COVID-19 Hypercoaguable State
What has now become routine for us to observe in the Intensive Care Unit with our COVID-19 patients, namely an elevated d-dimer, normal or high fibrinogen level, and elevated CRP, has gotten the attention of critical care doctors world wide with their concern for potential increased thrombotic risk.
A new study in the Journal Intensive Care Medicine confirms this suspicion by documenting an increase in thrombotic events:
https://link.springer.com/article/10.1007/s00134-020-06062-x
It is interesting to note that the COVID-19 hypercoaguable state appears to be distinct from the normal hypercoaguable state we see in classic DIC, in which we find moderate to severe thrombocytopenia (platelet count <50 x10 9 /L), prolongation of the PT and aPTT, extreme elevation of D-dimer, and decreased fibrinogen (< 1.0 g/L). Note that in COVID-19 patients the fibrinogen level is commonly normal or perhaps more likely elevated, while the PT and aPTT and PLT counts are also normal, and hemolysis from microangiopathy, again common in bacterial sepsis or trauma, is not routinely seen.
For more information on this topic please see:
https://www.hematology.org/covid-19/covid-19-and-coagulopathy
The next question is then what to do about this in terms of prophylaxis? Currently what is seen is that routine venous thromboembolism prophylaxis may be inadequate:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302085/pdf/ccm-publish-ahead-of-print-
10.1097.ccm.0000000000004466.pdf
This said, though some recommend full dose anticoagulation in this population based upon these observations, particularly if the d-dimer level is 3 times greater than normal, we await clinical trial outcomes of this intervention.
