Link to SCCM article on coagulopathy in COVID -19
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Thromboelastographic Results and Hypercoagulability Syndrome in Patients With Coronavirus Disease 2019 Who Are Critically Ill
• All patients with COVID-19 should undergo coagulation studies at admission, in particular:
D-dimer, prothrombin time, and platelet count.
• Because of the possibility of patients to develop coagulopathy later in their hospital course,
routine serial measurements of coagulation studies should be undertaken in all COVID-19
patients. The ideal interval has not yet been defined .
• All patients with COVID-19 should be placed on prophylactic doses of anticoagulation,
preferably with LMWH, unless there is a contraindication, such as acute kidney injury (AKI),
wherein unfractionated heparin is preferred.
• Therapeutic anticoagulation should be strongly considered in patients at high-risk for
coagulopathy (including CRRT and ECMO), demonstrating signs of microthrombi-induced
organ dysfunction, or with documented or strongly suspected macro-thromboembolism.
Determination of high-risk patients by laboratory measures of coagulopathy may include:
platelet count, prothrombin time, fibrinogen, fibrinogen-degradation products, D-dimer,
and TEG. Of note, some centers are therapeutically anticoagulating all patients on
admission when no absolute contraindications exist.
• Given the significant rate of AKI seen in COVID, intravenous contrast for imaging should be
used with caution. Duplex ultrasonography, echocardiography, and clinical suspicion can
play an increased role in these cases.
• Some early reports support extended-infusion tPA as a potential approach to refractory
cases
• Aspirin should be considered in cases with elevated troponin and cardiac dysfunction,
particularly with elevated maximal amplitude on TEG.
Conclusions Lancet study on TEG:
COVID-19 patients in the intensive care unit (ICU) demonstrated venous thromboembolism (VTE) in 27%, and arterial thrombosis in 3.7%.
Investigators observed the TEG parameter for lysis at 30 minutes (LY30) was statistically significantly linked to VTE, with an AUROC of 0.742 (P = .021). The TEG α-angle and D-dimer were significantly associated with new onset need for dialysis (0.771 [P = .035] and 0.779 [P = .005], respectively).
"As a rapid test to demonstrate complete fibinolysis shutdown, an LY30 of 0% in conjunction with D-dimer levers of 2600ng/ml may serve as a sensitive marker for the patients most at risk for VTE and other thrombotic complications," Wright and colleagues concluded.
• Because of the possibility of patients to develop coagulopathy later in their hospital course, routine serial measurements of coagulation studies should be undertaken in all COVID-19 patients. The ideal interval has not yet been defined .
• All patients with COVID-19 should be placed on prophylactic doses of anticoagulation, preferably with LMWH, unless there is a contraindication, such as acute kidney injury (AKI), wherein unfractionated heparin is preferred.
• Therapeutic anticoagulation should be strongly considered in patients at high-risk for coagulopathy (including CRRT and ECMO), demonstrating signs of microthrombi-induced organ dysfunction, or with documented or strongly suspected macro-thromboembolism. Determination of high-risk patients by laboratory measures of coagulopathy may include: platelet count, prothrombin time, fibrinogen, fibrinogen-degradation products, D-dimer, and TEG. Of note, some centers are therapeutically anticoagulating all patients on admission when no absolute contraindications exist.
• Given the significant rate of AKI seen in COVID, intravenous contrast for imaging should be used with caution. Duplex ultrasonography, echocardiography, and clinical suspicion can play an increased role in these cases.
• Some early reports support extended-infusion tPA as a potential approach to refractory cases
• Aspirin should be considered in cases with elevated troponin and cardiac dysfunction, particularly with elevated maximal amplitude on TEG.
Conclusions Lancet study on TEG:
COVID-19 patients in the intensive care unit (ICU) demonstrated venous thromboembolism (VTE) in 27%, and arterial thrombosis in 3.7%.
Investigators observed the TEG parameter for lysis at 30 minutes (LY30) was statistically significantly linked to VTE, with an AUROC of 0.742 (P = .021). The TEG α-angle and D-dimer were significantly associated with new onset need for dialysis (0.771 [P = .035] and 0.779 [P = .005], respectively).
"As a rapid test to demonstrate complete fibinolysis shutdown, an LY30 of 0% in conjunction with D-dimer levers of 2600ng/ml may serve as a sensitive marker for the patients most at risk for VTE and other thrombotic complications," Wright and colleagues concluded.
