A Case Series of Thromboelastography-Guided Anticoagulation in COVID-19 Patients with Inherited and Acquired Hypercoagulable States

Abstract

One of the complications of the novel coronavirus disease 2019 (COVID-19) is hypercoagulability. For this reason, patients presenting with COVID-19 are often put on therapeutic or intermediate anticoagulation upon hospitalization. A common issue of this anticoagulation is the progression to hypocoagulability resulting in hemorrhage. Therefore, monitoring the hemostatic integrity of critically ill COVID-19 patients is of utmost importance. In this case series, we present the cases of three coagulopathic COVID-19 patients whose anticoagulation was guided by thromboelastography (TEG). In each case, TEG permitted the clinical team to simultaneously prevent thrombotic and hemorrhagic events, a difficult task for COVID-19 patients admitted to the intensive care unit. The first two cases illustrate the utility of TEG to guide anticoagulant dosing for COVID-19 patients when the activated partial thromboplastin time (aPTT) is inaccurate. The first case was a severely ill COVID-19 patient with end-stage renal disease and a falsely elevated aPTT secondary to hypertriglyceridemia. The second case was a severely ill COVID-19 patient with chronic pulmonary disease who demonstrated a falsely elevated aPTT due to polycythemia and hemoconcentration. In both cases, TEG was sensitive to the hypercoagulability caused by the metabolic derangements which enabled the goal-directed titration of anticoagulants. The last case depicts a severely ill COVID-19 patient with an inherited factor V Leiden mutation who required abnormally high dosing to achieve therapeutic anticoagulation, guided by TEG. Hypercoagulopathic COVID-19 patients are difficult to anticoagulate without development of hypocoagulopathy. Treatment of these patients demands goal-directed therapy by diligent laboratory monitoring. This can be accomplished by the use of TEG coupled with aPTT to guide anticoagulation. This case series illustrates the necessity for active hemostatic monitoring of critically ill COVID-19 patients.

Serial Thromboelastography and the Development of Venous Thromboembolism in Critically Ill Patients With COVID-19

“…Hypercoagulable thromboelastography has been suggested as a tool to guide anticoagulation in this population (23,24). This study suggests that elevated thromboelastography MA, termed hypercoagulable in prior studies, may not accurately identify patients at increased risk of VTE.…”

“…The multiplatform randomized controlled trial of therapeutic anticoagulation in COVID-19 demonstrated that therapeutic anticoagulation for the entire critically ill COVID-19 population was not beneficial (22); whether subpopulations of critically ill COVID-19 patients may benefit from therapeutic anticoagulation remains unresolved. Hypercoagulable thromboelastography has been suggested as a tool to guide anticoagulation in this population (23, 24). This study suggests that elevated thromboelastography MA, termed hypercoagulable in prior studies, may not accurately identify patients at increased risk of VTE.…”

Coronavirus Disease 2019-Related Extensive Thrombosis in a Patient Receiving Therapeutic Anticoagulation With Dabigatran

“…Studies assessing the use of TEG monitoring in COVID-19 patients have reported it to be an effective strategy in guiding goal-directed anticoagulation of COVID-19 patients to improve patient outcomes. 13,14 Another important limitation to consider in this case report involves effects of COVID-19 that have not been studied that could have played a role in this thrombosis event. For example, it has been shown certain infections such as human immunodeficiency virus (HIV) have been shown to increase the expression of P-glycoprotein and increase the efflux of substrate medications.…”

Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation

“…Management is complicated because of fibrinolytic shutdown due to the reduction of natural fibrinolysis at the level of the endothelium. While a multitude of studies have shown the detrimental effect of fibrinolytic shutdown on COVID-19 patient outcomes, bleeding complications such as gastrointestinal bleeding and hemorrhagic stroke are also common, especially in patients on therapeutic anticoagulation ( 17 , 79 , 80 , 82 – 86 ). These patients tend to clot and bleed at the same time, a function of the “rollercoaster” phenomenon ( 77 ).…”