Fibrinolysis Shutdown Correlates to Thromboembolic Events in Severe COVID-19 Infection

Wright, Franklin L.; Vogler, Thomas O.; Moore, Ernest E.; Moore, Hunter B.; Wohlauer, Max V.; Urban, Shane; Nydam, Trevor L.; Moore, Peter K.; McIntyre, Robert C.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes patients to a prothrombotic state with demonstrated microvascular involvement. The degree of hypercoagulability appears to correlate with outcomes, however optimal criteria to assess for the highest risk patients for thrombotic events remain unclear; we hypothesized that deranged thromboelastography (TEG) measurements of coagulation would correlate with thromboembolic events. METHODS: Patients admitted to an intensive care unit with COVID-19 diagnoses that had TEG analyses performed were studied. Conventional coagulation assays, D-dimer levels, and viscoelastic parameters were analyzed using a receiver operating characteristic curve to predict thromboembolic outcomes and new onset renal failure. RESULTS: Forty-four patients with COVID-19 were included in the analysis. Derangements in coagulation laboratory values including elevated D-Dimer, fibrinogen, PT, and PTT were confirmed; viscoelastic parameters showed an elevated maximum amplitude and low lysis at 30 minutes. A complete lack of lysis of clot at 30 minutes was seen in 57% of patients and predicted VTE with an AUROC of .742 (p=0.021). A D-Dimer cutoff of 2600 ng/ml predicted need for dialysis with an AUROC of .779 (p=0.005). Overall, patients with no lysis of clot at 30 minutes and a D-Dimer of greater than 2600 ng/ml had a rate of VTE of 50% compared to 0% for patients with neither risk factor (p=0.008) and had a hemodialysis rate of 80% compared to 14% (p=0.004). CONCLUSIONS: Fibrinolysis shutdown, as evidenced by elevated D-Dimer and complete failure of clot lysis at 30 minutes on thromboelastography, predicts thromboembolic events and need for hemodialysis in critically ill patients with COVID-19. Further clinical trials are required to ascertain the need for early therapeutic anticoagulation or fibrinolytic therapy to address this state of fibrinolysis shutdown.