1. Prevention of thrombotic risk in hospitalized patients with COVID-19 and hemostasis monitoring
- Author
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Susen, Sophie, Tacquard, Charles Ambroise, Godon, Alexandre, Mansour, Alexandre, Garrigue, Delphine, Nguyen, Philippe, Godier, Anne, Testa, Sophie, Levy, Jerrold H, Albaladejo, Pierre, Gruel, Yves, GIHP and GFHT, Mullier, François, Département d'Hématologie [CHRU Lille], Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Service d'Anesthésie-Réanimation [Strasbourg], Nouvel Hôpital Civil [Strasbourg], CHU Strasbourg-CHU Strasbourg, Pôle anesthésie-réanimation (Grenoble), CHU Grenoble-Hôpital Michallon, Service d'Anesthésie Réanimation [Rennes], CHU Pontchaillou [Rennes], Service d'Hématologie [CHRU Lille], Hôpital Claude Huriez [Lille], CHU Lille-CHU Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Laboratoire d'Hématologie [CHU Reims], Centre Hospitalier Universitaire de Reims (CHU Reims), Hémostase et Remodelage Vasculaire Post-Ischémie (HERVI - EA 3801), Université de Reims Champagne-Ardenne (URCA), Service de Pneumologie et Soins Intensifs [CHU HEGHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Istituti Ospitalieri di Cremona, Duke University [Durham], Service d'hématologie [Tours], Centre Hospitalier Régional Universitaire de Tours (CHRU Tours)-Hôpital Bretonneau, UCL - SSS/IREC/MONT - Pôle Mont Godinne, UCL - (MGD) Laboratoire de biologie clinique, and Hôpital Bretonneau-Centre Hospitalier Régional Universitaire de Tours (CHRU Tours)
- Subjects
Risk ,medicine.medical_specialty ,ARDS ,medicine.drug_class ,medicine.medical_treatment ,Pneumonia, Viral ,Low molecular weight heparin ,030204 cardiovascular system & hematology ,Critical Care and Intensive Care Medicine ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,law ,[SDV.MHEP.MI]Life Sciences [q-bio]/Human health and pathology/Infectious diseases ,Internal medicine ,medicine ,Extracorporeal membrane oxygenation ,Humans ,030212 general & internal medicine ,Obesity ,Pandemics ,ComputingMilieux_MISCELLANEOUS ,Monitoring, Physiologic ,2. Zero hunger ,Hemostasis ,Coagulation ,business.industry ,Heparin ,Anticoagulant ,lcsh:Medical emergencies. Critical care. Intensive care. First aid ,COVID-19 ,Thrombosis ,[SDV.MHEP.HEM]Life Sciences [q-bio]/Human health and pathology/Hematology ,lcsh:RC86-88.9 ,medicine.disease ,Intensive care unit ,3. Good health ,Pulmonary embolism ,Hospitalization ,Cardiology ,business ,Coronavirus Infections - Abstract
COVID-19 is an infection induced by the SARS-CoV-2 coronavirus, and severe forms can lead to acute respiratory distress syndrome (ARDS) requiring intensive care unit (ICU) management. Severe forms are associated with coagulation changes, mainly characterized by an increase in D-dimer and fibrinogen levels, with a higher risk of thrombosis, particularly pulmonary embolism. The impact of obesity in severe COVID-19 has also been highlighted.In this context, standard doses of low molecular weight heparin (LMWH) may be inadequate in ICU patients, with obesity, major inflammation, and hypercoagulability. We therefore urgently developed proposals on the prevention of thromboembolism and monitoring of hemostasis in hospitalized patients with COVID-19.Four levels of thromboembolic risk were defined according to the severity of COVID-19 reflected by oxygen requirement and treatment, the body mass index, and other risk factors. Monitoring of hemostasis (including fibrinogen and D-dimer levels) every 48 h is proposed. Standard doses of LMWH (e.g., enoxaparin 4000 IU/24 h SC) are proposed in case of intermediate thrombotic risk (BMI 2, no other risk factors and no ARDS). In all obese patients (high thrombotic risk), adjusted prophylaxis with intermediate doses of LMWH (e.g., enoxaparin 4000 IU/12 h SC or 6000 IU/12 h SC if weight > 120 kg), or unfractionated heparin (UFH) if renal insufficiency (200 IU/kg/24 h, IV), is proposed. The thrombotic risk was defined as very high in obese patients with ARDS and added risk factors for thromboembolism, and also in case of extracorporeal membrane oxygenation (ECMO), unexplained catheter thrombosis, dialysis filter thrombosis, or marked inflammatory syndrome and/or hypercoagulability (e.g., fibrinogen > 8 g/l and/or D-dimers > 3 μg/ml). In ICU patients, it is sometimes difficult to confirm a diagnosis of thrombosis, and curative anticoagulant treatment may also be discussed on a probabilistic basis. In all these situations, therapeutic doses of LMWH, or UFH in case of renal insufficiency with monitoring of anti-Xa activity, are proposed.In conclusion, intensification of heparin treatment should be considered in the context of COVID-19 on the basis of clinical and biological criteria of severity, especially in severely ill ventilated patients, for whom the diagnosis of pulmonary embolism cannot be easily confirmed.
- Published
- 2020