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COVID-19 and Coagulopathy – Two Management Guidance Documents For Health Care Professionals

Dr. Stephan Moll writes (last updated: March 27th, 2020)…

Background and Questions: Infection with COVID-19 can lead to a coagulopathy. Are any of the coagulation markers helpful to predict good or bad outcome? Which coagulation tests should be obtained in hospitalized patients? Should the coagulopathy be treated and, if yes, how?

Two separate documents were published on March 25th, 2020, providing guidance to health care professionals about coagulation testing and management of coagulopathy and bleeding, summarized below. Both are solid common sense recommendations based on typical clinical practice from the non-COVID-19 era and some current observations on COVID-19 infected patients. The only differences between two documents’ recommendations are two relatively minor ones:

  1. Non-bleeding patient with coagulopathy: The ISTH document [ref 1] recommends that in non-bleeding patients the platelet count is to be kept above 20 x 109/L and fibrinogen above 2.0 g/L, whereas the HRM document [ref 2] recommends that abnormal coagulation test results do not require correction in patients who are not bleeding.
  2. Patient with (major) bleeding: The ISTH document [ref 1] recommends that in bleeding patients fibrinogen is to be kept above 2.0 g/L, whereas the HRM document [ref 2] recommends that it be kept above 1.5 g/dL.

A. ISTH Document

The International Society on Thrombosis and Haemostasis (ISTH) published a guidance document on March 25, 2020, to address the above mentioned questions and issues and provide a “simple and easily follow-able algorithm for the management of COVID-19 coagulopathy” – click here for ISTH algorithm [ref 1]. The key statements and guidance:

  • Caveat: The authors appropriately acknowledge that this is an interim guidance and that this statement will be modified with developing knowledge.
  • D-dimer: Data indicate that markedly elevated D-dimers are a predictor of mortality. The ISTH group suggests that patients with markedly elevated D-dimer level (which may be arbitrarily defined as 3-4-fold increase) should be considered for hospital admission even in the absence of other disease severity symptoms.
  • Low platelets: Data suggest that thrombocytopenia may also be a prognosticator for mortality, but this has not been a consistent finding.
  • Routine coagulation tests: Monitoring of the PT, D-dimer, platelet count and fibrinogen can be helpful in determining prognosis in COVID-19 patients requiring hospital admission.
  • VTE prophylaxis: All patients (including non-critically ill) who require hospital admission for COVID-19 infection should receive prophylactic dose low molecular weight heparin (LMWH), unless they have contra-indications (active bleeding and platelet count < 25 x 109/L), to (a) inhibit thrombin generation which may (!) have benefit in reducing mortality, and (b) protect from venous thromboembolism.
  • Management of bleeding: Bleeding is rare in the setting of COVID-19 infection. If bleeding occurs, general ISTH guidance with respect to transfusions may be followed (see figure, right lower corner).
  • Experimental therapy: Other treatments – antithrombin concentrate, recombinant thrombomodulin, hydroxychloroquine) – can only be considered to be experimental at the moment.

B. Hunt-Retter-McClintock (HRM) Document

Another comprehensive guidance document was also published on March 25, 2020 [ref 2; link here to full document]. The key recommendations:

  1. VTE prophylaxis: Venous thromboembolism (VTE) prophylaxis should be given to all high-risk patients.
  2. Considering PE: Consider the possibility of PE in patients with sudden onset of oxygenation deterioration, respiratory distress, reduced blood pressure.
  3. Use LMWH rather than oral anticoagulants: Consider switching patients who take a direct oral anticoagulant (DOAC) or vitamin K antagonist (e.g. warfarin) to low molecular weight heparin (LMWH).
  4. Coagulopathy, but no bleeding: Abnormal coagulation results (coagulopathy) in patients who are not bleeding does NOT require correction with transfusions.
  5. Major bleeding: For patients with major bleeding give empirical fresh frozen plasma (FFP) and red cells, followed by blood products determined by repeat coagulation testing:
    • If INR > 1.5 or aPTT ratio > 1.5, give FFP
    • If fibrinogen < 1.5 g/L, give cryoprecipitate or fibrinogen concentrate
    • If platelets < 50 x 109/L, give platelets.
    • If patient does NOT have DIC, also give tranexamic acid.
    • Do not use recombinant factor VIIa.
  6. If DIC is present and patient has major bleeding: Same management as under #5 above, but NO tranexamic acid.

References

  1. Thachil J et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. published: 25 March 25, 2020 (link here).
  2. Hunt B et al. Practical guidance for the prevention of thrombosis and management of coagulopathy and disseminated intravascular coagulation of patients infected with COVID-19. March 25, 2020. Published on thrombosisuk.org.

Disclosures: None

Stephan Moll