Fibrinolysis Shutdown and Thrombosis in a COVID-19 ICU

Abstract

The coronavirus disease (COVID-19) pandemic has threatened millions of lives worldwide with severe systemic inflammation, organ dysfunction, and thromboembolic disease. Within our institution, many critically ill COVID-19-positive patients suffered major thrombotic events, prompting our clinicians to evaluate hypercoagulability outside of traditional coagulation testing.We determined the prevalence of fibrinolysis shutdown via rotational thromboelastometry (ROTEM, Instrumentation Laboratories, Bedford, Mass) in patients admitted to the intensive care unit over a period of 3 weeks. In 25 patients who had a ROTEM test, we found that 11 (44%) met criteria for fibrinolysis shutdown. Eight of 9 (73%) of the VTE patients met criteria for fibrinolysis shutdown.Given the high rate of fibrinolysis shutdown in these patients, our data support using viscoelastic testing to evaluate for the presence of impaired fibrinolysis. This may help identify patient subsets who might benefit from the administration of fibrinolytics.

Fig. 1.

Comparison of ICU patient MLs in those diagnosed with and without thrombotic events. ICU indicates intensive care unit; ML, maximum lysis.

Fig. 2.. ROTEM EXTEM tracings in ICU patients with and without fibrinolysis shutdown.

The above are examples of ROTEM EXTEM tracings. ML is calculated by taking the difference between MCF and the lowest amplitude following MCF and then dividing this by MCF. The orange arrows demonstrate the two points used for this ML calculation and the resultant ML (orange circle). A, It demonstrates an EXTEM from a patient with an ML of 7% (no evidence of Fibrinolysis Shutdown). B, It demonstrates an EXTEM from a patient with an ML of 1% (diagnostic of fibrinolysis shutdown) ML indicates maximum lysis; ROTEM, rotational thromboelastometry; MCF, maximum clot firmness.