Thromboelastography-Guided Anticoagulant Therapy for the Double Hazard of Thrombohemorrhagic Events in COVID-19: A Report of 3 Cases

Abstract

Case series Patients: Female, 72-year-old • Female, 55-year-old • Female, 43-year-old Final Diagnosis: COVID provoked thromboembolism • COVID-19 • pulmonary embolism • rectus sheath hematoma Symptoms: Cough • fever • shortness of breath Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Diagnostics, Laboratory • Hematology • Infectious Diseases Objective: Unusual clinical course Background: The novel coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often manifests a coagulopathy in severely ill patients, which may cause hemorrhage and/or thrombosis of varying severity. This report comprises the cases of 3 patients with COVID-19-associated coagulopathy who were evaluated with thromboelastography (TEG) and activated partial thromboplastin time (aPTT) to enable personalized anticoagulant therapy. Case Reports: Three patients presented with COVID-19 pneumonia, confirmed by reverse transcription-polymerase chain reaction, who developed thrombohemorrhagic coagulopathy. Case 1 : A 72-year-old woman on long-term warfarin therapy for a history of venous thromboembolism developed a right upper lobe pulmonary embolus, despite an international normalized ratio of 6.4 and aPTT of 120.7 s. TEG enabled successful anticoagulation with heparin, and her pulmonary infarct was no longer present 2 weeks later. Case 2 : A 55-year-old woman developed a rectus sheath hematoma while on heparin, and TEG demonstrated increased fibrinolysis despite COVID-19 patients more commonly undergoing fibrinolytic shutdown. Case 3 : A 43-year-old woman had significant thrombus burden while severely hypocoagulable according to laboratory testing. As the venous thrombi enlarged in a disseminated intravascular coagulopathic-like state, the heparin dose was escalated to achieve a target aPTT of 70 to 80 s, resulting in a flat line TEG tracing. Conclusions: These 3 cases of COVID-19 pneumonia with complex and varied clinical histories demonstrated the clinical value of TEG combined with the measurement of aPTT to facilitate personalized anticoagulation, resulting in good clinical outcomes.

Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices

“…This is due to the fact that CCTs provide inadequate data in severely hemorrhaging patients. CAC strikes the endothelium, influencing every aspect of anticoagulation from initiation to termination, so more information than what is provided by CCTs is needed [133,160,172]. Increased D-dimer levels have often been described in COVID-19 patients, but the half-life of D-dimer is approximately eight hours or longer in cases of compromised renal function and in elderly patients; this indicates that highly increased D-dimer depicts fibrinolysis that occurred at a point earlier in time rather than fibrinolysis that is currently occurring [178].…”

“…The addition of heparinase to one of the cups allows the VHA assays to quantify the heparin affect, and these assays are therefore used frequently in liver transplantation and cardiac surgery. Most recently, they have been used to monitor ECMO patients, as well as heparinized COVID-19 patients [36,114,[133][134][135][136]. The assessment of non-thrombin-based platelet activation/inhibition can be assayed using TEG/PM ® and Multiplate ® , which is often used in concert with ROTEM ® .…”

Thromboelastography determined dynamics of blood coagulation and its correlation with complications and outcomes in patients with coronavirus disease 2019

“…TEG has been used to guide therapy in a few studies. Bunch et al 32 reported three cases in which TEG and aPTT facilitated personalized anticoagulation. Hranjec et al 33 showed that TEG with platelet mapping–guided antiplatelet therapy could decrease mortality by 82%, while non–algorithm‐guided anticoagulation leads to 10.3‐fold increased mortality risk.…”

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

“…( C ) represents the TEG in evolution without anticoagulation and the subacute recovery stage where the patient is less hypercoagulable (parameters intermediate between acute and remote). ( D ) represents the patient with or without anticoagulant with a hypocoagulopathic phenotype due to hypofibrinogenemia and/or a thrombocytopenia in spite of persistent fibrinolytic shutdown (long R, flat α, narrow MA, no lysis) ( 17 , 20 , 77 , 79 – 81 ). Created using Adobe Illustrator.…”

“…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 ).…”