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.
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Tags: Coagulopathy, COVID-19, hematology