Thromboelastography to Detect Hypercoagulability and Reduced Fibrinolysis in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Patients

Abstract

Objectives: Microvascular thrombosis contributes to acute respiratory distress syndrome pathophysiology and has been demonstrated in coronavirus disease 2019-associated acute respiratory distress syndrome. Clinical laboratory measurements of coagulation and disseminated intravascular coagulation, such as coagulation factor function, platelet count, and fibrinogen, may not fully reflect the extent of microvascular thrombosis present in these patients. We investigated thromboelastography in patients with coronavirus disease 2019-associated acute respiratory distress syndrome with the objective of characterizing suspected coagulopathy and impaired fibrinolysis.

Design: Retrospective observational cohort study.

Setting: Single-center academic medical center.

Patients: Ten patients with polymerase chain reaction-confirmed coronavirus disease 2019 disease complicated by acute respiratory distress syndrome.

Interventions: Measurement of thromboelastography (n = 10) and thrombolysis with alteplase (n = 4).

Measurements and main results: Hypercoagulability and decreased or absent fibrinolysis were demonstrated by thromboelastography. Thrombocytopenia and hypofibrinogenemia were not observed, while seven of 10 patients had elevated d-dimer values. For patients who received thrombolytic therapy, repeat thromboelastography demonstrated improvements in coagulation index and lysis at 30 minutes reflecting reduced hypercoagulability and increased fibrinolysis. One major bleeding complication was detected following thrombolysis. Eight of 10 patients survived and were successfully extubated, and six of 10 have since been discharged.

Conclusions: In coronavirus disease 2019 patients with acute respiratory distress syndrome in whom thromboelastography was performed, hypercoagulability and impaired fibrinolysis were observed. In the context of autopsy studies demonstrating pulmonary microvascular thromboses in coronavirus disease 2019 patients, noninvasive detection of hypercoagulability and deficient fibrinolysis in coronavirus disease 2019 acute respiratory distress syndrome using thromboelastography could improve understanding and management of coronavirus disease 2019.

Keywords: acute respiratory distress syndrome; coagulation; coronavirus disease 2019; microvascular thrombosis; thrombolysis.

Figure 1.

Thromboelastography tracings from representative patients. A, Patient A: Bottom precedes thrombolytic treatment with top performed after alteplase. B, Patient B: Progression from bottom to top demonstrating worsening fibrinolysis in the clinical context of bradycardia, ventricular tachycardia, and asystole. ANGLE = alpha angle (slope between R and K, measure of clot strengthening), CK = citrated kaolin, CKH = citrated kaolin with heparinase, K = kinetics, LY30 = lysis at 30 minutes, MA = maximum amplitude, R = reaction time.