ABSTRACT
INTRODUCTION: COVID-19 coagulopathy is described most frequently as a hypercoagualable state, often leading to empiric anti-coagulant therapy. However, COVID-19 can present with either thrombotic and/or hemorrhagic complications secondary to a platelet function diathesis or factor dysfunction. We hypothesized that thromboelastography with platelet mapping (TEG-PM) would more accurately characterize an individual's COVID-19 coagulopathic state and that TEG-guided medical therapy would reduce complications and improve outcomes. METHODS: Prospective, longitudinal chart reviews of 65 COVID-19 patients with TEG-PM data were performed at an 800-bed tertiary care hospital. Clinician-initiated TEG-PM was drawn on admission and q48-72 hrs whenever possible. Patients were divided into 2 groups depending on whether their coagulopathy ultimately resolved: 1) resolved/non-coagulopathic state (NC-TEG) or 2) persistent coagulopathic condition, either hyper- or hypo-coagulable (C-TEG). Outcomes included thrombotic/hemorrhagic complications, pulmonary failure, acute kidney injury (AKI) and non-survival. Standard therapy was provided independently by attending clinicians, including the option of using pre-existing TEG-guided treatment algorithms. RESULTS: D-dimer, CRP and ferritin, while significantly elevated in the sickest patients, could not differentiate coagulopathic from non-coagulopathic patients. Platelet hyperactivity (MA-AA/ADP >50min), with or without thrombocytosis, was associated with thrombotic/ischemic complications. Hemorrhagic complications (cerebrovascular, hemoptysis) were observed with elevated R (>8min) and decreased factor activity. C-TEG patients had nearly a 40-fold increased risk for mechanical ventilation (p=0.0002), 2.7 for AKI (p=0.0027), 33.7 dialysis (p=0.0152) and 13.3-fold increased risk of death (p<0.0001) with 12/16 (75%) C-TEG patients dying compared to 1 (2%) NC-TEG patient (<0.0001). TEG-PM guided anti-platelet treatment decreased mortality 73% (p=0.0108). In contrast, indiscriminate anti-coagulation (antifactor therapy: heparin/enoxaparin) resulted in 3.6-fold increased risk of death (p=0.0218). CONCLUSIONS: Proper characterization of coagulopathic patients with TEG-PM and TEG-tailored therapy (guided by algorithm) may decrease complications and improve outcomes for COVID-19 patients.