Background Coagulation abnormalities in COVID-19 patients have not been addressed in depth. Objective To perform a longitudinal evaluation of coagulation profile of patients admitted to the ICU with COVID-19. Methods Conventional coagulation tests, rotational thromboelastometry (ROTEM), platelet function, fibrinolysis, antithrombin, protein C and S were measured at days 0, 1, 3, 7 and 14. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10. Results Thirty patients were studied. Some conventional coagulation tests, as aPTT, PT and INR remained unchanged during the study period, while alterations on others coagulation laboratory tests were detected. Fibrinogen levels were increased in both groups. ROTEM maximum clot firmness increased in both groups from Day 0 to Day 14. Moreover, ROTEM–FIBTEM maximum clot firmness was high in both groups, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Also, D-dimer plasma levels were higher than normal reference range in both groups and free protein S plasma levels were low in both groups at baseline and increased over time, Finally, patients in group SOFA > 10 had lower plasminogen levels and Protein C ​​than patients with SOFA <10, which may represent less fibrinolysis activity during a state of hypercoagulability. Conclusion COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was not only detected by ROTEM but it much more complex, where changes were observed on the fibrinolytic and endogenous anticoagulation system.

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

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Background: Coagulation abnormalities in severe COVID-19 patients have not been addressed in depth. Methods: Prospective longitudinal single-center study involving COVID-19 patients admitted to the ICU. Conventional coagulation tests (prothrombin time, international normalized ratio and activated partial thromboplastin time), rotational thromboelastometry (ROTEM), platelet function, plasma fibrinolysis markers, antithrombin, protein C and S were measured at the time of study inclusion (baseline), and at days 1, 3, 7 and 14 after enrollment. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10.Results: From March, 2020 through May, 2020, 30 patients [median (IQR) age: 61 (52-83) yrs; SAPS III score: 49 (41-61) points] were included in this study. Conventional coagulation tests remained unchanged during the study period, while the majority of patients exhibited a hypercoagulability state based on ROTEM. Fibrinogen levels were increased in both groups. ROTEM (INTEM and EXTEM) maximum clot firmness increased in both study groups from day 0 to day 14. ROTEM – FIBTEM maximum clot firmness was high in both groups during the study period, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis (INTEM and EXTEM maximum lysis) was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Antithrombin slightly increased over time in group SOFA ≤ 10 while it remained stable in group SOFA > 10. Protein C plasma levels increased over time in both groups, although patients in group SOFA > 10 exhibited lower values in comparison to patients in group SOFA ≤ 10. Protein S plasma levels were low in both groups at baseline and increased over time with no between-group differences.Conclusion: COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was detected by ROTEM, but not with conventional coagulation tests.

We report the case of a patient in whom brain death was suspected and associated with atelectasis and moderate to severe hypoxemia even though the patient was subjected to protective ventilation, a closed tracheal suction system, positive end-expiratory pressure, and recruitment maneuvers. Faced with the failure to obtain an adequate partial pressure of oxygen for the apnea test, we elected to place the patient in a prone position, use higher positive end-expiratory pressure, perform a new recruitment maneuver, and ventilate with a higher tidal volume (8mL/kg) without exceeding the plateau pressure of 30cmH 2 O. The apnea test was performed with the patient in a prone position, with continuous positive airway pressure coupled with a T-piece. The delay in diagnosis was 10 hours, and organ donation was not possible due to circulatory arrest. This report demonstrates the difficulties in obtaining higher levels of the partial pressure of oxygen for the apnea test. The delays in the diagnosis of brain death and in the organ donation process are discussed, as well as potential strategies to optimize the partial pressure of oxygen to perform the apnea test according to the current recommendations.