Rotational Thromboelastometry predicts care level in COVID-19

Abstract

Background: High prevalence of thrombotic events in severely ill COVID-19 patients have been reported. Pulmonary embolism as well as microembolization of vital organs may in these individuals be direct causes of death. The identification of patients at high risk of developing thrombosis may lead to targeted, more effective prophylactic treatment. Objectives: To test whether Rotational Thromboelastometry (ROTEM) indicates hypercoagulopathy in COVID-19 patients, and whether patients with severe disease have a more pronounced hypercoagulopathy compared with less severely ill patients. Methods: The study was designed as a prospective observational study where COVID-19 patients over 18 years admitted to hospital were eligible for inclusion. Patients were divided into two groups depending on care level: 1) regular wards or 2) wards with specialized ventilation support. ROTEM was taken after admission and the data were compared with ROTEM in healthy controls. Results: The ROTEM variables Maximum Clot Firmness (EXTEM-/FIBTEM-MCF) were higher in COVID-19 patients compared with healthy controls (p<0.001) and higher in severely ill patients compared with patients at regular wards (p<0.05). Coagulation Time (EXTEM-CT) was longer and Clot Formation Time (EXTEM-CFT) shorter in COVID-19 patients compared with healthy controls. Our results suggest that hypercoagulopathy is present in hospitalized patients with mild to severe COVID-19 pneumonia. Conclusion: ROTEM variables were significantly different in COVID-19 patients early after admission compared with healthy controls. This pattern was more pronounced in patients with increased disease severity, suggesting that ROTEM-analysis may be useful to predict thromboembolic complications in these patients.

Venous thromboembolism in critically ill COVID-19 patients receiving prophylactic or therapeutic anticoagulation: a systematic review and meta-analysis

“…Viscoelastic observations with TEG among critically ill COVID-19 patients in the intensive care unit revealed hypercoagulable state with decreased R time and K time as well as elevated fibrinogen activity greater than a 73° angle and maximum amplitude more than 65 mm with heparinase correction [39,40]. Whereas, viscoelastic observations with ROTEM observed significantly higher maximum clot firmness and clotting time as well as significantly shorter clot formation time among COVID-19 patients compared with healthy controls (p < 0.001) [41]. In fact, comparison among COVID-19 patients reported that maximum clot firmness and clotting time were significantly longer in those admitted to medical wards relative to those in specialized wards (intermediate wards/intensive care units).…”

COVID-19 Infection-Related Coagulopathy and Viscoelastic Methods: A Paradigm for Their Clinical Utility in Critical Illness

“…Moreover, there was no significant correlation between the ROTEM parameters and the Sequential Organ Failure Assessment (SOFA) score. In another recent study, all hospitalized COVID-19 patients showed elevated values of EXTEM-MCF and FIBTEM-MCF at admission to the hospital, also suggesting a hypercoagulable state, and this pattern became more pronounced in patients with the more severe disease [ 19 ]. Specifically, the authors showed that all COVID-19 patients (both with mild and severe COVID-19 pneumonia) had significantly longer CT, increased MCF and shorter CFT, as compared with healthy controls, and that severely ill subjects had longer CT, increased MCF and shorter CFT compared with subjects with mild infections.…”

“…The mismatched D-dimer increments might be due to the augmentation of local fibrinolysis in alveoli by urokinase-type plasminogen activator (u-PA) released from alveolar macrophages [ 25 ]. It is noteworthy that critically ill COVID-19 patients demonstrated a more hypercoagulable and hypofibrinolytic profile related to those with COVID-19 mild illness, while hypercoagulability and hypofibrinolysis were evident in both patient groups, as compared to healthy controls [ 19 ]. This indicates that hypercoagulability in COVID-19 infection might be associated with disease severity.…”

“…However, a correlation between ROTEM parameters and severity illness scores has not been reported [ 18 ]. It should be also pointed out that, in most cases, ICU COVID-19 patients have longer or normal CT/R values [ 12 , 13 , 17 , 18 , 19 ]. This is the only parameter not supporting the procoagulant profile of critically ill COVID-19 patients.…”

Viscoelastic Tests in the Evaluation of Haemostasis Disturbances in SARS-CoV2 Infection

“…12 Thromboelastometry has shown to be useful in identifying hypercoagulability in various clinical settings not detected by SCT, 25 through the presence of (a) an accelerated clot formation with significantly lower clot formation time (decreased CFT-EXTEM/INTEM/FIBTEM) due to the increase of plasma fibrinogen and excessive thrombin generation, and/or (b) an increase in clot strength (increased MCF-EXTEM/INTEM/FIBTEM and A10) and higher α angle. 2,[25][26][27] INTEM clot firmness at 10 minutes (A10) was the best predictor of thromboembolic complications. 26 MCF is a reliable marker of hypercoagulability.…”