Integral Use of Thromboelastography With Platelet Mapping to Guide Appropriate Treatment, Avoid Complications, and Improve Survival of Patients With Coronavirus Disease 2019–Related Coagulopathy

Abstract

Objectives: Coagulopathy of coronavirus disease 2019 is largely described as hypercoagulability, yet both thrombotic and hemorrhagic complications occur. Although therapeutic and prophylactic anticoagulant interventions have been recommended, empiric use of antifactor medications (heparin/enoxaparin) may result in hemorrhagic complications, including death. Furthermore, traditional (antifactor) anticoagulation does not address the impact of overactive platelets in coronavirus disease 2019. The primary aim was to evaluate if algorithm-guided thromboelastography with platelet mapping could better characterize an individual’s coronavirus disease 2019-relatedcoagulopathic state and, secondarily, improve outcomes. Design, Setting, and Patients: Coronavirus disease 2019 patients ( n = 100), receiving thromboelastography with platelet mapping assay upon admission to an 800-bed tertiary-care hospital, were followed prospectively by a hospital-based thromboelastography team. Treating clinicians were provided with the option of using a pre-established algorithm for anticoagulation, including follow-up thromboelastography with platelet mapping assays. Two groups evolved: 1) patients managed by thromboelastography with platelet mapping algorithm (algorithm-guided-thromboelastography); 2) those treated without thromboelastography with platelet mapping protocols (non-algorithm-guided). Outcomes included thrombotic/hemorrhagic complications, pulmonary failure, need for mechanical ventilation, acute kidney injury, dialysis requirement, and nonsurvival. Interventions: Standard-of-care therapy with or without algorithm-guided-thromboelastography support. Measurements and Main Results: Although d -dimer, C-reactive protein, and ferritin were elevated significantly in critically ill (nonsurvivors, acute kidney injury, pulmonary failure), they did not distinguish between coagulopathic and noncoagulopathic patients. Platelet hyperactivity (maximum amplitude-arachidonic acid/adenosine diphosphate > 50 min), with or without thrombocytosis, was associated with thrombotic/ischemic complications, whereas severe thrombocytopenia (platelet count < 100,000/μL) was uniformly fatal. Hemorrhagic complications were observed with decreased factor activity (reaction time > 8 min). Non-algorithm-guided patients had increased risk for subsequent mechanical ventilation (relative risk = 10.9; p < 0.0001), acute kidney injury (relative risk = 2.3; p = 0.0017), dialysis (relative risk = 7.8; p < 0.0001), and death (relative risk = 7.7; p < 0.0001), with 17 of 28 non-algorithm-guided patients (60.7%) dying versus four algorithm-guided-thromboelastography patients (5.6%) ( p < 0.0001). Thromboelastography with platelet mapping–guided antiplatelet treatment decreased m...

The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review

“…This may be a reflection of the fact that the massive inflammatory response seen in patients with COVID-19 has a greater impact on fibrinogen, von Willebrand Factor (vWF), and platelet levels, and less of an impact on coagulation factors. While the timelines of our literature search only identified one manuscript reporting the use of the TEG PlateletMapping assay to record platelet function [ 15 ], a recently published prospective study explored the use of thromboelastography with the platelet mapping algorithm to manage patients with COVID-19 [ 28 ]. The study found that the use of thromboelastography with platelet mapping could be used to characterize the spectrum of COVID-19 and reduced the risk for mechanical ventilation, acute kidney injury, and death ( p < 0.0001 versus non-algorithm-guided patients for all).…”

“…The study found that the use of thromboelastography with platelet mapping could be used to characterize the spectrum of COVID-19 and reduced the risk for mechanical ventilation, acute kidney injury, and death ( p < 0.0001 versus non-algorithm-guided patients for all). Using thromboelastography with platelet mapping to guide antiplatelet therapy treatment in patients with COVID-19 also decreased mortality by 82% ( p = 0.0002) [ 28 ]. However, studies of platelet function using multiple electrode aggregometry did not show any change in platelet aggregability in patients with COVID-19 [ 29 ], suggesting further observations are necessary to elucidate the role of platelet function in the etiology and progression of COVID-19.…”

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

“…Recently, various papers have shown the significance of TEG ® and the levels of coagulopathy in COVID-19 (an important measurement value of the TEG ® ) in managing COVID-19 patients is also getting more traction (Chandel, et al 2021, Görlinger and Levy 2021, Hranjec, et al 2020) (Smolarz, et al 2021). Hranjec and co-workers in 2020 also noted that TEG ® with platelet mapping, better characterizes the spectrum of COVID-19 coagulation-related abnormalities and may guide more tailored, patient-specific therapies these patients (Hranjec, et al 2020). Another important test is the PFA-200 platelet test.…”

International COVID-19 thrombosis biomarkers colloquium: COVID-19 diagnostic tests

“…In a study of 100 patients with COVID-19, the TEG platelet mapping assay (TEG-PM) results (maximum amplitude-arachidonic acid/adenosine diphosphate > 50 mm) were associated with thrombotic/ischemic complications and TEG-PM assay guided antithrombotic therapy (n = 72) was associated with decreased mortality (p = 0.0002) as compared to patients receiving non-guided therapy (n = 28) [ 19 ]. These results provide evidence to support the use of bedside viscoelastic assay in patients with COVID-19, but more evidence is needed to include this assay for routine measurement as a diagnostic and prognostic assay.…”