Early management of severe COVID-19 coagulopathy should be guided by TEG^®, microclot and platelet mapping

Abstract

The coronavirus disease 2019 (COVID-19) (SARS-Cov-2) has caused a worldwide, sudden and substantial increase in hospitalizations for pneumonia with multiorgan problems. An important issue is also that there is still no unified standard for the diagnosis and treatment of COVID-19. Substantial vascular events are significant accompaniments to lung complications in COVID-19 patients. Various papers have now also shown the significance of thromboelastrography (TEG) as point-of-care technology to determine the levels of coagulopathy (both clotting and bleeding) in COVID-19, in managing COVID-19 patients. Here we present two treatment protocols that may used to treat thrombotic and bleeding or thrombocytopenia pathologies. We also present a case study, where the thrombotic pathology was successfully treated with the thrombotic protocol. Both the protocols use clinical parameters like D-dimer and CRP, as well as the TEG, to closely follow the daily clotting propensity of COVID-19 patients. We conclude by suggesting that the treatment of COVID-19 patients, should be based on a combination of blood biomarkers, and results from point-of-care analyses like the TEG. Such a combination approach closely follow the physiological responses of the immune system, the haematological, as well as the coagulation system, in real-time.

Relative Hypercoagulopathy of the SARS-CoV-2 Beta and Delta Variants when Compared to the Less Severe Omicron Variants Is Related to TEG Parameters, the Extent of Fibrin Amyloid Microclots, and the Severity of Clinical Illness

“…29 45 In conjunction with this, our research group has suggested that fibrin amyloid microclot (currently available only as a research laboratory tool) might be of great importance to determine clotting pathology in individuals with acute COVID-19 infection. 29 36 Microclots are defined as fibrinogen (and other plasma proteins) that clot into an anomalous “amyloid” from fibrin (“fibrinaloid”) with higher than normal resistance to fibrinolysis, and a size range from 1 to 200 µm when measured on the longest axis. 27 Our group has previously shown amyloid fibrin deposits in numerous inflammatory conditions.…”

“…It is well established that the earlier variants (before omicron) caused severe disease and resulted in coagulopathies in critically ill patients. 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 In contrast, the heavily mutated omicron variants have been shown to have milder symptoms than the earlier variants. The five most prevalent symptoms during omicron infection were reported to be runny nose, rhinitis headache, fatigue (either mild or severe), sneezing, and sore throat.…”

“…Using point-of-care technologies such as thromboelastography (TEG) poses an opportunity to improve early management of severe COVID-19-associated coagulopathy. 29 45 In conjunction with this, our research group has suggested that fibrin amyloid microclot (currently available only as a research laboratory tool) might be of great importance to determine clotting pathology in individuals with acute COVID-19 infection. 29 36 Microclots are defined as fibrinogen (and other plasma proteins) that clot into an anomalous “amyloid” from fibrin (“fibrinaloid”) with higher than normal resistance to fibrinolysis, and a size range from 1 to 200 µm when measured on the longest axis.…”

“…Due to the reduction in omicron symptoms and fatalities, we investigated the differences between new omicron VOCs and the previously circulating SARS-CoV-2 variants using TEG clotting profiles and an assessment of the extent of microclots in the plasma by means of fluorescence microscopy. 29 36 Because of the nature of the blood collections from patients who reported at our clinical collaborator's practice, we did not focus on a specific sublineage of the omicron variant.…”

Modified Thromboelastography for Peri-interventional Assessment of Platelet Function in Cardiology Patients: A Narrative Review

“…Around 20% of COVID-19 patients rapidly progress to a severe illness that includes extensive thrombotic complications. 77 Patients may experience both thrombotic and hemorrhagic symptoms, due to overactivation of platelets altering normal clotting, or to secondary inflammation resulting in decreased platelet count and low fibrinogen, usually as a result of consumption. 12…”