial. J. Thorac. Cardiovasc. Surg. 2010, 140, 1117–1124.e2.
  8. Fayed, N.; Mourad, W.; Yassen, K.; Görlinger, K. Preoperative thromboelastometry as a predictor of transfusion requirements during adult living donor liver transplantation. Transfus. Med. Hemotherapy 2015, 42, 99–108.
  9. Dötsch, T.M.; Dirkmann, D.; Bezinover, D.; Hartmann, M.; Treckmann, J.W.; Paul, A.; Saner, F.H. Assessment of standard laboratory tests and rotational thromboelastometry for the prediction of postoperative bleeding in liver transplantation. Br. J. Anaesth. 2017, 119, 402–410.
  10. Chapman, M.P.; Moore, E.E.; Ramos, C.R.; Ghasabyan, A.M.; Harr, J.N.; Chin, T.L.; Stringham, J.R.; Sauaia, A.; Silliman, C.C.; Banerjee, A. Fibrinolysis greater than 3% is the critical value for initiation of antifibrinolytic therapy. J. Trauma Acute Care Surg. 2013, 75, 961–967.
  11. Baksaas-Aasen, K.; Gall, L.S.; Stensballe, J.; Juffermans, N.P.; Curry, N.; Maegele, M.; Brooks, A.; Rourke, C.; Gillespie, S.; Murphy, J.; et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): A randomized, controlled trial. Intensiv. Care Med. 2021, 47, 49–59.
  12. Bell, S.; Roberts, T.; Pereira, J.F.M.; De Lloyd, L.; Amir, Z.; James, D.; Jenkins, P.; Collis, R.; Collins, P. The sensitivity and specificity of rotational thromboelastometry (ROTEM) to detect coagulopathy during moderate and severe postpartum haemorrhage: A prospective observational study. Int. J. Obstet. Anesth. 2022, 49, 103238.
  13. Jokinen, S.; Kuitunen, A.; Uotila, J.; Yli-Hankala, A. Thromboelastometry-guided treatment algorithm in postpartum haemorrhage: A randomised, controlled pilot trial. Br. J. Anaesth. 2023, 130, 165–174.
  14. Snegovskikh, D.; Souza, D.; Walton, Z.; Dai, F.; Rachler, R.; Garay, A.; Snegovskikh, V.V.; Braveman, F.R.; Norwitz, E.R. Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. J. Clin. Anesth. 2017, 42, 14–20.
  15. Toukh, M.; Siemens, D.R.; Black, A.; Robb, S.; Leveridge, M.; Graham, C.H.; Othman, M. Thromboelastography identifies hypercoagulablilty and predicts thromboembolic complications in patients with prostate cancer. Thromb. Res. 2014, 133, 88–95.
  16. Cohen, T.; Haas, T.; Cushing, M.M. The strengths and weaknesses of viscoelastic testing compared to traditional coagulation testing. Transfusion 2020, 60, S21–S28.
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Subjects: Hematology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register : Mordechai Hershkop ,
Behnam Rafiee
, Mark T. Friedman
View Times: 215
Online Date: 05 Aug 2025
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