Preventing Thrombohemorrhagic Complications of Heparinized COVID-19 Patients Using Adjunctive Thromboelastography: A Retrospective Study - PubMed (original) (raw)

. 2021 Jul 14;10(14):3097.

doi: 10.3390/jcm10143097.

Anthony V Thomas 1, John E Stillson 1, Laura Gillespie 2, Rashid Z Khan 3, Nuha Zackariya 1, Faadil Shariff 4, Mahmoud Al-Fadhl 5, Nicolas Mjaess 5, Peter D Miller 6, Michael T McCurdy 7, Daniel H Fulkerson 8, Joseph B Miller 9, Hau C Kwaan 10, Ernest E Moore 11, Hunter B Moore 11, Matthew D Neal 12, Peter L Martin 13, Mark L Kricheff 14, Mark M Walsh 1 5 14

Affiliations

Preventing Thrombohemorrhagic Complications of Heparinized COVID-19 Patients Using Adjunctive Thromboelastography: A Retrospective Study

Connor M Bunch et al. J Clin Med. 2021.

Abstract

Background: The treatment of COVID-19 patients with heparin is not always effective in preventing thrombotic complications, but can also be associated with bleeding complications, suggesting a balanced approach to anticoagulation is needed. A prior pilot study supported that thromboelastography and conventional coagulation tests could predict hemorrhage in COVID-19 in patients treated with unfractionated heparin or enoxaparin, but did not evaluate the risk of thrombosis.

Methods: This single-center, retrospective study included 79 severely ill COVID-19 patients anticoagulated with intermediate or therapeutic dose unfractionated heparin. Two stepwise logistic regression models were performed with bleeding or thrombosis as the dependent variable, and thromboelastography parameters and conventional coagulation tests as the independent variables.

Results: Among all 79 patients, 12 (15.2%) had bleeding events, and 20 (25.3%) had thrombosis. Multivariate logistic regression analysis identified a prediction model for bleeding (adjusted R2 = 0.787, p < 0.001) comprised of increased reaction time (p = 0.016), decreased fibrinogen (p = 0.006), decreased D-dimer (p = 0.063), and increased activated partial thromboplastin time (p = 0.084). Multivariate analysis of thrombosis identified a weak prediction model (adjusted R2 = 0.348, p < 0.001) comprised of increased D-dimer (p < 0.001), decreased reaction time (p = 0.002), increased maximum amplitude (p < 0.001), and decreased alpha angle (p = 0.014). Adjunctive thromboelastography decreased the use of packed red cells (p = 0.031) and fresh frozen plasma (p < 0.001).

Conclusions: Significantly, this study demonstrates the need for a precision-based titration strategy of anticoagulation for hospitalized COVID-19 patients. Since severely ill COVID-19 patients may switch between thrombotic or hemorrhagic phenotypes or express both simultaneously, institutions may reduce these complications by developing their own titration strategy using daily conventional coagulation tests with adjunctive thromboelastography.

Keywords: COVID-19; anticoagulants; blood coagulation; blood coagulation tests; coagulopathy; hemorrhage; heparin; thromboelastography; thrombosis.

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Conflict of interest statement

E.E.M., H.B.M., M.D.N., and M.M.W. have received research grants from Haemonetics Inc. (Boston, MA, USA) outside the submitted work. M.M.W. has received honoraria from Alexion Pharmaceuticals (Boston, MA, USA). M.D.N. has received an honorarium from Haemonetics for a speaking engagement and research support from Janssen Pharmaceuticals (Beerse, Belgium) and Noveome (Pittsburgh, PA, USA) outside the submitted work. He has served as a consultant to Janssen and CSL Behring (King of Prussia, PA, USA), and serves on the Scientific Advisory Board of Haima Therapeutics (Cleveland, OH, USA).

Figures

Figure 1

Figure 1

Sample TEG/CCT-based protocol for UFH dosing of hospitalized COVID-19 patients. The presence/absence of a thrombosis determines initial UFH dosing. Further goal-directed titration of UFH was achieved via monitoring of aPTT and TEG parameters R and MA. Adopted from protocols for guiding heparin in ECMO, liver transplantation, cardiac surgery, and trauma surgery [22,36]. aPTT, activated partial thromboplastin time; CCT, conventional coagulation test; COVID-19, coronavirus disease 2019; ICU, intensive care unit; MA, maximum amplitude; R, reaction time; TEG, thromboelastography; UFH, unfractionated heparin.

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