Thromboelastography to Detect Hypercoagulability and Reduced Fibrinolysis in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Patients

Sadd, Corey; Rowe, Timothy; Nazeef, Moniba; Kory, Pierre; Sultan, Samir; Faust, H

doi:10.1097/cce.0000000000000192

Cited by 11 publications

(23 citation statements)

References 10 publications

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“…Reduced fibrinolytic activity was also observed in patients with COVID-19, with all studies reporting LY30 less than 1%, including three which showed complete fibrinolytic shutdown (LY30 of 0%) [ 18 , 23 , 25 ]. A shortened R-time of less than 5 min was observed in patients from four studies [ 18 , 20 , 22 , 26 ], indicating a shorter time to clot formation in hypercoagulable patients, although the R-value was within the range of normal in most studies ( Figure 4 ), implying that the change in R-time is less consistent than the increased MA [ 5 , 14 , 15 , 19 ] and fibrinolytic shutdown in the characterization of COVID-19. Platelet function, measured by the PlateletMapping ADP assay, was in the high normal range for the majority (81%) of patients with COVID-19 in the one study where this parameter was measured [ 15 ].…”

Section: Resultsmentioning

confidence: 99%

The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review

et al. 2021

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Coronavirus disease 2019 (COVID-19)-associated coagulopathy (CAC), characterized by hypercoagulability and an increased risk of thrombotic complications, is an important consideration in the management of patients with COVID-19. As COVID-19 is a new disease, no standard of care for the diagnosis or management of its associated coagulopathy is yet established. Whole blood viscoelastic tests, such as thromboelastography (TEG® hemostasis analyzer), analyze whole blood to provide a complete overview of the coagulation status. We conducted a systematic review of thromboelastography for management of patients with COVID-19, using MEDLINE (PubMed) and Cochrane databases. TEG® parameter measurements and clinical outcomes data were extracted for analysis. Our review found 15 publications, with overall results showing thromboelastography can identify and assess a hypercoagulable state in patients with COVID-19. Furthermore, utilization of thromboelastography in this patient population was shown to predict thrombotic complications. The benefits of thromboelastography presented here, in addition to advantages compared with laboratory coagulation tests, position thromboelastography as an important opportunity for optimizing diagnosis of CAC and improving patient management in COVID-19. Given that the benefits of thromboelastography have already been demonstrated in several other clinical applications, we anticipate that clinical data from future studies in patients with COVID-19 will further elucidate the optimal use of thromboelastography in this patient population.

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Section: Resultsmentioning

confidence: 99%

The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review

et al. 2021

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“…VETs were performed using ROTEM (25 studies), TEG (15 studies), Quantra (two prospective studies [66,67]) and ClotPro (one retrospective study [24] and one case report [68]); no study compared two devices. Among articles reporting data about TEG, four were prospective studies [52,[59][60][61], ten were retrospective studies [51,[53][54][55][56][57][58][62][63][64], and one was a case report [65]. Among articles dealing with ROTEM, thirteen were prospective studies [28][29][30][31][32][39][40][41][42][43][44][45][46], seven were retrospective studies [27,[33][34][35][36]48,49], one was a cross-sectional study [47], and four were case reports [26,37,38,50].…”

Section: Characteristics Of the Selected Studiesmentioning

confidence: 99%

“…Testing was carried out either on admission or within the following days, but the timing of blood collection for VET was specified only for 29 studies [24,26,27,[29][30][31]33,[35][36][37][38]41,[43][44][45][46][47][48]50,53,[55][56][57][58][59][65][66][67]. In some studies, the measurements were repeated during the patientʹs stay, either because of a pre-established protocol [26,27,29,45,53,59,60,67] or because of the occurrence of a thromboembolic event [65,68].…”

Section: Characteristics Of the Selected Studiesmentioning

confidence: 99%

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Viscoelastometric Testing to Assess Hemostasis of COVID-19: A Systematic Review

Bareille

Hardy

Douxfils

et al. 2021

JCM

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Infection by SARS-CoV-2 is associated with a high risk of thrombosis. The laboratory documentation of hypercoagulability and impaired fibrinolysis remains a challenge. Our aim was to assess the potential usefulness of viscoelastometric testing (VET) to predict thrombotic events in COVID-19 patients according to the literature. We also (i) analyzed the impact of anticoagulation and the methods used to neutralize heparin, (ii) analyzed whether maximal clot mechanical strength brings more information than Clauss fibrinogen, and (iii) critically scrutinized the diagnosis of hypofibrinolysis. We performed a systematic search in PubMed and Scopus databases until December 31st, 2020. VET methods and parameters, and patients’ features and outcomes were extracted. VET was performed for 1063 patients (893 intensive care unit (ICU) and 170 non-ICU, 44 studies). There was extensive heterogeneity concerning study design, VET device used (ROTEM, TEG, Quantra and ClotPro) and reagents (with non-systematic use of heparin neutralization), timing of assay, and definition of hypercoagulable state. Notably, only 4 out of 25 studies using ROTEM reported data with heparinase (HEPTEM). The common findings were increased clot mechanical strength mainly due to excessive fibrinogen component and impaired to absent fibrinolysis, more conspicuous in the presence of an added plasminogen activator. Only 4 studies out of the 16 that addressed the point found an association of VETs with thrombotic events. So-called functional fibrinogen assessed by VETs showed a variable correlation with Clauss fibrinogen. Abnormal VET pattern, often evidenced despite standard prophylactic anticoagulation, tended to normalize after increased dosing. VET studies reported heterogeneity, and small sample sizes do not support an association between the poorly defined prothrombotic phenotype of COVID-19 and thrombotic events.

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“…A group including one of the authors (PK) recently published a case series of TEG studies from the first wave of COVID-19 patients encountered which consistently revealed hypercoagulability with rapid and large amplitudes of clot formation with little to no fibrinolytic activity present. 80,81 These early insights, along with the large amount of subsequent investigations reviewed below, served as an initial basis for the more aggressive anti-coagulation regimen incorporated within MATHþ.…”

Section: Anticoagulation and Covid-19mentioning

confidence: 99%

RETRACTED: Clinical and Scientific Rationale for the “MATH+” Hospital Treatment Protocol for COVID-19

Kory

Meduri

Iglesias

et al. 2020

J Intensive Care Med

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In December 2019, COVID-19, a severe respiratory illness caused by the new coronavirus SARS-CoV-2 (COVID-19) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies’ recommended “supportive care only” avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net ). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of “ what was working and what wasn’t working,” the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically. The review concludes with a comparison of published multi-national mortality data with MATH+ center outcomes.

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Thromboelastography to Detect Hypercoagulability and Reduced Fibrinolysis in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Patients

Abstract: Supplemental Digital Content is available in the text.

Cited by 11 publications

References 10 publications

The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review

The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review

Viscoelastometric Testing to Assess Hemostasis of COVID-19: A Systematic Review

RETRACTED: Clinical and Scientific Rationale for the “MATH+” Hospital Treatment Protocol for COVID-19

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