Anticoagulation for COVID-19 (correspondence in the European Heart Journal)

Anticoagulation Management COVID-19

UNC Chapel Hill developed an anticoagulation algorithm (link here) in which COVID-19 patients to use anticoagulants and at what dose-intensities. The algorithm was created through discussions between UNC hematologists, intensivists, and pulmonologists, consideration of published data, and discussions with national hematology-coagulation colleagues. It is neither overly aggressive, nor overly passive; it’s an intermediate anticoagulant approach.

Link to SCCM article on coagulopathy in COVID -19

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COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up

JACC State-of-the-Art Review

Role of TEG in COVID-19? reference letter in JAMA 

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.

Money Isn't Everything

How were Kerala, India and Vietnam so successful vs #COVID19?
“Countries that took early, aggressive action, using proven methods, have severely limited the virus. ..if you reduce fast enough, you never reach the point of exponential growth.” @toddmpollack https://t.co/5oWeISdNu7 pic.twitter.com/VJ19ZAkbtA

— Eric Topol (@EricTopol) May 8, 2020

How to Ventilate Patients with COVID-19

Severe SARS CoV-2 diagnosis, CT Chest Findings and Management Strategies for the Intensivist

There are multiple educational resources available for prevention and management . The following 2 Webinars and the online article from ESCIM are particularly helpful in severe cases:

Above are data from Wuhan.

>>>>>> More CT findings form the Lancet article can be found here

Below are data mainly from Lombardy 

additional CT resources from Belgium and Wuhan 

EKG challenge

Both EKG's have the same diagnosis !

The Effect of Xenobiotics on the EKG

Slide presentation on the effect of xenobiotics on the 12 lead EKG. Podcast addendum to follow