Thromboelastography Profiles of Critically Ill Patients With Coronavirus Disease 2019

Abstract

Objectives: The rate of thromboembolic events among patients with coronavirus disease 2019 is high; however, there is no robust method to identify those at greatest risk. We reviewed thromboelastography studies in critically ill patients with coronavirus disease 2019 to characterize their coagulation states. Design: Retrospective. Setting: Tertiary ICU in New York City. Patients: Sixty-four patients with coronavirus disease 2019 admitted to the ICU with thromboelastography performed. Interventions: None. Measurements and Main Results: Fifty percent of patients had a clotting index in the hypercoagulable range (clotting index > 3) (median 3.05). Reaction time and K values were below the lower limit of normal in 43.8% of the population consistent with a hypercoagulable profile. The median α angle and maximum amplitude (75.8° and 72.8 mm, respectively) were in the hypercoagulable range. The α angle was above reference range in 70.3% of patients indicative of rapid clot formation. Maximum amplitude, a factor of fibrinogen and platelet count and function, and a measure of clot strength was above reference range in 60.1% of patients. Thirtyone percent had thromboembolic events; thromboelastography parameters did not correlate with events in our cohort. Those with d-dimer values greater than 2,000 were more likely to have shorter reaction times compared with those with d-dimer levels less than or equal to 2,000 (4.8 vs 5.6 min; p = 0.001). Conclusions: A large proportion of critically ill patients with coronavirus disease 2019 have hypercoagulable thromboelastography profiles with additional derangements related to fibrinogen and platelet function. As the majority of patients have an elevated thromboelastography maximum amplitude, a follow-up study evaluating platelet aggregation would be instructive.

Thromboelastography findings in critically ill COVID-19 patients

“…TEG has been widely used to detect HS in post-operative and septic patients [4,5]. The incidence of HS in our COVID-19 ICU patients of 30.8% is much lower than what had been previously reported in this patient population (ranging from 50 to 90%) [1][2][3].The difference between our HS incidence and the other reports might be explained by the fact that TEG was performed within the first 3 days of ICU admission in the other studies, while it was done at a median of 9 days of ICU admission in our study [1][2][3]. Another explanation could be the dissimilar populations between our study and the others.…”

“…Severe acute respiratory syndrome coronavirus-2 (SAR-CoV-2) responsible for the coronavirus disease 2019 (COVID-19) has hit the world as a global pandemic at an unprecedented scale. High rates of venous and arterial thrombotic events (TE) were observed in COVID-19 critically ill patients [1,2]. The high TE rate may be the result of a hypercoagulable state (HS) induced by the inflammatory reaction induced by SAR-CoV-2.…”

“…Thromboelastography (TEG) is a point-of-care test explicitly designed to assess overall clotting formation and dissolution in whole blood. A few recent studies showed different rates of HS in COVID-19 patients based on the TEG study [1][2][3]. However, there were conflicting results regarding the association between a HS and TE [1,2].…”

Prevalence of readily detected amyloid blood clots in ‘unclotted’ Type 2 Diabetes Mellitus and COVID-19 plasma: A preliminary report

“…A poor prognosis for recovery, is linked to various comorbidities, of which Type 2 Diabetes Mellitus (T2DM) is probably the most frequently mentioned comorbidity. It is widely recognised [11][12][13][14][15][16][17][18][19][20][21] that extensive blood clotting has a major role in the pathophysiology of COVID-19 disease severity and progression, yet so can excessive bleeding [22,23]. The solution to this apparent paradox lies in the recognition [24] that these phases are separated in time: the later bleeding is mediated by the earlier clotting-induced depletion of brinogen and of von Willebrand factor (VWF).…”

Prevalence of amyloid blood clots in COVID-19 plasma

“…It is widely recognised (8)(9)(10)(11)(12)(13) that extensive blood clotting has a major role in the pathophysiology of COVID-19 disease severity and progression, yet so can excessive bleeding (14,15). The solution to this apparent paradox lies in the recognition (16) that these phases are separated in time, with excessive clotting preceding the later bleeding that is mediated by the clotting-induced depletion of fibrinogen and of von Willebrand factor (VWF).…”