BACK

Thromboelastographic Results and Hypercoagulability Syndrome in Patients With Coronavirus Disease 2019 Who Are Critically Ill

Background:Severe and apparently frequent coagulopathies occur in association with COVID – 19 infection including disseminated intravascular coagulopathy.Mechanisms related to this disorder are incompletely understood.

Study Details:

  • This report covers all patients (pts) admitted to the Baylor St. Luke’s Medical Center in Houston March 15-April 9, 2020 with COVID – 19 infection.
  • Standard deep venous thrombosis chemoprophylaxis was administered to all ICU admissions.
  • Heparin infusion or enoxaparin treatment was administered to all patients with thrombotic complications.
  • The definition of hypercoagulability was fibrinogen activity > 730 angle or maximum amplitude (MA) > 65 mm with heparinase correction

Patients Parameters

  • Patients studied – 21; Mean age 68, range 50-89 yrs. 57% male.
  • Comorbidities occurred in 20/21 (95%) pts ranging from 1-7 with a mean of 3.
  • Thromboembolism risk factors included atrial fibrillation, malignant tumors or chronic kidney disease in 4 (19%) pts; ECMO was used in 4 (19%) pts, while 18 (85%) pts were treated with renal replacement therapy.
  • Two (10%) pts died of pulseless electrical activity after development of acute pulmonary hypertension.

Results:

  • Cohort mean INR, PTT and platelets were in normal ranges.
  • Mean Fibrinogen and D-Dimer levels were elevated for the cohort.
  • TEG results hypercoagulable in 19 (90%) of pts.
  • Thrombotic events occurred in 13 (62%) of patients including 42 events, ranging from 1-8 per patient including arterial, central venous and or dialysis catheter or filter thrombosis.
  • INR, PTT and platelet counts were not different between 10 pts with > thrombotic events compared to pts with <2 thrombotic episodes.
  • Conversely, TEG MA for high event rate pts was significantly greater compared to the low event rate pts. Mean 75 vs. 61 mm. P=0.01.
  • Overall TEG MA was 100% sensitive with a 100% negative predictive value.

Key Points:

  • Despite thrombosis prophylaxis there was a high incidence of thrombotic complications not predicted by INR, PTT or platelet count.
  • The D-Dimer and TEG results suggest complex inflammatory and coagulopathy mechanisms in COVID pts.
  • The thrombotic risk of COVID – 19 may be often underdiagnosed or treated.
  • Some institutions have gone to full anticoagulation of all high-risk ICU pts, but this puts all patients at increased bleeding complications.
  • TEG may provide a method to effectively identify patients at high-risk and allow targeted systemic anticoagulation to minimize the risk of thromboembolic events.

Mortus JR, Manek SE, Brubaker LS, et. al. Key Points: Thromboelastographic Results and Hypercoagulability Syndrome in Patients With Coronavirus Disease 2019 Who Are Critically Ill. JAMA Network Open. 2020;3(6):e2011192. doi:10.1001/jamanetworkopen.2020.11192