Coagulopathy in COVID-19 and Its Implication for Safe and Efficacious Thromboprophylaxis

Abstract

The novel coronavirus, SARS-CoV-2, is causing a global pandemic of life-threatening multiorgan disease, called COVID-19. Accumulating evidence indicates that patients with COVID-19 are at significant risk of thromboembolic complications, mainly affecting the venous, but also the arterial vascular system. While the risk of venous thromboembolism (VTE) appears to be higher in patients requiring intensive care unit support compared to those admitted to general wards, recent autopsy findings and data on the timing of VTE diagnosis relative to hospitalization clearly suggest that thromboembolic events also contribute to morbidity and mortality in the ambulatory setting. In addition to a severe hypercoagulable state caused by systemic inflammation and viral endotheliitis, some patients with advanced COVID-19 may develop a coagulopathy, which meets established laboratory criteria for disseminated intravascular coagulation, but is not typically associated with relevant bleeding. Similar to other medical societies, the Society of Thrombosis and Haemostasis Research has issued empirical recommendations on initiation, dosing, and duration of pharmacological VTE prophylaxis in COVID-19 patients.

Mechanical ventilation and mortality among 223 critically ill patients with coronavirus disease 2019: A multicentric study in Germany

“… 6 ( [4] , [5] , [6] , [7] , [8] , [9] , [10] ) 7 ( [4] , [5] , [6] , [7] , [8] , [9] , [10] ) 0.412 SOFA – 24h (pts.) 10 ( [7] , [8] , [9] , [10] , [11] ) 11 ( [8] , [9] , [10] , [11] , [12] , [13] ) 0.020 ARDS No ARDS 4 ( 4 ) 0 (0) 0.093 Mild 8 ( 9 ) 4 ( 5 ) 0.287 Moderate 47 (51) 23 ( 31 ) 0.007 Severe 34 ( 37 ) 47 (64) < 0.001 Mechanical Ventilation On admission 40 (43) 26 ( 35 ) 0.191 Begin of MV (days) 1 ( [1] , [2] ) 1 (0 – 2) 0.398 Duration of MV (days) 16 ( [8] , [9] , [10] , …”

“…Thromboembolic events are frequently observed in autopsy studies, representing yet another potentially life-threatening complication in critically ill patients with COVID-19 ( 36 ). These findings led to recommendation of, at least, prophylactic anticoagulation in critically ill patients with COVID-19 ( 37 ).…”

Risk of venous thromboembolism in patients with COVID‐19: A systematic review and meta‐analysis

“…Our findings support guidance statements from experts and scientific societies, which suggest that thromboprophylaxis is a key element in the medical care of patients with COVID-19, especially in those with severe illness. 7,8,[102][103][104] However, VTE occurred in many patients despite the use of thromboprophylaxis, and even patients with therapeutic anticoagulation developed VTE.…”

The management of surgical patients in emergency setting during COVID-19 pandemic. The WSES position paper

“…This is due to a heparin resistance with UFH or sub-optimal anti-Xa peak with LMWH that seems to be common in COVID-19 intensive care unit patients that received therapeutic anticoagulation. Consequently it is important to measure anti-Xa levels for patients on therapeutic LMWH to ensure adequate dosing and continue with careful monitoring for those on UFH [88][89]. Empirical antifungal treatment should only be considered in critically COVID-19 patients, presenting fever of unknown origin, with new pulmonary in ltrate superimposed on a viral pneumonitis pattern, with the aim of con rming the diagnosis by invasive techniques and/or the use of fungal biomarkers (moderate level of evidence B).…”