ISTH interim guidance on recognition and management of coagulopathy in COVID‐19: A comment

Barrett, Christopher D.; Moore, Hunter B.; Yaffe, Michael B.; Moore, Ernest E.

doi:10.1111/jth.14860

Cited by 207 publications

(253 citation statements)

References 32 publications

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“…Our patients were managed following these recommendations. (23,24) Our study has several limitations: it is a small descriptive case series report, and there may be confounders in the analysis of the results, in concordance with most described data in the current literature. Another disadvantage is the lack of generalisability and the fact that 9 patients remained in the hospital at the time of data censoring on April 19, 2020.…”

Section: Discussionsupporting

confidence: 67%

COVID-19 severe pneumonia in Mexico City – First experience in a Mexican hospital

Valente-Acosta

2020

Preprint

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Background: Coronavirus Disease 2019 pandemic since its first confirmed case, has changed the world. The need for accurate and truthful information is vital.Mexico and Latin America have been widely affected, so having local epidemiological data, will be of great clinical utility.Methods: A total of 33 hospitalized patients with Covid-19 pneumonia (either severe or critical) were identified from electronic health record in a third level care private hospital in Mexico City from March 13rd to April 13rd, 2020. We conducted a descriptive study of patients for characterization of the clinical, laboratory and radiologic findings, as well as complications.Results: The mean age was 60.6±12.68 years and 23 (69.7%) were males. Twentythree patients (69.6%) were overweight or obese. The median duration of symptoms before admission was 7 days. All the patients required mechanical invasive ventilation.The median duration of the mechanical ventilation was 12±2.6 days and all patients were extubated except one. All patients were started on antiviral treatment in the first 24 hours after admission once the diagnosis of Covid19 pneumonia was made. There was no difference between the treatment option and the length of stay. The extubation rate was higher (91.6%) than in other series, with no fatalities even though they were treated with different regimens. Conclusions:This one-centre experience describes the epidemiology, treatment and outcome of 33 patients with severe or critical COVID pneumonia admitted to the ICU.Most patients in our series were overweight or obese male, which we observed were of

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Section: Discussionsupporting

confidence: 67%

COVID-19 severe pneumonia in Mexico City – First experience in a Mexican hospital

Valente-Acosta

2020

Preprint

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“…As is the case with sepsis, prophylactic anticoagulation of patients with severe COVID-19 may be recommended [6]. Recent recommendations on coagulopathy management, based on the follow-up of standard coagulation markers (D-dimers, prothrombin time, fibrinogen, and platelet count), have been put forward by the International Society of Thrombosis and Haemostasis (ISTH) [7]. In another retrospective study stratifying patients based on sepsis-induced coagulopathy (SIC) score or D-dimer level, Tang et al [8] suggested that heparin would decrease mortality in severe COVID-19 patients who met the SIC criteria or have markedly elevated D-dimers.…”

Section: Introductionmentioning

confidence: 99%

High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study

et al. 2020

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Purpose: Little evidence of increased thrombotic risk is available in COVID-19 patients. Our purpose was to assess thrombotic risk in severe forms of SARS-CoV-2 infection. Methods:All patients referred to 4 intensive care units (ICUs) from two centers of a French tertiary hospital for acute respiratory distress syndrome (ARDS) due to COVID-19 between March 3rd and 31st 2020 were included. Medical history, symptoms, biological data and imaging were prospectively collected. Propensity score matching was performed to analyze the occurrence of thromboembolic events between non-COVID-19 ARDS and COVID-19 ARDS patients.Results: 150 COVID-19 patients were included (122 men, median age 63 [53; 71] years, SAPSII 49 [37; 64] points). Sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients, mainly pulmonary embolisms (16.7%). 28/29 patients (96.6%) receiving continuous renal replacement therapy experienced circuit clotting. Three thrombotic occlusions (in 2 patients) of centrifugal pump occurred in 12 patients (8%) supported by ECMO. Most patients (> 95%) had elevated D-dimer and fibrinogen. No patient developed disseminated intravascular coagulation. Von Willebrand (vWF) activity, vWF antigen and FVIII were considerably increased, and 50/57 tested patients (87.7%) had positive lupus anticoagulant. Comparison with non-COVID-19 ARDS patients (n = 145) confirmed that COVID-19 ARDS patients (n = 77) developed significantly more thrombotic complications, mainly pulmonary embolisms (11.7 vs. 2.1%, p < 0.008). Coagulation parameters significantly differed between the two groups. Conclusion:Despite anticoagulation, a high number of patients with ARDS secondary to COVID-19 developed life-threatening thrombotic complications. Higher anticoagulation targets than in usual critically ill patients should therefore probably be suggested.

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“…This pathologic fibrin deposition reflects a dysfunctional clotting system, with enhanced clot formation and propagation as well as fibrinolysis suppression, 29–31 largely due to tissue factor produced by alveolar epithelial cells and macrophages, 32 and high levels of plasminogen activator inhibitor‐1 (PAI‐1) produced by endothelial cells or activated platelets 33,34 . Consistent with this, prothrombin time prolongation, elevated D‐dimer and fibrin degradation products, and uniquely elevated fibrinogen levels have been reported in severely ill patients with COVID‐19, particularly in nonsurvivors 3,4,20,35–38 . Similar findings have been observed in sepsis, 29,39 endotoxemia, 40 and extensive tissue disruption, 18 in which early activation of coagulation and fibrinolysis is followed by late fibrinolytic shutdown and endothelial dysfunction.…”

Section: Fibrinolysis Ards and The Possible Role Of Fibrinolytic Thmentioning

confidence: 63%

“…With respect to COVID‐19 ICU patients on mechanical ventilation where death is as likely as survival, life‐threatening hemorrhage is the most relevant for consideration, which again suggests the GUSTO study of over 40 000 patients including over 10 000 patients in the alteplase bolus plus heparin group is likely the most relevant for risk considerations for fibrinolytic therapy in severe, medically refractory hypoxemic respiratory failure in COVID‐19 65 . Furthermore, given the profound hypercoagulable/thrombotic coagulopathy in the majority of critically ill COVID‐19 patients 20,35,38,70,71 where bleeding is quite rare and thrombosis predominates, the risk of systemic fibrinolysis therapy may be even lower. Similarly, while we posit that intravascular delivery of t‐PA would likely be more effective, if intra‐airway t‐PA were to be pursued and effective, the available case reports of t‐PA airway delivery have thus far showed no bleeding events 46,61 …”

Section: Risk Considerations For Fibrinolytic Therapy In Covid‐19 Ardsmentioning

confidence: 99%

Fibrinolytic therapy for refractory COVID‐19 acute respiratory distress syndrome: Scientific rationale and review

Barrett

Moore

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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The coronavirus disease 2019 (COVID‐19) pandemic has caused respiratory failure and associated mortality in numbers that have overwhelmed global health systems. Thrombotic coagulopathy is present in nearly three quarters of patients with COVID‐19 admitted to the intensive care unit, and both the clinical picture and pathologic findings are consistent with microvascular occlusive phenomena being a major contributor to their unique form of respiratory failure. Numerous studies are ongoing focusing on anticytokine therapies, antibiotics, and antiviral agents, but none to date have focused on treating the underlying thrombotic coagulopathy in an effort to improve respiratory failure in COVID‐19. There are animal data and a previous human trial demonstrating a survival advantage with fibrinolytic therapy to treat acute respiratory distress syndrome. Here, we review the extant and emerging literature on the relationship between thrombotic coagulopathy and pulmonary failure in the context of COVID‐19 and present the scientific rationale for consideration of targeting the coagulation and fibrinolytic systems to improve pulmonary function in these patients.

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ISTH interim guidance on recognition and management of coagulopathy in COVID‐19: A comment

Cited by 207 publications

References 32 publications

COVID-19 severe pneumonia in Mexico City – First experience in a Mexican hospital

COVID-19 severe pneumonia in Mexico City – First experience in a Mexican hospital

High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study

Fibrinolytic therapy for refractory COVID‐19 acute respiratory distress syndrome: Scientific rationale and review

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