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Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic tests of whole blood that provide real-time analyses of coagulation. TEG and ROTEM are often used to guide blood product administration in the trauma and surgical settings. These tests are increasingly being explored for their use in other disease states encountered in critically ill patients and in the management of antithrombotic medications. As the medication experts, pharmacists should be familiar with how to interpret and apply viscoelastic tests to disease state and medication management. The purpose of this narrative review is to provide a primer for pharmacists on viscoelastic tests and their interpretation and to explore non-trauma indications for viscoelastic testing in critical care. Literature evaluating the use of TEG and ROTEM for patients with acute and chronic liver disease, ischemic and hemorrhagic stroke, myocardial infarction, cardiac arrest, coronavirus disease 2019, and extracorporeal membrane oxygenation are described. Current applications of viscoelastic tests by pharmacists and potential future roles of critical care pharmacists in expanding the use of viscoelastic tests are summarized.Copyright © 2023 The Authors. JACCP: Journal of the American College of Clinical Pharmacy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.
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Introduction: COVID-19 infection can be complicated by coagulation derangement and a high risk of thromboembolic episodes. Our study aimedto investigate coagulation parameters in COVID-19 patients and their correlation with clinical severity. Methods: We analyzed coagulation parameters PT, APTT, D-Dimer, and Fibrinogen in 98 RT-PCR-confirmed COVID-19 patients admitted to the Government Institute of Medical Sciences, Gautam Buddha Nagar, Uttar Pradesh, India. Results: This study involved 69 males (70.50%), and 29 (29.5%) were females. The mortality rate was 6.12% (n= 06). Forty-six patients (46.94%) had comorbidities. Thirty-four patients had elevated PT, and 7 had high APTT, whereas D-dimer and fibrinogen levels were raised in 68 and 61 patients, respectively. Among all four parameters, D-Dimer levels were significantly associated with disease severity. Conclusion: Derangement of D-dimer levels is significantly associated with disease severity in COVID-19 infection.
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BackgroundPatients with autoimmune rheumatic disease (AIRD) are at risk of severe COVID-19 infection and vaccine has been demonstrated to be able to reduce the severity of infection. Malaysia has a low flu vaccination coverage rate (approximately 3%) and hence it is important to assess the perception and hesitancy of COVID-19 vaccine especially among the vulnerable group.ObjectivesTo study the perception of COVID-19 vaccine and to determine the prevalence of vaccine hesitancy among AIRD patients in Malaysia.MethodsThis was a cross-sectional survey using online Google Forms® that was conducted among adult AIRD patients (18 years and older) from August 2021 until February 2022. Patients were recruited from the outpatient clinics as well as distribution of the survey through social medias. The survey was in English and Malay language. The survey collected data on the socio-demographic background, prior history of other vaccination after the age of 18 and COVID-19 vaccination with reasons of hesitancy, defined as being unsure or unwilling to be vaccinated. The survey also assessed the patients' perception by specifying the level of agreement to COVID-19 vaccine statements using the Likert response scale: 1-Strongly disagree;2- Disagree;3-Neither agree nor disagree;4-Agree;5-Strongly agree.ResultsA total of 162 patients participated in the survey and majority of them were females (87.7%). Our multi-racial cohort consisted of Malay (n=103, 63.5%), followed by Chinese (n=38, 23.5%), Sabahan Bumiputra (n=12, 7.4%) and Indian (n=7, 4.3%). More than half (n=107,66.6%) have not had any history of other vaccination after the age of 18. Only 16.7% (n=27) agreed/strongly agreed that COVID-19 vaccine can be given to patients with co-morbidities and 24.1 (n=39) agreed/strongly agreed that COVID-19 vaccine can be given to patients who have history of allergy to other drugs or food. At the time of the survey, vast majority of the respondents have received at least the 1st dose of Covid-19 vaccine (n=148, 91.4%). A total of 9 (5.6%) patients were hesitant to be vaccinated (6 were unsure and 3 patients were not willing to be vaccinated). The commonest reasons of being unsure or not willing to be vaccinated was worried of the vaccine's adverse effects (66.7%), worried of the blood clot complication (33,3%), worried of disease flare post-vaccine (33,3%), worried of allergic reaction (22.2%), lack of information on the safety of the vaccine in patients with AIRD from government and media (22.2%), face mask and social distancing measures were adequate (22.2%). Statistical analysis revealed that more patients who had vaccine hesitancy were from the lower socioeconomic status (income <1066 Euro/month), 88.9% vs 11.1%, p=0.03 but no association with ethnicity, education status, marital status or place of residence (urban vs rural).ConclusionCOVID-19 vaccine hesitancy is low in Malaysian patients with AIRD but patients with a low socioeconomic status are prone to have vaccine hesitancy. More education on the vaccine's efficacy and safety especially among patients with co-morbidities are warranted.Reference[1]Knowledge, acceptance and perception on COVID-19 vaccine among Malaysians: A web-based survey. Mohamed NA, Solehan HM, Mohd Rani MD, Ithnin M, Che Isahak CI (2021) Knowledge, acceptance and perception on COVID-19 vaccine among Malaysians: A web-based survey. PLOS ONE 16(8): e0256110.Acknowledgements:NIL.Disclosure of InterestsSyahrul Sazliyana Shaharir Speakers bureau: Pfizer,Novartis, Lydia Kamaruzaman: None declared, Theepa Nesam Mariamutu: None declared, Mohd Shahrir Mohamed Said: None declared, Azmawati Mohammed Nawi: None declared, Wan Syamimee Wan Ghazali: None declared, Malehah Mohd Noh: None declared.
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Background and Aim: Coronavirus disease 2019 (COVID-19) is a respiratory disorder that can affect many body systems, including the hemostatic system. In this study, we aim to investigate the role of hemostatic system and the blood coagulation in COVID-19. Methods & Materials In this review study, the articles were searched using the keywords COVID-19, Respiratory infection, and Coagulopathy in Google Scholar, PubMed, Google Springer and Science Direct databases. Ethical Considerations: Ethical principles in writing this article were observed in accordance with the guidelines of the National Ethics Committee and the Committee on Publication Ethics (COPE). Results Many changes in the coagulation profile of infected patients were reported, including changes in the platelet count, fibrinogen/fibrin degradation product, D-Dimer, fibrinogen, prothrombin time, and activated partial thromboplastin time. With the increase in the number of patients with COVID-19, several studies found out the occurrence of thrombosis and coagulopathy in patients. Conclusion: Due to the increase in the occurrence of coagulation disorders in patients with COVID-19, the administration of anticoagulants is needed for their treatment;it can play an effective role in improving the prognosis of patients.
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The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) caused a new coronavirus disease (COVID-19), which is highly contagious and its pathogenesis has not been fully elucidated. In COVID-19, the inflammation and blood coagulation systems are excessively activated. SARS-CoV-2 damages endothelial cells and pneumocytes, which leads to disruption of hemostasis in SARS. Thromboembolism is the main cause of mortality in patients with COVID-19. Clots, including pulmonary embolism (PE) and deep vein thrombosis (DVT), ranging from minor to fatal complications of the SARS-CoV-2 infection are known. Individuals with pre-existing diseases are more susceptible to the development of blood clots and poor outcomes. High levels of circulating cytokines and D-dimer (DD) are influential biomarkers of poor outcomes in COVID-19. The latter occurs as a result of hyperfibrinolysis and hypercoagulation. Plasmin is a key player in fibrinolysis and is involved in the cleavage of many viral envelope proteins, including SARS-CoV. Due to this function penetration of viruses into the host cell occurs. In addition, plasmin is involved in the pathophysiology of acute respiratory distress syndrome (ARDS) in SARS and promotes the secretion of cytokines, such as IL-6 and TNF, from activated macrophages. The focus of existing treatment to alleviate fibrinolysis in patients with COVID-19 is the use of systemic fibrinolytic therapy given thrombotic pathology in severe forms of COVID-19 which may lead to death. However, fibrinolytic therapy may be harmful in the advanced stages of COVID-19, when the status of disseminated intravascular coagulation (DIC) changes from suppressed fibrinolysis to its enhancement during the progression of the disease. This narrative review aims to elucidate the pathogenesis of COVID-19, which will further help in precise diagnosis and treatment. Take-home message: The COVID-19 virus disrupts haemostasis and thromboembolism by over activating the inflammation and blood coagulation systems. High levels of cytokines and D-dimer are indicators of pre-existing diseases and blood clots. Systemic fibrinolytic treatment can reduce severe fibrinolysis in COVID-19, which is caused by plasmin. In the late stages of DIC, when fibrinolysis increases, it may be dangerous. To improve therapy and results, understanding COVID-19 pathogenicity is critical. © 2023 by the authors.
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Although the main complication of coronavirus infection (COVID19) is severe lung infection and acute respiratory failure, it also affects other organs in the body, and non-respiratory infections can have significant side effects. One of these problems is a disorder of the blood coagulation system and thrombosis. Although the body's coagulation system and the formation of blood clots are essential for wound healing, ectopic thrombosis in the body's arteries and veins can lead to ischemia and dysfunction of the heart, lungs, and brain. Thrombosis and blood clots have recently emerged as one of the most important and serious complications of coronavirus infection. Knowledge of the signs and symptoms of thrombosis and their treatment plays an important role in the treatment of coronary artery infection and its complications. © 2023, Bulgarian Society for Microbiology (Union of Scientists in Bulgaria). All rights reserved.
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Introduction: According to scientific studies, a high incidence of thrombotic events is known in hospitalized patients with COVID-19. Less than 50% of pulmonary embolisms (PE) are associated with signs of deep vein thrombosis (DVT) of the lower extremities. Background: To identify significant risk factors for thrombosis thrombosis (DVT) in intensive care patients with COVID-19. Materials and methods: We conducted a prospective cross-sectional study that included 465 adult patients with laboratory-confirmed COVID-19 admitted to the intensive care unit. All patients underwent computer tomography of the chest organs, ultrasound angioscanning of lower extremities, body mass index was calculated, the presence of comorbotity diseases and indicators of volumetric blood saturation were considered. The level of D-dimer in blood plasma, coagulation parameters (fibrinogen, factor VIII) were taken from laboratory parameters in calculations. For subgroups with 5 or fewer people, the chi-square test and Fisher's exact test were used. For quantitative variables, analysis of variance (ANOVA) and the Pearson and Spearman correlation coefficient were used. For multiple variables, ordered logistic regression models were built, with likelihood ratio tests performed to compare the models. Results: A total of 465 patients were included in the study. Comorbidities were present in 435 of 465 patients (93.55%) had at least one comorbidity. The most common was arterial hypertension - 370 (79.57%), followed by chronic heart failure - 196 (42.15%), obesity - 161 (34.62%), diabetes mellitus - 144 (30.97%), chronic renal failure (CRF) -58 (12.47%) and oncological diseases -25 (5.38%). The average body mass index was 29.7 kg/m2. In patients with DVT and venostasis, the body mass index (BMI) was more than 30 kg/m2 than without DVT (32.57+or-10.92 kg/m2, and 30.24+or-6.85 kg/m2, versus 29.22+or-6.46 kg/m2, respectively). Ultrasound angioscanning (USAS) confirmed deep vein thrombosis in 60 patients (13.8%) and was associated with older age (71.12+or-13.98 versus 67.20+or-11.16, p < 0.006), venous stasis was detected in 56 patients (12%) no DVT was detected in the rest of the studied patients. In the majority of cases, DVT was detected in the tibial segment -26 (43.33%), in 18 (30%) patients it was diagnosed in the popliteal veins and in 14 (23.33%) cases in the femoral segment. Diabetes mellitus (p=0.041), obesity (p=0.01) and CRF (p=0.028) were also significant risk factors for DVT. Conclusions: Significant risk factors for deep vein thrombosis in intensive care patients with COVID-19 are high levels of D-dimer (>=2.33 g/ml) and comorbidities such as obesity, chronic kidney failure, and diabetes mellitus.
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Introduction: It has been shown that thrombocytopenia, like coagulation disorders, are common complications of COVID-19, increasing the risk of thrombosis and bleeding, producing in patients symptoms such as hematomas, petechiae, equimosis and bleeding from natural cavities, which are usually related to the severity of thrombocytopenia. For this reason, the present research aimed to establish the relationship between thrombocytopenia and the probability of mortality with the SOFA, APACHE II and NEWS-2 scoring systems in patients with COVID-19 admitted to the Ambato General Hospital during the period June 2021-November 2021. Materials and Methods : For the development of the research, there was a sample of 216 hospitalized patients who met the inclusion criteria, where 156 patients were in the clinical unit and 60 patients in the intensive care unit. Ifit was a descriptive, retrospective and crosssectional study, in which data from hospitalized patients were collected through the internal results reporting system DATALAB, and the AS-400 medical system for the review of patients' medical records, in addition to finding the relationship that existed between the study variables, the statistical program SPSS 25 was used. Results and Conclusions : The results indicate that, in terms of the risk factors of the patients, it was found that 64.81% were male, 54.6% over 50 years, 43.1% of hospitalized patients did not present or did not know their pathological history. When analyzing the analytical data of thrombocytopenia it was found that 14.8% of pacientis the presented during hospitalization, finally when analyzing the relationship between thrombocytopenia and the scoring systems SOFA, APACHE II and NEWS-2, Chi-square values of 1.329;3.327;2.406 respectively were obtained, indicating that no This is a correlation between the variables. It was concluded that there is no statistically significant relationship between thrombocytopenia and scoring systems. Further analyses with a larger population and that they have all theparameters necessary for the calculation of scoring systems are recommended. [ FROM AUTHOR] Copyright of Journal of Pharmaceutical Negative Results is the property of ResearchTrentz and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
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The article discusses the task of radiologic technologists to know clotting disorders and image them best. Topics covered include the various symptoms and blood clots of patients with thrombotic disorders, and medical imaging's beneficial indication of the severity and blood clots' location in the patient's circulatory system, and support for accurate diagnosis and appropriate treatment. Also noted is the boost for positive patient outcomes when the health care team works together.
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Studying the activity of coagulation hemostasis in the main groups of coronavirus infection helps to prevent life-threatening complications. In the clinical study, 350 patients were examined, including 100 patients with mild, 150 moderate and 100 severe coronavirus infections. Coagulation hemostasis indicators did not reliably change in patients with mild coronavirus infection, but hypercoagulation was detected in moderate and severe coronavirus infection: active partial thromboplastin time decreased by 26 - 40%, INR decreased to 0.79 +or- 0.05*, thrombin time 22, decreased by 3-45.2%, fibrinogen increased by 37.4 - 58.6%, D dimer increased by 69% and more.
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The COVID-19 pandemic poses a huge challenge to the global economy and healthcare. Coagulation dysfunction and thrombosis are the main clinical features of severe COVID-19 patients, and closely related to the risk of death. Several mechanisms of thrombosis in COVID-19 have been proposed, such as immune inflammation, hypoxia, imbalance of angiotensin system, endothelial injury etc, and other high-risk factors such as combined with basic diseases, bed rest braking and intravenous catheterization.In this review, we summarize the mechanisms that may increase the risk of thrombosis in patients with severe COVID-19, in order to improve people's understanding of coagulation abnormalities and thrombosis complications in patients with severe COVID-19, and further explore effective methods to prevent and treat COVID-19 related thrombosis.
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Introduction: Scrub typhus is tropical zoonotic disease, commonly presented with multi organ dysfunction and high mortality rate in untreated patients. This study was done to identify clinical features commonly associated with scrub typhus during COVID pandemics, parameters associated with severe scrub typhus and mortality. Methods: This retrospective study was done in a tertiary care hospital with a total of 52 admitted scrub typhus positive patients in October 2020 to February 2022. Diagnosis was established by scrub IgM ELISA or Rapid antigen test. The clinical and laboratory data, duration of hospital stay and outcomes were collected. Common clinical and laboratory findings were of descriptive analysis. Factors associated with mortality were analysed using Chi-square test. Results: Fever was the most common presenting symptoms on admission (94.2%) followed by respiratory abnormalities (38.46%). Acute kidney injury was the most common organ failure on admission (67.3%), followed by acute liver injury (46.2%) and thrombocytopenia (32.7%). MODS was seen in 46.15%. Of the total, 30.8% were admitted in ICU. Mortality was seen in 7.7% of all patients. On Chi-square analysis, altered mental status and coagulopathy were associated with significant mortality with p value <0.05. Conclusion: Scrub typhus can manifest with potentially life-threatening complications such as acute kidney injury, acute liver injury, thrombocytopenia and MODS. The overall case-fatality rate was 7.7%, and presence of altered mental status and coagulopathy were associated with higher mortality. As per literature, COVID has changed few clinical profiles of scrub typhus compared to same center experience before.
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Objectives: To reveal the importance of the laboratory routine determination of some hematological, coagulation and biochemical parameters in the prognosis of COVID-19. Materials and methods: The basic characteristic information such as age, gender, clinical symptoms and the clinical laboratory data of 300 COVID-19 patients that were admitted to the Respiratory Care Unit, Al-lmam Al-Hussein Medical City, Kerbala, Iraq were obtained from the patients' records. The patients were 146 males and 154 females, their ages were between 20 and 50 years (34.3±8.6). Results: According to their clinical status, patients were divided into moderate and severe groups. Among the 300 patients, 177 were considered as moderate cases and 123 were severe cases. Ferritin, D-Dimer, and C-reactive protein (CRP) levels were significantly higher in severe cases (P<0.05), as were lymphocytes and white blood cells (WBC) levels (P=0.0001). Hematocrit and hemoglobin were at almost the same levels in both groups (P>0.05). Platelet counts showed normal values in moderate and severe cases. In severe cases, lactate dehydrogenase (LDH) was significantly increased (P=0.0001). The receiver operating characteristic (ROC) curve exhibited that WBC, D-Dimer and LDH have fair values regarding the discriminative ability between the moderate and severe groups (AUC 0.788, 0.718 and 0.761, respectively, P-value of 0.0001). Conclusion: The laboratory routine determination is of a key importance in the prognosis and handling of the cases of COVID-19, especially those that could develop acute respiratory failure, so further deterioration can be avoided.
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Background: Best practice for prevention, diagnosis, and management of venous thromboembolism (VTE) in patients with coronavirus disease 2019 (COVID-19) is unknown due to limited published data in this population. Objectives: We aimed to assess current global practice and experience in management of COVID-19-associated coagulopathy to identify information to guide prospective and randomized studies. Methods: Physicians were queried about their current approach to prophylaxis, diagnosis, and treatment of VTE in patients with COVID-19 using an online survey tool distributed through multiple international organizations between April 10 and 14, 2020. Results: Five hundred fifteen physicians from 41 countries responded. The majority of respondents (78%) recommended prophylactic anticoagulation for all hospitalized patients with COVID-19, with most recommending use of low-molecular-weight heparin or unfractionated heparin. Significant practice variation was found regarding the need for dose escalation of anticoagulation outside the setting of confirmed or suspected VTE. Respondents reported the use of bedside testing when unable to perform standard diagnostic imaging for diagnosis of VTE. Two hundred ninety-one respondents reported observing thrombotic complications in their patients, with 64% noting that the complication was pulmonary embolism. Of the 44% of respondents who estimated incidence of thrombosis in patients with COVID-19 in their hospital, estimates ranged widely from 1% to 50%. One hundred seventy-four respondents noted bleeding complications (34% minor bleeding, 14% clinically relevant nonmajor bleeding, and 12% major bleeding). Conclusion: Well-designed epidemiologic studies are urgently needed to understand the incidence and risk factors of VTE and bleeding complications in patients with COVID-19. Randomized clinical trials addressing use of anticoagulation are also needed.
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Viscoelastic testing (VET), including thromboelastography and thromboelastometry, provides a rapid and comprehensive picture of whole blood coagulation dynamics and hemostasis that can be reviewed and evaluated at the point-of-care. This technology is over 50 years old; however, over the past few years, there has been a significant increase in research examining the use of VET. Best practice guidelines for the use of VET exist in both the United States and Europe, particularly for elective cardiac surgery, although recommendations for implementation are somewhat limited in some clinical areas by the lack of studies constituting high-grade evidence. Other challenges to implementation surround validation of the technology in some care settings as well as lack of training. Nevertheless, there is a wide range of potential clinical applications, such as treating coagulopathies in liver disease and transplant surgery, critical care, as well as within obstetrical hemorrhage. In this illustrated review, we provide an overview of viscoelastic testing technology (also called viscoelastic hemostatic assays) and describe how the assays can be used to provide a broad overview of hemostasis from clot formation to clot lysis, while highlighting the contribution of coagulation factors and platelets. We then summarize the major clinical applications for viscoelastic testing, including more recent applications, such as in COVID-19. Each section describes the clinical context, and key publications, followed by a representative algorithm and key guidelines.
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Therapeutic anticoagulation is indicated for a variety of circumstances and conditions in several fields of medicine to prevent or treat venous and arterial thromboembolism. According to the different mechanisms of action, the available parenteral and oral anticoagulant drugs share the common principle of hampering or blocking key steps of the coagulation cascade, which unavoidably comes at the price of an increased propensity to bleed. Hemorrhagic complications affect patient prognosis both directly and indirectly (ie, by preventing the adoption of an effective antithrombotic strategy). Inhibition of factor XI (FXI) has emerged as a strategy with the potential to uncouple the pharmacological effect and the adverse events of anticoagulant therapy. This observation is based on the differential contribution of FXI to thrombus amplification, in which it plays a major role, and hemostasis, in which it plays an ancillary role in final clot consolidation. Several agents were developed to inhibit FXI at different stages (ie, suppressing biosynthesis, preventing zymogen activation, or impeding the biological action of the active form), including antisense oligonucleotides, monoclonal antibodies, small synthetic molecules, natural peptides, and aptamers. Phase 2 studies of different classes of FXI inhibitors in orthopedic surgery suggested that dose-dependent reductions in thrombotic complications are not paralleled by dose-dependent increases in bleeding compared with low-molecular-weight heparin. Likewise, the FXI inhibitor asundexian was associated with lower rates of bleeding compared with the activated factor X inhibitor apixaban in patients with atrial fibrillation, although no evidence of a therapeutic effect on stroke prevention is available so far. FXI inhibition could also be appealing for patients with other conditions, including end-stage renal disease, noncardioembolic stroke, or acute myocardial infarction, for which other phase 2 studies have been conducted. The balance between thromboprophylaxis and bleeding achieved by FXI inhibitors needs confirmation in large-scale phase 3 clinical trials powered for clinical end points. Several of such trials are ongoing or planned to define the role of FXI inhibitors in clinical practice and to clarify which FXI inhibitor may be most suited for each clinical indication. This article reviews the rationale, pharmacology, results of medium or small phase 2 studies, and future perspectives of drugs inhibiting FXI.
Subject(s)
Stroke , Thrombosis , Venous Thromboembolism , Humans , Factor XI , Anticoagulants/adverse effects , Venous Thromboembolism/drug therapy , Blood Coagulation , Thrombosis/drug therapy , Thrombosis/prevention & control , Hemorrhage/etiology , Stroke/drug therapyABSTRACT
Paediatric multi-system inflammatory syndrome in the form of multi-system inflammatory syndrome in children (MIS-C) and neonatal multisystem inflammatory syndrome (MIS-N) are being reported all over the world. While MIS-C is seen few weeks after active severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection in the same child, MIS-N is proposed to be occurring in neonates after active SARS-CoV-2 infection in the mother in antenatal period and hyperimmune response to the transplacentally transferred maternal IgG antibodies specific to SARS-CoV-2. Most of the cases which develop MIS-N present with cardiac findings in the form of rhythm disturbances. In this article, we report data, clinical presentation and management of 15 preterm and growth-restricted term neonates who presented with bleeding in the first 2 days of life. The coagulopathy could not be explained by the common causes of bleeding in this population and was refractory to the general line of management. Laboratory results had signs of hyperimmune response (raised procalcitonin [PCT], C-reactive protein [CRP]) and remarkably deranged coagulation profile (very high d-dimer levels with normal platelet counts and normal-to-high fibrinogen values). Most of the mothers had history of symptomatic COVID-19 infection in the antenatal period, and although all (including neonates) were negative by real-time polymerase chain reaction for SARS-CoV-2, serological testing showed positivity for IgG fraction of antibodies specific to SARS-CoV-2, but negative for IgM antibodies. This observation was similar to the phenomenon of MIS-N; however in our study, the hyperinflammatory response primarily affected the coagulation system. Although COVID-19 coagulopathy has been described in adults, it has been reported in the presence of severe active SARS-CoV-2 infection, unlike a delay of several weeks seen in our study. Hence, the term 'Neonatal post-COVID-19 coagulopathy' as proposed in this article needs further research and validation.
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There is a trend towards increased perioperative bleeding in patients with plasma fibrinogen levels < 200 mg/dL-1. This study aimed to assess whether there is an association between preoperative fibrinogen levels and perioperative blood-product transfusion up to 48 h after major orthopedic surgery. This cohort study included 195 patients who underwent primary or revision hip arthroplasty for nontraumatic etiologies. Plasma fibrinogen, blood count, coagulation tests, and platelet count were measured preoperatively. A plasma fibrinogen level of 200 mg/dL-1 was the cutoff value used to predict blood transfusion. The mean (SD) plasma fibrinogen level was 325 (83) mg/dL-1. Only thirteen patients had levels < 200 mg/dL-1, and only one of them received a blood transfusion, with an absolute risk of 7.69% (1/13; 95%CI: 1.37-33.31%). Preoperative plasma fibrinogen levels were not associated with the need for blood transfusion (p = 0.745). The sensitivity and the positive predictive value of plasma fibrinogen < 200 mg/dL-1 as a predictor of blood transfusion were 4.17% (95%CI: 0.11-21.12%) and 7.69% (95%CI: 1.12-37.99%), respectively. Test accuracy was 82.05% (95%CI: 75.93-87.17%), but positive and negative likelihood ratios were poor. Therefore, preoperative plasma fibrinogen level in hip-arthroplasty patients was not associated with the need for blood-product transfusion.
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In addition to the respiratory compromise typical for COVID-19 many papers reported on the thromboembolic complications in these often critically ill patients. In this report, three cases of patients that developed spontaneous major bleeding following treatment with therapeutic anticoagulation for thromboembolic complications of COVID-19 were described. Two cases were treated with coil-embolization and one patient could be treated conservatively. These cases illustrate the presence of a relevant bleeding risk against the background of the well-known thromboembolic complications associated with COVID-19. The increased risks of thromboembolic complications in COVID-19 warrant adequate prophylactic anticoagulation. The optimal dose to obtain a significant risk reduction without a significant increase in the incidence of major bleeding requires further research.