Integral Use of Thromboelastography With Platelet Mapping to Guide Appropriate Treatment, Avoid Complications, and Improve Survival of Patients With Coronavirus Disease 2019-Related Coagulopathy

• Published in: Critical care explorations 2020-12, Vol.2 (12), p.e0287-e0287
• Main Authors: Hranjec, Tjasa, Estreicher, Michael, Rogers, Bradley, Kohler, Lisa, Solomon, Rachele, Hennessy, Sara, Cibulas, Megan, Hurst, Deborah, Hegazy, Mohamed, Lee, Jieun, Perez, Donny, Doctor, Norman, Kiffin, Chauniqua, Pigneri, Danielle, LaGuardia, Heather, Shaw, Kathryn, Arenas, Juan, Rosenthal, Andrew, Katz, Randy S, Sawyer, Robert G, Pepe, Paul E
• Format: Article
• Language: English
• Subjects: Observational Study
• ISSN: 2639-8028; 2639-8028
• DOI: 10.1097/CCE.0000000000000287

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. Coronavirus disease 2019 patients ( = 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. Standard-of-care therapy with or without algorithm-guided-thromboelastography support. 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; < 0.0001), acute kidney injury (relative risk = 2.3; = 0.0017), dialysis (relative risk = 7.8; < 0.0001), and death (relative risk = 7.7; < 0.0001), with 17 of 28 non-algorithm-guided patients (60