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Porfidia A, Talerico R, Mosoni C, Porceddu E, Pola R. CT Pulmonary Angiography for the Diagnosis of Pulmonary Embolism in Patients with COVID-19: When, Why, and for Who? Radiology 2021; 299:E287. [PMID: 33754832 PMCID: PMC8026115 DOI: 10.1148/radiol.2021210400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Angelo Porfidia
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - Rosa Talerico
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - Carolina Mosoni
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - Enrica Porceddu
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
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52
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Schiavone M, Gasperetti A, Gobbi C, Busana M, Forleo GB. Reply to: Assessment of administering antithrombosis in COVID-19 patients with acute hypoxemic respiratory failure. Int J Cardiol 2021; 332:238. [PMID: 33705842 PMCID: PMC7938788 DOI: 10.1016/j.ijcard.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/03/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Marco Schiavone
- Cardiology Unit, ASST Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Alessio Gasperetti
- Cardiology Unit, ASST Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Cecilia Gobbi
- Cardiology Unit, Saint Martin Private Hospital Center, Caen, France
| | - Mattia Busana
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Giovanni B Forleo
- Cardiology Unit, ASST Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy.
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53
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Akhter MS, Hamali HA, Mobarki AA, Rashid H, Oldenburg J, Biswas A. SARS-CoV-2 Infection: Modulator of Pulmonary Embolism Paradigm. J Clin Med 2021; 10:1064. [PMID: 33806540 PMCID: PMC7961449 DOI: 10.3390/jcm10051064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 12/29/2022] Open
Abstract
Pulmonary embolism (PE) is a life-threatening complication arising from venous thromboembolism with a difficult diagnosis and treatment and is often associated with increased mortality and morbidity. PE had a significantly low incidence prior to the COVID-19 epidemic. This condition saw a sharp surge during the COVID-19 pandemic, indicating an evident viral influence on PE's pathophysiology in COVID-19 patients. The hypercoagulable state induced by the viral load seems to be the major contributor, and the classical causative factors seem to play a lesser role. PE in COVID-19 infection has become a mammoth challenge since the diagnosis is quite challenging due to overlapping symptoms, lack of prior-known predisposing risk factors, limited resources, and viral transmittance risk. Numerous factors arising out of the viral load or treatment lead to an increased risk for PE in COVID-19 patients, besides the fact that certain unknown risk factors may also contribute to the incidence of PE in COVID-19 patients. The management of PE in COVID-19 infection mainly comprises thromboprophylaxis and anticoagulant therapy with mechanical ventilation, depending on the risk stratification of the patient, with a post-COVID-19 management that prevents recurrent PE and complications. This review aims to discuss various aspects of COVID-19-infection-associated PE and major differential aspects from non-COVID-19 PE.
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Affiliation(s)
- Mohammad Suhail Akhter
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia; (M.S.A.); (H.A.H.); (A.A.M.)
| | - Hassan A. Hamali
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia; (M.S.A.); (H.A.H.); (A.A.M.)
| | - Abdullah A. Mobarki
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia; (M.S.A.); (H.A.H.); (A.A.M.)
| | - Hina Rashid
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia;
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, 53127 Bonn, Germany;
| | - Arijit Biswas
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, 53127 Bonn, Germany;
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54
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Singh B, Mechineni A, Kaur P, Reid RJ, Maroules M. COVID-19 and bleeding at unusual locations: Report of four cases. Hematol Transfus Cell Ther 2021; 43:214-218. [PMID: 33681709 PMCID: PMC7919512 DOI: 10.1016/j.htct.2021.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/27/2021] [Indexed: 01/08/2023] Open
Affiliation(s)
- Balraj Singh
- Saint Joseph's University Medical Center, Paterson, NJ, United States.
| | - Ashesha Mechineni
- Saint Joseph's University Medical Center, Paterson, NJ, United States
| | - Parminder Kaur
- Saint Joseph's University Medical Center, Paterson, NJ, United States
| | - Ro-Jay Reid
- Saint Joseph's University Medical Center, Paterson, NJ, United States
| | - Michael Maroules
- Saint Joseph's University Medical Center, Paterson, NJ, United States
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55
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Hajjar LA, Costa IBSDS, Rizk SI, Biselli B, Gomes BR, Bittar CS, de Oliveira GQ, de Almeida JP, de Oliveira Bello MV, Garzillo C, Leme AC, Elena M, Val F, de Almeida Lopes M, Lacerda MVG, Ramires JAF, Kalil Filho R, Teboul JL, Landoni G. Intensive care management of patients with COVID-19: a practical approach. Ann Intensive Care 2021; 11:36. [PMID: 33604873 PMCID: PMC7891474 DOI: 10.1186/s13613-021-00820-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/29/2021] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient's survival.
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Affiliation(s)
- Ludhmila Abrahão Hajjar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil.
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil.
| | | | - Stephanie Itala Rizk
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Bruno Biselli
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Brenno Rizerio Gomes
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Cristina Salvadori Bittar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
| | | | - Juliano Pinheiro de Almeida
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | | | - Cibele Garzillo
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Alcino Costa Leme
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Moizo Elena
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fernando Val
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
| | | | | | - José Antonio Franchini Ramires
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Le Kremlin Bicêtre, France
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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56
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Berkman SA. Post-hospital discharge venous thromboembolism prophylaxis in medically ill patients. Postgrad Med 2021; 133:51-63. [PMID: 33435758 DOI: 10.1080/00325481.2021.1876387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
There is a widely expressed concern about an unmet need for post hospitalization venous thromboembolism (VTE) prophylaxis in medically ill patients, however, physicians and hospitals have been slow to implement this measure. Recommendations against extended VTE prophylaxis in medical patients from the American Society of Hematology (ASH) in 2018 and the withholding of approval of betrixiban by the European Medicines Agency also in 2018 may have been influential in this regard. Furthermore, rivaroxaban the other drug approved for this indication in the U.S has not yet been approved in Europe. In addition, hospital administrators, those monitoring expenses in the U.S, have been reluctant to support a treatment which will mostly involve outpatients. Internal medicine physicians, hospitalists and nursing home physicians have not shared the fervor for post hospital VTE prophylaxis, whether with anticoagulants or aspirin, that their orthopedic surgery colleagues have, particularly in hip and knee arthroplasty. This is despite an increased risk of post hospital discharge thrombosis in both groups of patients. Enter hospitalized patients with COVID-19, a potentially severe medical illness with high hospitalization related thrombosis risk, and questions arise as to whether these medical patients, who are clearly more hypercoagulable during hospitalization than those in previous studies, should warrant post hospital discharge prophylaxis.
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Affiliation(s)
- Samuel A Berkman
- Department of medicine, Division of hematology/Oncology UCLA, California
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57
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Del Borrello G, Giraudo I, Bondone C, Denina M, Garazzino S, Linari C, Mignone F, Pruccoli G, Scolfaro C, Spadea M, Pollio B, Saracco P. SARS-COV-2-associated coagulopathy and thromboembolism prophylaxis in children: A single-center observational study. J Thromb Haemost 2021; 19:522-530. [PMID: 33305475 PMCID: PMC9906296 DOI: 10.1111/jth.15216] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/09/2020] [Accepted: 12/07/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Multiple investigators have described an increased incidence of thromboembolic events in SARS-CoV-2-infected individuals. Data concerning hemostatic complications in children hospitalized for COVID-19/multisystem inflammatory syndrome in children (MIS-C) are scant. OBJECTIVES To share our experience in managing SARS-CoV-2-associated pro-coagulant state in hospitalized children. METHODS D-dimer values were recorded at diagnosis in children hospitalized for SARS-CoV-2-related manifestations. In moderately to critically ill patients and MIS-C cases, coagulation and inflammatory markers were checked at multiple time points and median results were compared. Pro-thrombotic risk factors were appraised for each child and thromboprophylaxis was started in selected cases. RESULTS Thirty-five patients were prospectively enrolled. D-dimer values did not discriminate COVID-19 of differing severity, whereas were markedly different between the COVID-19 and the MIS-C cohorts. In both cohorts, D-dimer and C-reactive protein levels increased upon clinical worsening but were not accompanied by decreased fibrinogen or platelet values, with all parameters returning to normal upon disease resolution. Six patients had multiple thrombotic risk factors and were started on pharmacological thromboprophylaxis. No deaths or thrombotic or bleeding complications occurred. CONCLUSIONS COVID-19 pediatric patients show mildly altered coagulation and inflammatory parameters; on the other hand, MIS-C cases showed laboratory signs of an inflammatory driven pro-coagulant status. Universal anticoagulant prophylaxis in hospitalized children with SARS-CoV-2-related manifestations is not warranted, but may be offered to patients with other pro-thrombotic risk factors in the context of a multi-modal therapeutic approach.
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Affiliation(s)
| | - Isaac Giraudo
- Sciences of Public Health and Paediatrics, University of Turin, Torino, Italy
| | - Claudia Bondone
- Paediatric Emergency Department, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Marco Denina
- Paediatric Infectious Disease Unit, Department of Paediatrics, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Silvia Garazzino
- Paediatric Infectious Disease Unit, Department of Paediatrics, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Claudia Linari
- Laboratory Medicine, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Federica Mignone
- Paediatric Infectious Disease Unit, Department of Paediatrics, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Giulia Pruccoli
- Sciences of Public Health and Paediatrics, University of Turin, Torino, Italy
| | - Carlo Scolfaro
- Paediatric Infectious Disease Unit, Department of Paediatrics, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Manuela Spadea
- Sciences of Public Health and Paediatrics, University of Turin, Torino, Italy
| | - Berardino Pollio
- Immune-Haematology and Transfusion Medicine, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Paola Saracco
- Paediatric Haematology Unit, Department of Paediatrics, University Hospital "Città della Salute e della Scienza di Torino", Torino, Italy
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58
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Ahmed HY, Papali A, Haile T, Shrestha GS, Schultz MJ, Lundeg G, Akrami KM, For The Covid-Lmic Task Force. Pragmatic Recommendations for the Management of Anticoagulation and Venous Thrombotic Disease for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:99-109. [PMID: 33432908 PMCID: PMC7957232 DOI: 10.4269/ajtmh.20-1305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/23/2020] [Indexed: 12/19/2022] Open
Abstract
New studies of COVID–19 are constantly updating best practices in clinical care. Often, it is impractical to apply recommendations based on high-income country investigations to resource limited settings in low- and middle-income countries (LMICs). We present a set of pragmatic recommendations for the management of anticoagulation and thrombotic disease for hospitalized patients with COVID-19 in LMICs. In the absence of contraindications, we recommend prophylactic anticoagulation with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for all hospitalized COVID-19 patients in LMICs. If available, we recommend LMWH over UFH for venous thromboembolism (VTE) prophylaxis to minimize risk to healthcare workers. We recommend against the use of aspirin for VTE prophylaxis in hospitalized COVID-19 and non–COVID-19 patients in LMICs. Because of limited evidence, we suggest against the use of “enhanced” or “intermediate” prophylaxis in COVID-19 patients in LMICs. Based on current available evidence, we recommend against the initiation of empiric therapeutic anticoagulation without clinical suspicion for VTE. If contraindications exist to chemical prophylaxis, we recommend mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or graduated compression stockings (GCS) for hospitalized COVID-19 patients in LMICs. In LMICs, we recommend initiating therapeutic anticoagulation for hospitalized COVID-19 patients, in accordance with local clinical practice guidelines, if there is high clinical suspicion for VTE, even in the absence of testing. If available, we recommend LMWH over UFH or Direct oral anticoagulants for treatment of VTE in LMICs to minimize risk to healthcare workers. In LMIC settings where continuous intravenous UFH or LMWH are unavailable or not feasible to use, we recommend fixed dose heparin, adjusted to body weight, in hospitalized COVID-19 patients with high clinical suspicion of VTE. We suggest D-dimer measurement, if available and affordable, at the time of admission for risk stratification, or when clinical suspicion for VTE is high. For hospitalized COVID-19 patients in LMICs, based on current available evidence, we make no recommendation on the use of serial D-dimer monitoring for the initiation of therapeutic anticoagulation. For hospitalized COVID-19 patients in LMICs receiving intravenous therapeutic UFH, we recommend serial monitoring of partial thromboplastin time or anti-factor Xa level, based on local laboratory capabilities. For hospitalized COVID-19 patients in LMICs receiving LMWH, we suggest against serial monitoring of anti-factor Xa level. We suggest serial monitoring of platelet counts in patients receiving therapeutic anticoagulation for VTE, to assess risk of bleeding or development of heparin induced thrombocytopenia.
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Affiliation(s)
- Hanan Y Ahmed
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - Tewodros Haile
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Amsterdam University Medical Centers, Location 'Academic Medical Center', Amsterdam, The Netherlands
| | - Ganbold Lundeg
- Critical Care and Anaesthesia Department, Mongolian National University of Medical Sciences, Ulan Bator, Mongolia
| | - Kevan M Akrami
- Divisions of Infectious Disease and Critical Care Medicine, University of California San Diego, San Diego, California.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
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Robba C, Battaglini D, Ball L, Valbusa A, Porto I, Della Bona R, La Malfa G, Patroniti N, Brunetti I, Loconte M, Bassetti M, Giacobbe DR, Vena A, Silva CLM, Rocco PRM, Pelosi P. Coagulative Disorders in Critically Ill COVID-19 Patients with Acute Distress Respiratory Syndrome: A Critical Review. J Clin Med 2021; 10:E140. [PMID: 33401632 PMCID: PMC7795033 DOI: 10.3390/jcm10010140] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022] Open
Abstract
In critically ill patients with acute respiratory distress syndrome (ARDS) coronavirus disease 2019 (COVID-19), a high incidence of thromboembolic and hemorrhagic events is reported. COVID-19 may lead to impairment of the coagulation cascade, with an imbalance in platelet function and the regulatory mechanisms of coagulation and fibrinolysis. Clinical manifestations vary from a rise in laboratory markers and subclinical microthrombi to thromboembolic events, bleeding, and disseminated intravascular coagulation. After an inflammatory trigger, the mechanism for activation of the coagulation cascade in COVID-19 is the tissue factor pathway, which causes endotoxin and tumor necrosis factor-mediated production of interleukins and platelet activation. The consequent massive infiltration of activated platelets may be responsible for inflammatory infiltrates in the endothelial space, as well as thrombocytopenia. The variety of clinical presentations of the coagulopathy confronts the clinician with the difficult questions of whether and how to provide optimal supportive care. In addition to coagulation tests, advanced laboratory tests such as protein C, protein S, antithrombin, tissue factor pathway inhibitors, D-dimers, activated factor Xa, and quantification of specific coagulation factors can be useful, as can thromboelastography or thromboelastometry. Treatment should be tailored, focusing on the estimated risk of bleeding and thrombosis. The aim of this review is to explore the pathophysiology and clinical evidence of coagulation disorders in severe ARDS-related COVID-19 patients.
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Affiliation(s)
- Chiara Robba
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (D.B.); (L.B.); (N.P.); (I.B.); (M.L.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Denise Battaglini
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (D.B.); (L.B.); (N.P.); (I.B.); (M.L.); (P.P.)
| | - Lorenzo Ball
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (D.B.); (L.B.); (N.P.); (I.B.); (M.L.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Alberto Valbusa
- Dipartimento CardioToracoVascolare, Ospedale Policlinico San Martino IRCCS, 16132 Genoa, Italy; (A.V.); (I.P.); (R.D.B.); (G.L.M.)
| | - Italo Porto
- Dipartimento CardioToracoVascolare, Ospedale Policlinico San Martino IRCCS, 16132 Genoa, Italy; (A.V.); (I.P.); (R.D.B.); (G.L.M.)
- Dipartimento di Medicina Interna e Specialità Mediche (DIMI), University of Genoa, 16132 Genoa, Italy
| | - Roberta Della Bona
- Dipartimento CardioToracoVascolare, Ospedale Policlinico San Martino IRCCS, 16132 Genoa, Italy; (A.V.); (I.P.); (R.D.B.); (G.L.M.)
| | - Giovanni La Malfa
- Dipartimento CardioToracoVascolare, Ospedale Policlinico San Martino IRCCS, 16132 Genoa, Italy; (A.V.); (I.P.); (R.D.B.); (G.L.M.)
- Dipartimento di Medicina Interna e Specialità Mediche (DIMI), University of Genoa, 16132 Genoa, Italy
| | - Nicolò Patroniti
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (D.B.); (L.B.); (N.P.); (I.B.); (M.L.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Iole Brunetti
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (D.B.); (L.B.); (N.P.); (I.B.); (M.L.); (P.P.)
| | - Maurizio Loconte
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (D.B.); (L.B.); (N.P.); (I.B.); (M.L.); (P.P.)
| | - Matteo Bassetti
- Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS, 16132 Genoa, Italy; (M.B.); (D.R.G.); (A.V.)
- Department of Health Sciences (DISSAL), University of Genoa, 16132 Genoa, Italy
| | - Daniele R. Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS, 16132 Genoa, Italy; (M.B.); (D.R.G.); (A.V.)
| | - Antonio Vena
- Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS, 16132 Genoa, Italy; (M.B.); (D.R.G.); (A.V.)
| | - Claudia Lucia M. Silva
- Laboratory of Biochemical and Molecular Pharmacology, Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil;
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil;
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (D.B.); (L.B.); (N.P.); (I.B.); (M.L.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
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60
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Elekhnawy E, Kamar AA, Sonbol F. Present and future treatment strategies for coronavirus disease 2019. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2021; 7:84. [PMID: 33850936 PMCID: PMC8033289 DOI: 10.1186/s43094-021-00238-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/29/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The recent pandemic of coronavirus disease 2019 (COVID-19) has resulted in many challenges to the healthcare organizations around the world. Unfortunately, until now, there are no proven effective therapeutic agents against this virus. MAIN BODY Several evolving studies suggest repurposing a potential list of drugs which have appropriate pharmacological and therapeutic effects to be used in treating COVID-19 cases. In the present review, we will summarize the potential drugs suggested to be repurposed to be utilized in the treatment of COVID-19 patients like lopinavir-ritonavir, ribavirin, baloxavir marboxil, favipiravir, remdesvir, umifenovir, chloroquine, hydroxychloroquine, azithromycin, corticosteroids, losartan, statins, interferons, nitric oxide, epoprostenol, tocilizumab, siltuximab, sarilumab anakinra, and ruxolitinib. In addition, we discussed the possible future therapeutic regimens based on the recent molecular and genomic discoveries. CONCLUSION This review could provide beneficial information about the potential current and future treatment strategies to treat the pandemic COVID-19 disease.
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Affiliation(s)
- Engy Elekhnawy
- grid.412258.80000 0000 9477 7793Pharmaceutical Microbiology, Faculty of Pharmacy, Tanta University, Tanta, El Gharbia Governorate Egypt
| | - Amal Abo Kamar
- grid.412258.80000 0000 9477 7793Pharmaceutical Microbiology, Faculty of Pharmacy, Tanta University, Tanta, El Gharbia Governorate Egypt
| | - Fatma Sonbol
- grid.412258.80000 0000 9477 7793Pharmaceutical Microbiology, Faculty of Pharmacy, Tanta University, Tanta, El Gharbia Governorate Egypt
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Pluta J, Trzebicki ACJ. COVID-19: coagulation disorders and anticoagulant treatment in patients hospitalised in ICU. Anaesthesiol Intensive Ther 2021; 53:153-161. [PMID: 34006056 PMCID: PMC10158437 DOI: 10.5114/ait.2021.105783] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/07/2021] [Indexed: 11/17/2022] Open
Abstract
Patients hospitalized in the intensive care unit (ICU) due to the COVID-19 experience a high incidence (up to 43%) of venous thromboembolic events. While laboratory findings in COVID-19-associated coagulopathy (CAC) show increased D-dimer and fibrinogen levels, the abnormalities in standard coagulation tests and platelet count are minimal. Recent studies suggest contribution of fibrinolysis shutdown to this phenomenon. Endothelial injury and alteration of its antithrombotic activity can lead to micro- and macrovascular thrombosis in the lungs, occurrence of which is associated with poor clinical outcome in critically ill patients with COVID-19. Additionally, the hypercoagulability induced by activation of coagulation pathways during the immune response to SARS-CoV-2 infection contributes to impaired organ perfusion. This, alongside with hypoxemia, leads to multiorgan failure. Various diagnostic regimens, some of which include global assays of haemostasis, are currently being published and discussed. Numerous guidelines and recommendations of scientific societies and groups of specialists have been published. However, there is no single optimal algorithm for anticoagulation treatment and monitoring specific to the ICU patients with COVID-19. The authors have attempted to summarize the data related to CAC and thrombotic disease and develop an algorithm consistent with the latest clinical practice guideline recommendations.
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Affiliation(s)
- Jan Pluta
- Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Poland
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White-Dzuro G, Gibson LE, Zazzeron L, White-Dzuro C, Sullivan Z, Diiorio DA, Low SA, Chang MG, Bittner EA. Multisystem effects of COVID-19: a concise review for practitioners. Postgrad Med 2021; 133:20-27. [PMID: 32921198 PMCID: PMC7651182 DOI: 10.1080/00325481.2020.1823094] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023]
Abstract
While COVID-19 has primarily been characterized by the respiratory impact of viral pneumonia, it affects every organ system and carries a high consequent risk of death in critically ill patients. Higher sequential organ failure assessment (SOFA) scores have been associated with increased mortality in patients critically ill patients with COVID-19. It is important that clinicians managing critically ill COVID-19 patients be aware of the multisystem impact of the disease so that care can be focused on the prevention of end-organ injuries to potentially improve clinical outcomes. We review the multisystem complications of COVID-19 and associated treatment strategies to improve the care of critically ill COVID-19 patients.
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Affiliation(s)
- Gabrielle White-Dzuro
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren E. Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Luca Zazzeron
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colin White-Dzuro
- School of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Zachary Sullivan
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daren A. Diiorio
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sarah A. Low
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G. Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Ménager P, Brière O, Gautier J, Riou J, Sacco G, Brangier A, Annweiler C. Regular Use of VKA Prior to COVID-19 Associated with Lower 7-Day Survival in Hospitalized Frail Elderly COVID-19 Patients: The GERIA-COVID Cohort Study. Nutrients 2020; 13:nu13010039. [PMID: 33374341 PMCID: PMC7824717 DOI: 10.3390/nu13010039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/20/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
Background. Vitamin K concentrations are inversely associated with the clinical severity of COVID-19. The objective of this cohort study was to determine whether the regular use of vitamin K antagonist (VKA) prior to COVID-19 was associated with short-term mortality in frail older adults hospitalized for COVID-19. Methods. Eighty-two patients consecutively hospitalized for COVID-19 in a geriatric acute care unit were included. The association of the regular use of VKA prior to COVID-19 with survival after 7 days of COVID-19 was examined using a propensity-score-weighted Cox proportional-hazards model accounting for age, sex, severe undernutrition, diabetes mellitus, hypertension, prior myocardial infarction, congestive heart failure, prior stroke and/or transient ischemic attack, CHA2DS2-VASc score, HAS-BLED score, and eGFR. Results. Among 82 patients (mean ± SD age 88.8 ± 4.5 years; 48% women), 73 survived COVID-19 at day 7 while 9 died. There was no between-group difference at baseline, despite a trend for more frequent use of VKA in those who did not survive on day 7 (33.3% versus 8.2%, p = 0.056). While considering “using no VKA” as the reference (hazard ratio (HR) = 1), the HR for 7-day mortality in those regularly using VKA was 5.68 [95% CI: 1.17; 27.53]. Consistently, COVID-19 patients using VKA on a regular basis had shorter survival times than the others (p = 0.031). Conclusions. Regular use of VKA was associated with increased mortality at day 7 in hospitalized frail elderly patients with COVID-19.
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Affiliation(s)
- Pierre Ménager
- Department of Geriatric Medicine, Le Mans Hospital, F-72037 Le Mans, France;
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Olivier Brière
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Jennifer Gautier
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Jérémie Riou
- INSERM, MINT, 1066, University of Angers, F-49000 Angers, France;
- Delegation to Clinical Research and Innovation, Angers University Hospital, F-49933 Angers, France
| | - Guillaume Sacco
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Antoine Brangier
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Cédric Annweiler
- Department of Geriatric Medicine, Le Mans Hospital, F-72037 Le Mans, France;
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
- UPRES EA 4638, University of Angers, F-49000 Angers, France
- Gérontopôle Autonomie Longévité des Pays de la Loire, F-44000 Nantes, France
- Robarts Research Institute, Department of Medical Biophysics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON N6A 5K8, Canada
- Correspondence: ; Tel.: +33-2-4135-4725; Fax: +33-2-4135-4894
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Waite AAC, Hamilton DO, Pizzi R, Ageno W, Welters ID. Hypercoagulopathy in Severe COVID-19: Implications for Acute Care. Thromb Haemost 2020; 120:1654-1667. [PMID: 33368088 PMCID: PMC7869057 DOI: 10.1055/s-0040-1721487] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
COVID-19 was first described in late 2019 and has since developed into a pandemic affecting more than 21 million people worldwide. Of particular relevance for acute care is the occurrence of COVID-19-associated coagulopathy (CAC), which is characterised by hypercoagulability, immunothrombosis and venous thromboembolism, and contributes to hypoxia in a significant proportion of patients. This review describes diagnosis and treatment of CAC in the emergency department and in intensive care. We summarise the pathological mechanisms and common complications of CAC such as pulmonary thrombosis and venous thromboembolic events and discuss current strategies for thromboprophylaxis and therapeutic anti-coagulation in the acute care setting.
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Affiliation(s)
- Alicia A C Waite
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom.,Department of Intensive Care Medicine, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - David O Hamilton
- Department of Intensive Care Medicine, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Roberto Pizzi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ingeborg D Welters
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom.,Department of Intensive Care Medicine, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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Hranjec T, Estreicher M, Rogers B, Kohler L, Solomon R, Hennessy S, Cibulas M, Hurst D, Hegazy M, Lee J, Perez D, Doctor N, Kiffin C, Pigneri D, LaGuardia H, Shaw K, Arenas J, Rosenthal A, Katz RS, Sawyer RG, Pepe PE. Integral Use of Thromboelastography With Platelet Mapping to Guide Appropriate Treatment, Avoid Complications, and Improve Survival of Patients With Coronavirus Disease 2019-Related Coagulopathy. Crit Care Explor 2020; 2:e0287. [PMID: 33381763 PMCID: PMC7769351 DOI: 10.1097/cce.0000000000000287] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Coagulopathy of coronavirus disease 2019 is largely described as hypercoagulability, yet both thrombotic and hemorrhagic complications occur. Although therapeutic and prophylactic anticoagulant interventions have been recommended, empiric use of antifactor medications (heparin/enoxaparin) may result in hemorrhagic complications, including death. Furthermore, traditional (antifactor) anticoagulation does not address the impact of overactive platelets in coronavirus disease 2019. The primary aim was to evaluate if algorithm-guided thromboelastography with platelet mapping could better characterize an individual's coronavirus disease 2019-relatedcoagulopathic state and, secondarily, improve outcomes. DESIGN SETTING AND PATIENTS Coronavirus disease 2019 patients (n = 100), receiving thromboelastography with platelet mapping assay upon admission to an 800-bed tertiary-care hospital, were followed prospectively by a hospital-based thromboelastography team. Treating clinicians were provided with the option of using a pre-established algorithm for anticoagulation, including follow-up thromboelastography with platelet mapping assays. Two groups evolved: 1) patients managed by thromboelastography with platelet mapping algorithm (algorithm-guided-thromboelastography); 2) those treated without thromboelastography with platelet mapping protocols (non-algorithm-guided). Outcomes included thrombotic/hemorrhagic complications, pulmonary failure, need for mechanical ventilation, acute kidney injury, dialysis requirement, and nonsurvival. INTERVENTIONS Standard-of-care therapy with or without algorithm-guided-thromboelastography support. MEASUREMENTS AND MAIN RESULTS Although d-dimer, C-reactive protein, and ferritin were elevated significantly in critically ill (nonsurvivors, acute kidney injury, pulmonary failure), they did not distinguish between coagulopathic and noncoagulopathic patients. Platelet hyperactivity (maximum amplitude-arachidonic acid/adenosine diphosphate > 50 min), with or without thrombocytosis, was associated with thrombotic/ischemic complications, whereas severe thrombocytopenia (platelet count < 100,000/μL) was uniformly fatal. Hemorrhagic complications were observed with decreased factor activity (reaction time > 8 min). Non-algorithm-guided patients had increased risk for subsequent mechanical ventilation (relative risk = 10.9; p < 0.0001), acute kidney injury (relative risk = 2.3; p = 0.0017), dialysis (relative risk = 7.8; p < 0.0001), and death (relative risk = 7.7; p < 0.0001), with 17 of 28 non-algorithm-guided patients (60.7%) dying versus four algorithm-guided-thromboelastography patients (5.6%) (p < 0.0001). Thromboelastography with platelet mapping-guided antiplatelet treatment decreased mortality 82% (p = 0.0002), whereas non-algorithm-guided (compared with algorithm-guided-thromboelastography) use of antifactor therapy (heparin/enoxaparin) resulted in 10.3-fold increased mortality risk (p = 0.0001). CONCLUSIONS Thromboelastography with platelet mapping better characterizes the spectrum of coronavirus disease 2019 coagulation-related abnormalities and may guide more tailored, patient-specific therapies in those infected with coronavirus disease 2019.
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Affiliation(s)
- Tjasa Hranjec
- Division of Transplantation, Memorial Regional Hospital, Hollywood, FL
- Division of Trauma/Acute Care/Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL
| | | | | | - Lisa Kohler
- Division of Trauma/Acute Care/Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL
| | - Rachele Solomon
- Division of Transplantation, Memorial Regional Hospital, Hollywood, FL
| | - Sara Hennessy
- Department of Surgery, Division of Trauma/Acute Care/Critical Care Surgery, Bariatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Deborah Hurst
- Division of Trauma/Acute Care/Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL
| | - Mohamed Hegazy
- Division of Transplantation, Memorial Regional Hospital, Hollywood, FL
| | - Jieun Lee
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL
| | - Donny Perez
- Emergency Department, Memorial Regional Hospital, Hollywood, FL
| | | | - Chauniqua Kiffin
- Division of Trauma/Acute Care/Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL
| | - Danielle Pigneri
- Division of Trauma/Acute Care/Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL
| | - Heather LaGuardia
- Division of Transplantation, Memorial Regional Hospital, Hollywood, FL
| | - Kathryn Shaw
- Division of Transplantation, Memorial Regional Hospital, Hollywood, FL
| | - Juan Arenas
- Division of Transplantation, Memorial Regional Hospital, Hollywood, FL
| | - Andrew Rosenthal
- Division of Trauma/Acute Care/Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL
| | - Randy S Katz
- Emergency Department, Memorial Regional Hospital, Hollywood, FL
| | - Robert G Sawyer
- Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI
| | - Paul E Pepe
- Metropolitan Emergency Medical Services Medical Directors Alliance, Dallas, TX
- Department of Management, Policy and Community Health, University of Texas Health Sciences Center, School of Public Health, Houston, TX
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