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#Grand Rounds

Is Blood Viscosity Greater in Patients with Severe COVID-19?

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PURPOSE:

  • Coagulation disorders and thrombosis are recognized COVID-19 complications, particularly for patients with severe disease
  • Maier et al. (Lancet, 2020) found evidence for multiple anticoagulation failures at their institution among patients with severe COVID-19
  • Therefore, the authors sought to identify other mechanisms to explain ‘refractory hypercoagulability’ (i.e. when prophylactic/ therapeutic dosing of medications such as heparin do not prevent significant VTE)

METHODS:

  • Case series
  • Participants
    • COVID-19 pneumonia, critically ill and admitted to the ICU
  • Testing
    • Capillary viscometry which tests for plasma viscosity

RESULTS:

  • 15 patients included
    • Intubation for ARDS: 14 patients
    • Shock requiring vasopressors: 12 patients
    • Renal failure (on renal replacement therapy): 11 patients

Anticoagulation

  • D-dimer ≥3 μg/mL
    • Clinical concern for thrombotic event: 5 patients received therapeutic anticoagulation | 2 patients received IV heparin and 3 patients received direct thrombin inhibitor (argatroban or bivalirudin)
    • No clinical concern for thrombotic event: 6 patients received intermediate dosing (subtherapeutic) of LMWH or IV heparin
  • D-dimer <3 μg/mL: 4 patients received low dose thromboprophylaxis with LMWH or subcutaneous heparin

Viscosity Testing Results

  • All patients had plasma viscosity measurements >95% normal
    • 1.9 to 4.2 centipoise | Normal range 1.4 to 1.8
  • 4 patients >3.5 centipoise had thrombotic events
    • PE | limb ischemia and PE | Renal treatment related clotting (2 patients)
  • Centipoise levels were highly correlated with disease severity (p<0.001)

Fibrinogen Levels

  • Fibrinogen results significantly elevated
    • Median fibrinogen: 708 mg/dL (range 459 to 1188) | Normal reference range 200 to 393

CONCLUSION:

  • Hyperviscous plasma can damage endothelium and lead to thrombosis
  • Patients with severe COVID-19 had significantly increased plasma viscosity compared to normal range
    • Plasma viscosity was highly correlated with disease severity
  • Cellular components associated with inflammation (e.g. fibrinogen or immunoglobulin) can lead to increased viscosity
  • The authors conclude that

Our novel observation might provide an important link between inflammation and coagulopathy in critically ill patients with COVID-19

We are actively exploring any beneficial role of therapeutic plasma exchange, a highly effective treatment for symptomatic hyperviscosity in other conditions such as hypergammaglobulinaemia, in the clinical management of these patients

Learn More – Primary Sources:

COVID-19-associated hyperviscosity: a link between inflammation and thrombophilia?

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Related ObG Topics:

ARDS, Critical Care and COVID-19: ‘Surviving Sepsis Campaign’ Guidelines and Key Points
NIH COVID-19 Treatment Guidelines
COVID-19 and Coagulopathy: ISTH Issues Guidance on Diagnosis and Management
COVID-19 and Coagulopathy

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