Slide 1: What is COVID19-associated coagulopathy (CAC)? A disorder of clotting cascade that typically presents like disseminated intravascular coagulation (DIC)? [Chart of clotting factors in DIC versus CAC]

Slide 2: Why is CAC/DIC important to recognize? CAC/DIC exists along a spectrum, and as clinical course worsens, patients may present with over DIC. Progression of CAC represents a harbinger of poor prognosis and helps predict who will benefit most from anticoagulation. [Chart of DIC grading criteria]

Slide 3: What are some important management points for CAC? Risk of abnormal coags: Low bleeding risk despite abnormal PT/aPTTT. Check CBC, PT/aPTT, fibrinogen, and D-Dimer on admission. Trend if abnormal. May predict improvement or decline. Prophylaxis. All hospitalized patients with COVID19 (floor or ICU) require pharmacologic VTE prophylaxis unless contraindicated. Bleeding. If bleeding and coagulopathy present, reversal may be warranted. Prefer PCC plus or minus cryoprecipitate instead of multiple units of FFP. Hypervolemia may worsen ARDS physiology

Slide 4: Recommendations for VTE chemoprophylaxis for admitted patients with COVID19. Normal chemoprophylactic dosing. All patients should receive VTE chemoprophylaxis (LMWH or Fondaparinux favored over heparin). Do not hold abnormal PT/aPTT unless bleeding present. When to hold chemoprophylaxis. Platelets less that 25k cells/ul. Fibrinogen less than 0.5 g/L. When to infuse blood products to correct coagulopathy. In bleeding patients when platelets less than 50k cells/ul. INR greater than 1.8. Fibrinogen less than 1.5 g/l. In non-bleeding patients when platelets are greater than 25k cells/ul. What about full does anticoagulation? Consider for mechanically ventilated or critically ill patients.

References

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  • Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-847. PMID 32073213.
  • Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020;18(5):1023-1026. PMID 32338827.
  • Griffiths MJD, McAuley DF, Perkins GD, et al. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res. 2019;6(1):e000420. Published 2019 May 24. PMID 31258917.
  • National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564-2575. PMID 16714767.
  • Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(23):2950-2973. PMID 32311448.
  • Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018;2(22):3198-3225. PMID 30482763.
  • Paranjpe I, Fuster V, Lala A, et al. Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19 [published online ahead of print, 2020 May 5]. J Am Coll Cardiol. 2020;S0735-1097(20)35218-9. PMID 32387623.
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