key: cord-341420-bfzto2lz authors: Mohamed, Chekkal; Tahra, Deba; Soraya, Hadjali; Hassiba, Lamara; Hanifa, Oulaa; Karima, Zouai; Ghania, Hariti title: Prevention and treatment of COVID-19-associated hypercoagulability: recommendations of the Algerian society of transfusion and hemobiology date: 2020-10-03 journal: Transfus Clin Biol DOI: 10.1016/j.tracli.2020.09.004 sha: doc_id: 341420 cord_uid: bfzto2lz Since December 2019, an outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, has spread throughout the world. Coagulation dysfunction is one of the major causes of death in patients with severe COVID-19. Several recent observations in Algeria and elsewhere maintain that a pulmonary embolism is frequent in patients with COVID-19 with a high incidence in intensive care. In addition, other studies have shown that many deceased patients have diagnostic criteria for disseminated intravascular coagulation (DIC) set by the International Society of Hemostasis and Thrombosis (ISTH) The office of the Algerian Society of Transfusion and Hemobiology composed of hemostasis and blood transfusion experts from Algerian hospitals on the epidemic front line have established a consensus on the issue through 4 axes: Indication of thromboprophylaxis, monitoring of hemostasis, indications of transfusion in the event of Disseminated Intravascular Coagulation (DIC) and anticoagulant treatment after discharge China and has spread to the rest of the world [1] . The association between COVID-19 and hypercoagulability is now widely recognized. About 20% of infected patients have abnormal hemostasis results [2] . Also, these abnormalities are present in almost all patients in severe or critical conditions and represent for them one of the main causes of mortality [3] . Several recent observations in Algeria and elsewhere support that pulmonary embolism is common in patients with COVID-19 with a high incidence in intensive care. In a recent Dutch study, in 184 critically ill patients, the cumulative incidence of venous thromboembolism (VTE) was 27% with a majority of pulmonary embolism despite all patients where under prophylactic doses of low molecular weight heparin (LMWH) [4] . Thus, the stratification of the thrombotic risk by using clinical and biological criteria becomes essential to adapt the thromboprophylaxis to each case. Also, other studies have shown that many deceased patients had diagnostic criteria for disseminated intravascular coagulation (DIC) set by the International Society of Hemostasis and Thrombosis (ISTH) [5] . The summary of 3 recommendations is presented in table 1. All hospitalized patients with COVID-19 should receive LMWH thromboprophylaxis unless the risk of bleeding is greater such as in cases of thrombocytopenia with a blood platelet count less than 50 x 10 9 /L, thrombopathy, history of bleeding episodes, coagulation factor deficiency or a stroke in the last 3 months. In this situation mechanical thromboprophylaxis should be considered by intermittent pneumatic compression. In the event of obesity with added risk factors for thrombosis or with artificial ventilation and also in the event of catheter thrombosis, ECMO, D dimers level >3µg/mL, marked inflammatory syndrome (fibrinogen > 8g/L), therapeutic doses are recommended either of LMWH (e.g. Enoxaparin 100IU/Kg/12h SC without exceeding 10 000 IU/12h) or UFH 500IU/Kg/24h in case of ECMO or CrCl < 30ml/min. Also, in the event of oral anticoagulant treatment already initiated before infection, we recommend a relay with heparins at therapeutic doses. The figure 1 illustrates the decision algorithm for the indications of anticoagulants and dosage adjustment according to different clinical and laboratory criteria. The minimum admission assessment should relate to the following hemostasis parameters: the platelet count, the prothrombin time (PT), the activated partial time thromboplastin (aPTT), the fibrinogen and the D dimers. The assessment should be renewed regularly depending on the patient's clinical condition. In the event of elevation of D dimers at a level > 3µg/mL, therapeutic doses of LMWH or UFH should be instituted taking into account the risk of bleeding. In the event of a decrease in the level of platelets and fibrinogen, a DIC should be researched using the ISTH score of DIC based on the PT, the level of fibrinogen, the level of D dimers or fibrin degradation products (FDP) and the platelet count. After confirmation of DIC, anticoagulant treatment must be readjusted given the risk of bleeding. The summary of 2 recommendations is presented in table 2. The diagnosis of DIC is made using the ISTH DIC score. The decision to transfuse should not be guided by biological criteria alone but reserved for hemorrhagic syndromes or a situation at risk of bleeding. In adult patients with COVID-19-associated DIC presenting with bleeding or candidates for an invasive procedure, platelet transfusion should be performed (3 à 6 x 10 11 ) if the platelet count is < 50 x 10 9 /L, 15 to 25 ml/Kg of fresh frozen plasma (FFP) if the PT ratio is >1.5 and fibrinogen or cryoprecipitate if the fibrinogen level is < 1.5 g/l. It is recommended to continue anticoagulant treatment with LMWHs at prophylactic doses or with direct oral anticoagulants for up to 45 days in patients with added risk factors for thrombosis: e.g. prolonged immobilization, age > 70 years, history of VTE, co morbidity (cancers+++), D dimers > 2 times the normal rate (threshold adjusted according to age [9] ). The thrombotic manifestations are particularly feared complications in patients with COVID-19. The use of anticoagulants and transfusion therapy must take into account the haemostatic balance between the risk of bleeding and the risk of thrombosis. Close collaboration between hemobiologists and clinicians should allow effective prevention of thrombotic risk in these patients. A novel coronavirus from patients with pneumonia in China Prevention and treatement of venous thromboembolism associated with coronavirus disease 2019 infection : A consensus statement before guidelines Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease Incidence of thrombotic complications in critically ill ICU patients with COVID-19 Abnormal Coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia COVID-19 and VTE/Anticoagulation COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up Traitement anticoagulant pour la prévention du risque thrombotique chez un patient hospitalisé avec covid-19 et surveillance de l'hémostase propositions du GIHP ET DU GFHT Groupe Français d'études sur l'Hémostase et la Thrombose Disponible sur The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded