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Páramo JA. Thrombotic risk associated with COVID-19 and diabetes; Is PAI-1 the link? CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024; 36:227-228. [PMID: 38944564 DOI: 10.1016/j.arteri.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/01/2024]
Affiliation(s)
- José A Páramo
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Instituto de investigaciones Sanitaria de Navarra (IdiSNA), Pamplona, Navarra, España.
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Volod O, Bunch CM, Miller J, Moore EE, Moore HB, Kwaan HC, Patel SS, Wiarda G, Aboukhaled M, Thomas SG, Fulkerson D, Erdman L, Tincher A, Walsh MM. Reply to Bareille et al. Are Viscoelastometric Assays of Old Generation Ready for Disposal? Comment on "Volod et al. Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J. Clin. Med. 2022, 11, 860". J Clin Med 2023; 12:jcm12020478. [PMID: 36675408 PMCID: PMC9862366 DOI: 10.3390/jcm12020478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/16/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023] Open
Abstract
We are pleased to see that Bareille et al. have written a Commentary: "Are viscoelastometric assays of old generation ready for disposal?" [...].
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Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Correspondence:
| | - Connor M. Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48402, USA
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48402, USA
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Health Sciences Center, Denver, CO 80204, USA
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Health Sciences Center, Denver, CO 80204, USA
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Shivani S. Patel
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Grant Wiarda
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Michael Aboukhaled
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA
| | - Lee Erdman
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Anna Tincher
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mark M. Walsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
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Breel JS, Wensing AGCL, Eberl S, Preckel B, Schober P, Müller MCA, Klautz RJM, Hollmann MW, Hermanns H. Patients with infective endocarditis undergoing cardiac surgery have distinct ROTEM profiles and more bleeding complications compared to patients without infective endocarditis. PLoS One 2023; 18:e0284329. [PMID: 37053130 PMCID: PMC10101476 DOI: 10.1371/journal.pone.0284329] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND The coagulation system is crucial in the pathogenesis of infective endocarditis and undergoes significant changes during course of the disease. However, little is known about the implications of those changes in the perioperative period. Aim of the present study was to delineate the specific coagulation patterns and their clinical consequence in patients undergoing cardiac surgery due to infective endocarditis. METHODS In this single-centre, exploratory, prospective observational study, we investigated the incidence and degree of coagulopathy in patients with (n = 31) and without infective endocarditis (n = 39) undergoing cardiac valve surgery. The primary outcome was the differences between these two groups in rotational thromboelastometry (ROTEM) results before, during and after surgery. The secondary outcomes were the differences between the groups in heparin sensitivity, bleeding complications, and transfusion requirements. RESULTS Most ROTEM parameters in EXTEM, INTEM and FIBTEM assays were significantly altered in patients with infective endocarditis. Clotting time in the EXTEM assay was significantly prolonged in the endocarditis group at all time-points, while all clot firmness parameters (A5, A10 and MCF) were significantly increased. The heparin sensitivity index was significantly lower in the endocarditis group (median index 0.99 vs 1.17s. IU-1.kg-1, p = .008), indicating increased heparin resistance. Patients with infective endocarditis had more bleeding complications as assessed by the universal definition of perioperative bleeding score (OR 3.0, p = .018), and more patients with endocarditis underwent early re-exploration (p = .018). CONCLUSIONS The findings of this exploratory investigation show significantly altered coagulation profiles in patients with infective endocarditis, with concomitant hyper- and hypocoagulability. Furthermore, the incidence of bleeding complications and transfusion requirements were increased in patients with endocarditis. These results show the potential of ROTEM to detect coagulation abnormalities in patients with infective endocarditis. Existing point-of-care coagulation testing guided algorithms for optimizing perioperative coagulation management possibly need to be adjusted for these high-risk patients undergoing cardiac surgery.
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Affiliation(s)
- Jennifer S Breel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Agnes G C L Wensing
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Susanne Eberl
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Patrick Schober
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Robert J M Klautz
- Department of Cardiac Surgery, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Henning Hermanns
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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Kruger A, Vlok M, Turner S, Venter C, Laubscher GJ, Kell DB, Pretorius E. Proteomics of fibrin amyloid microclots in long COVID/post-acute sequelae of COVID-19 (PASC) shows many entrapped pro-inflammatory molecules that may also contribute to a failed fibrinolytic system. Cardiovasc Diabetol 2022; 21:190. [PMID: 36131342 PMCID: PMC9491257 DOI: 10.1186/s12933-022-01623-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/07/2022] [Indexed: 02/07/2023] Open
Abstract
Background Post-acute sequelae of COVID-19 (PASC), also now known as long COVID, has become a major global health and economic burden. Previously, we provided evidence that there is a significant insoluble fibrin amyloid microclot load in the circulation of individuals with long COVID, and that these microclots entrap a substantial number of inflammatory molecules, including those that might prevent clot breakdown. Scientifically, the most challenging aspect of this debilitating condition is that traditional pathology tests such as a serum CRP (C-reactive protein) may not show any significant abnormal inflammatory markers, albeit these tests measure only the soluble inflammatory molecules. Elevated, or abnormal soluble biomarkers such as IL-6, D-Dimer or fibrinogen indicate an increased risk for thrombosis or a host immune response in COVID-19. The absence of biomarkers in standard pathology tests, result in a significant amount of confusion for patients and clinicians, as patients are extremely sick or even bed-ridden but with no regular identifiable reason for their disease. Biomarkers that are currently available cannot detect the molecules present in the microclots we identified and are therefore unable to confirm their presence or the mechanisms that drive their formation. Methods Here we analysed the protein content of double-digested microclots of 99 long COVID patients and 29 healthy controls. The patients suffering from long COVID reported their symptoms through a questionnaire completed by themselves or their attending physician. Results Our long COVID cohort’s symptoms were found to be in line with global findings, where the most prevalent symptoms were constant fatigue (74%,) cognitive impairment (71%) and depression and anxiety (30%). Our most noteworthy findings were a reduced level of plasma Kallikrein compared to our controls, an increased level of platelet factor 4 (PF4) von Willebrand factor (VWF), and a marginally increased level of α-2 antiplasmin (α-2-AP). We also found a significant presence of antibodies entrapped inside these microclots. Conclusion Our results confirm the presence of pro-inflammatory molecules that may also contribute to a failed fibrinolysis phenomenon, which could possibly explain why individuals with long COVID suffer from chronic fatigue, dyspnoea, or cognitive impairment. In addition, significant platelet hyperactivation was noted. Hyperactivation will result in the granular content of platelets being shed into the circulation, including PF4. Overall, our results provide further evidence of both a failed fibrinolytic system in long COVID/PASC and the entrapment of many proteins whose presence might otherwise go unrecorded. These findings might have significant implications for individuals with pre-existing comorbidities, including cardiovascular disease and type 2 diabetes.
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Affiliation(s)
- Arneaux Kruger
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa
| | - Mare Vlok
- Central Analytical Facility, Mass Spectrometry Stellenbosch University, Tygerberg Campus, Room 6054, Clinical Building, Francie Van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Simone Turner
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa
| | - Chantelle Venter
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa
| | | | - Douglas B Kell
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa. .,Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK. .,The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Kemitorvet 200, 2800, Kongens Lyngby, Denmark.
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa. .,Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK.
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Heubner L, Greiner M, Vicent O, Beyer-Westendorf J, Tiebel O, Scholz U, Güldner A, Mirus M, Fries D, Koch T, Spieth PM. Predictive ability of viscoelastic testing using ClotPro® for short-term outcome in patients with severe Covid-19 ARDS with or without ECMO therapy: a retrospective study. Thromb J 2022; 20:48. [PMID: 36038895 PMCID: PMC9421107 DOI: 10.1186/s12959-022-00403-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND SARS-CoV-2 infections are suspected to trigger the coagulation system through various pathways leading to a high incidence of thromboembolic complications, hypercoagulation and impaired fibrinolytic capacity were previously identified as potentially mechanisms. A reliable diagnostic tool for detecting both is still under discussion. This retrospective study is aimed to examine the prognostic relevance of early viscoelastic testing compared to conventional laboratory tests in COVID-19 patients with acute respiratory distress syndrome (ARDS). METHODS All mechanically ventilated patients with COVID-19 related ARDS treated in our intensive care unit (ICU) between January and March 2021 were included in this study. Viscoelastic testing (VET) was performed using the ClotPro® system after admission to our ICU. Prevalence of thromboembolic events was observed by standardized screening for venous and pulmonary thromboembolism using complete compression ultrasound and thoracic computed tomography pulmonary angiography at ICU admission, respectively. We examined associations between the severity of ARDS at admission to our ICU, in-hospital mortality and the incidence of thromboembolic events comparing conventional laboratory analysis and VET. ECMO related coagulopathy was investigated in a subgroup analysis. The data were analyzed using the Mann-Whitney U test. RESULTS Of 55 patients enrolled in this study, 22 patients required treatment with ECMO. Thromboembolic complications occurred in 51% of all patients. Overall hospital mortality was 55%. In patients with thromboembolic complications, signs of reduced fibrinolytic capacity could be detected in the TPA assay with prolonged lysis time, median 460 s (IQR 350-560) vs 359 s (IQR 287-521, p = 0.073). Patients with moderate to severe ARDS at admission to our ICU showed increased maximum clot firmness as a sign of hypercoagulation in the EX-test (70 vs 67 mm, p < 0.05), FIB-test (35 vs 24 mm, p < 0.05) and TPA-test (52 vs 36 mm, p < 0.05) as well as higher values of inflammatory markers (CRP, PCT and IL6). ECMO patients suffered more frequently from bleeding complications (32% vs 15%). CONCLUSION Although, the predictive value for thromboembolic complications or mortality seems limited, point-of-care viscoelastic coagulation testing might be useful in detecting hypercoagulable states and impaired fibrinolysis in critically ill COVID-19 ARDS patients and could be helpful in identifying patients with a potentially very severe course of the disease.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Marvin Greiner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I, Thrombosis Research University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Ute Scholz
- MVZ Labor Dr. Reising-Ackermann Und Kollegen, Center of Hemostasis, Leipzig, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany.
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Schröder TA, Leonhardt H, Haim D, Bräuer C, Papadopoulos KK, Vicent O, Güldner A, Mirus M, Schmidt J, Held HC, Tiebel O, Birkner T, Beyer-Westendorf J, Lauer G, Spieth PM, Koch T, Heubner L. Enhancing Anticoagulation Monitoring and Therapy in Patients Undergoing Microvascular Reconstruction in Maxillofacial Surgery: A Prospective Observational Trial. J Pers Med 2022; 12:jpm12081229. [PMID: 36013177 PMCID: PMC9410460 DOI: 10.3390/jpm12081229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background: In reconstructive surgery, loss of a microvascular free flap due to perfusion disorders, especially thrombosis, is a serious complication. In recent years, viscoelastic testing (VET) has become increasingly important in point-of-care (POC) anticoagulation monitoring. This paper describes a protocol for enhanced anticoagulation monitoring during maxillofacial flap surgery. Objective: The aim of the study will be to evaluate, in a controlled setting, the predictive value of POC devices for the type of flap perfusion disorders due to thrombosis or bleeding. VET, Platelet monitoring (PM) and standard laboratory tests (SLT) are comparatively examined. Methods/Design: This study is an investigator-initiated prospective trial in 100 patients undergoing maxillofacial surgery. Patients who undergo reconstructive surgery using microvascular-free flaps will be consecutively enrolled in the study. All patients provide blood samples for VET, PM and SLT at defined time points. The primary outcome is defined as free flap loss during the hospital stay. Statistical analyses will be performed using t-tests, including the Bonferroni adjustment for multiple comparisons. Discussion: This study will help clarify whether VET can improve individualized patient care in reconstruction surgery. A better understanding of coagulation in relation to flap perfusion disorders may allow real-time adaption of antithrombotic strategies and potentially prevent flap complications.
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Affiliation(s)
- Tom A. Schröder
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Henry Leonhardt
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Dominik Haim
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Christian Bräuer
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Kiriaki K. Papadopoulos
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Jürgen Schmidt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Hanns C. Held
- Department of General, Thoracic and Vascular Surgery, Carl Gustav Carus Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Thomas Birkner
- Center for Evidence-Based Healthcare (ZEGV), Carl Gustav Carus Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I, Thrombosis Research University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Günter Lauer
- Department of Oral and Maxillofacial Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (T.A.S.); (H.L.); (D.H.); (C.B.); (K.K.P.); (G.L.)
| | - Peter M. Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
| | - Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (O.V.); (A.G.); (M.M.); (J.S.); (P.M.S.); (T.K.)
- Correspondence: ; Tel.: +49-351-45811660
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Snegovskikh D, Kendall MC, Levinson A, Sarpatwari R, Pisano D, Görlinger K, De Oliveira G. Thromboelastometry Predicts Thromboembolic Events, Hospital Length of Stay, and Mortality in Patients with COVID-19 Infection and Mild Hypoxemia: A Prospective Observational Study. J Blood Med 2022; 13:363-372. [PMID: 35789896 PMCID: PMC9250315 DOI: 10.2147/jbm.s363999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background The aim of this study was to assess changes in hemostasis and associated outcome of hospitalized patients with COVID-19 infection and mild hypoxemia. Methods Adult patients with COVID-19 infection and hypoxemia admitted to ICU were included in this prospective observational study. The primary outcome was defined as an unfavorable course of the disease if a patient: (1) developed a thromboembolic event while receiving anticoagulation prophylaxis, (2) had prolonged ICU stay, or (3) died. Demographic data, laboratory parameters and thromboelastometry (ROTEM) test results were collected. Results Twenty-five patients were recruited into the study. There were 16 patients with an unfavorable course of the disease. Compared to the 9 patients in the favorable course group, patients with an unfavorable course had a lower platelet count, median difference of 154 (95% CI, 26 to 223 x109/L), P = 0.012, and lower clot firmness parameters in EXTEM assay: amplitude at 20 minutes (A20), median difference of 7 (95% CI, 2 to 11) P = 0.006, maximum clot firmness (MCF), median difference of 6 (95% CI, 3 to 10) P = 0.006 and area under the curve (AUC) with a median difference of 671 (95% CI, 244 to 1029) P = 0.005. They also demonstrated suppression of fibrinolysis: higher lysis index 60, median difference of -3 (95% CI, -6 to 0), P = 0.023. Results of functional fibrinogen (FIBTEM) assay were similar between the groups. Conclusion The platelet count and the results of EXTEM assay, but not FIBTEM assay, were associated with the difference in clinical outcome among patients with COVID-19 infection and hypoxemia. The role of platelets in the outcome of COVID-19 infection calls for further investigation. Future studies on adjusting anticoagulant therapy based on the results of viscoelastic testing may be beneficial.
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Affiliation(s)
- Denis Snegovskikh
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mark C Kendall
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew Levinson
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ravi Sarpatwari
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Dominic Pisano
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Medical Department, Tem Innovations, Munich, Germany
| | - Gildasio De Oliveira
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Tricarico G, Travagli V. Approach to the management of COVID-19 patients: When home care can represent the best practice. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2022; 33:249-259. [PMID: 35786662 DOI: 10.3233/jrs-210064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The pandemic that began around February 2020, caused by the viral pathogen SARS-CoV-2 (COVID-19), has still not completed its course at present in June 2022. OBJECTIVE The open research to date highlights just how varied and complex the outcome of the contagion can be. METHOD The clinical pictures observed following the contagion present variabilities that cannot be explained completely by the patient's age (which, with the new variants, is rapidly changing, increasingly affecting younger patients) nor by symptoms and concomitant pathologies (which are no longer proving to be decisive in recent cases) in relation to medium-to-long term sequelae. In particular, the functions of the vascular endothelium and vascular lesions at the pre-capillary level represent the source of tissue hypoxia and other damage, resulting in the clinical evolution of COVID-19. RESULTS Keeping the patient at home with targeted therapeutic support, aimed at not worsening vascular endothelium damage with early and appropriate stimulation of endothelial cells, ameliorates the glycocalyx function and improves the prognosis and, in some circumstances, could be the best practice suitable for certain patients. CONCLUSION Clinical information thus far collected may be of immense value in developing a better understanding of the present pandemic and future occurrences regarding patient safety, pharmaceutical care and therapy liability.
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Affiliation(s)
| | - Valter Travagli
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy.,Dipartimento di Eccellenza Nazionale, Università degli Studi di Siena, Siena, Italy
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9
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Al-Mamoori HS, Ahmed MH, Al-Nafie TYS, Al-Attar Z. Assessment of the Level of Protein C in Hospitalized Iraqi Patients with COVID-19 and its Correlation with Hematological and Inflammatory Markers. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND: COVID-19 coagulopathy manifests by elevation of certain marker of active coagulation as fibrinogen and this increment associated with increased markers of inflammations.
AIM: To measure protein C (PC) level in hospitalized patients with COVID-19 and to find a possible correlation with hematological and inflammatory markers.
PATIENTS AND METHODS: Seventy-five hospitalized Iraqi adult patients with COVID-19 were included in a descriptive cross-sectional research. PC, D-dimer, and erythrocyte sedimentation rate (ESR) blood samples were collected, and further information was received from patient’s records. Statistical analysis was conducted using SPSS version 23 and Microsoft Office Excel 2019.
RESULTS: Mean age of 75 patients included in the study was 60.13 ± 14.65 years. Sixty-two (62.7%) of patients exhibited neutrophilia, whereas 41 had lymphopenia (54.7%). High ratio of neutrophil/lymphocyte (N/L) was seen in 66 (88.0%), eosinopenia was seen in 46 (61.3%), high lactate dehydrogenase level was seen 68 (90.7%), serum ferritin was high in 66 (88.0%), and high level of C-reactive protein was seen in 68 (90.7%), increased ESR was seen in 69 (92.0%) and high level of D-dimer was seen in 56 (74.7%), while low level of PC was seen in 12 (16.0%) patients. PC had significant negative correlation with prothrombin and partial thromboplastin time but no significant correlation with hematological and inflammatory parameters.
CONCLUSION: COVID-19 coagulopathy is common in majority of patients which include significant changes in WBCs counts, inflammatory markers, PC, and D-dimer levels. Such changes may have a great impact on morbidity and mortality and thus need to be monitored throughout treatment and convalescence.
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Heubner L, Mirus M, Vicent O, Güldner A, Tiebel O, Beyer-Westendorf J, Fries D, Spieth PM. Point of care coagulation management in anesthesiology and critical care. Minerva Anestesiol 2022; 88:615-628. [PMID: 35416466 DOI: 10.23736/s0375-9393.22.16380-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Point of care (POC) devices are increasingly used in the ICU and in anesthesia. Besides POC-devices for blood gas analysis, several devices are available for coagulation measurements. Although basic principles for thromboelastographic measurements are not novel, some promising developments were made during the last decade improving both user-friendliness and measurement reliability. For instance, POC measurements of activated clotting time (ACT) for heparin monitoring is still regarded as standard-of-care in cardiac interventions and surgery. In the field of anesthesia and intensive care medicine, POC-devices for thromboelastographic and platelet aggregation measurements are widely used. Their impact in case of bleeding and patient blood management for cardiothoracic and trauma surgery is well known. Moreover, there are promising concepts for anticoagulation monitoring including new oral anticoagulant drugs. Coagulation POC-devices may also identify patients at specific risk for thromboembolic events quickly. On the other hand, benefits of POC-devices need to be balanced against limitations, which include technical restrictions and operator related errors, mainly affecting reproducibility and interpretation of results. Therefore, it is recommendable to consider results of POC-coagulation testing in comparison to standard laboratory tests (SLT). Nevertheless, in urgent or emergency situations POC results enable fast decision making to optimize patient care.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany. -
| | - Martin Mirus
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Peter M Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
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Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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12
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Magoon R, Choudhary N, Jose J. Fibrinolysis and D-dimer in COVID-19: A Twisted Plot! Indian J Crit Care Med 2022; 26:164-166. [PMID: 35712729 PMCID: PMC8857708 DOI: 10.5005/jp-journals-10071-24105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Coronavirus disease-2019 (COVID-19) and the associated pathophysiological perturbations continue to bewilder the fraternity at large. In this context, the thromboembolic predisposition in COVID-19 has particularly emerged as a matter of an ardent debate. The index commentary aims to present an account of the recent developments in the understanding of the immunothrombosis in the enigmatical setting of COVID-19.
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Affiliation(s)
- Rohan Magoon
- Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
- Nitin Choudhary, Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India, Phone: +91 8447698566, e-mail:
| | - Nitin Choudhary
- Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Jes Jose
- Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Laubscher GJ, Lourens PJ, Venter C, Kell DB, Pretorius E. TEG ®, Microclot and Platelet Mapping for Guiding Early Management of Severe COVID-19 Coagulopathy. J Clin Med 2021; 10:jcm10225381. [PMID: 34830660 PMCID: PMC8621180 DOI: 10.3390/jcm10225381] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 02/08/2023] Open
Abstract
An important component of severe COVID-19 disease is virus-induced endothelilitis. This leads to disruption of normal endothelial function, initiating a state of failing normal clotting physiology. Massively increased levels of von Willebrand Factor (VWF) lead to overwhelming platelet activation, as well as activation of the enzymatic (intrinsic) clotting pathway. In addition, there is an impaired fibrinolysis, caused by, amongst others, increased levels of alpha-(2) antiplasmin. The end result is hypercoagulation (proven by thromboelastography® (TEG®)) and reduced fibrinolysis, inevitably leading to a difficult-to-overcome hypercoagulated physiological state. Platelets in circulation also plays a significant role in clot formation, but they themselves may also drive hypercoagulation when they are overactivated due to the interactions of their receptors with the endothelium, immune cells or circulating inflammatory molecules. From the literature it is clear that the role of platelets in severely ill COVID-19 patients has been markedly underestimated or even ignored. We here highlight the value of early management of severe COVID-19 coagulopathy as guided by TEG®, microclot and platelet mapping. We also argue that the failure of clinical trials, where the efficacy of prophylactic versus therapeutic clexane (low molecular weight heparin (LMWH)) were not always successful, which may be because the significant role of platelet activation was not taken into account during the planning of the trial. We conclude that, because of the overwhelming alteration of clotting, the outcome of any trial evaluating an any single anticoagulant, including thrombolytic, would be negative. Here we suggest the use of the degree of platelet dysfunction and presence of microclots in circulation, together with TEG®, might be used as a guideline for disease severity. A multi-pronged approach, guided by TEG® and platelet mapping, would be required to maintain normal clotting physiology in severe COVID-19 disease.
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Affiliation(s)
| | | | - Chantelle Venter
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch 7602, South Africa;
| | - Douglas B Kell
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch 7602, South Africa;
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
- Correspondence: (D.B.K.); (E.P.)
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch 7602, South Africa;
- Correspondence: (D.B.K.); (E.P.)
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