Is Blood Viscosity Greater in Patients with Severe COVID-19?
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)
COVID-19 pneumonia, critically ill and admitted to the ICU
Capillary viscometry which tests for plasma viscosity
15 patients included
Intubation for ARDS: 14 patients
Shock requiring vasopressors: 12 patients
Renal failure (on renal replacement therapy): 11 patients
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 results significantly elevated
Median fibrinogen: 708 mg/dL (range 459 to 1188) | Normal reference range 200 to 393
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
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