Rotational thromboelastometry results are associated with care level in COVID-19

  1. Lou M. Almskog
  2. Agneta Wikman
  3. Jonas Svensson
  4. Michael Wanecek
  5. Matteo Bottai
  6. Jan van der Linden
  7. Anna Ågren

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Abstract

High prevalence of thrombotic events in severely ill COVID-19 patients have been reported. Pulmonary embolism as well as microembolization of vital organs may in these individuals be direct causes of death. The identification of patients at high risk of developing thrombosis may lead to targeted, more effective prophylactic treatment. The primary aim of this study was to test whether rotational thromboelastometry (ROTEM) at admission indicates hypercoagulopathy and predicts the disease severity, assessed as care level, in COVID-19 patients. The study was designed as a prospective, observational study where COVID-19 patients over 18 years admitted to hospital were eligible for inclusion. Patients were divided into two groups depending on care level: (1) regular wards or (2) wards with specialized ventilation support. Conventional coagulation tests, blood type and ROTEM were taken at admission. 60 patients were included; age 61 (median), 67% men, many with comorbidities (e.g. hypertension, diabetes). The ROTEM variables Maximum Clot Firmness (EXTEM-/FIBTEM-MCF) were higher in COVID-19 patients compared with in healthy controls (p < 0.001) and higher in severely ill patients compared with in patients at regular wards (p < 0.05). Our results suggest that hypercoagulopathy is present early in patients with mild to moderate disease, and more pronounced in severe COVID-19 pneumonia. Non-O blood types were not overrepresented in COVID-19 positive patients. ROTEM variables showed hypercoagulopathy at admission and this pattern was more pronounced in patients with increased disease severity. If this feature is to be used to predict the risk of thromboembolic complications further studies are warranted.

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  1. Version published to 10.1007/s11239-020-02312-3
  2. Version published to 10.1101/2020.06.11.20128710v2 on medRxiv
  3. ScreenIT

    SciScore for 10.1101/2020.06.11.20128710: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    BlindingROTEM test results were blinded for clinicians, but CCTs were not.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    However, both these tests have caveats: the D-dimer blood test is nonspecific and may be increased in a variety of conditions including malignancy, inflammation and infection 13; fibrinogen is an acute phase reactant, and high levels of P-fibrinogen may reflect a patient with a high inflammatory profile, which itself may amplify the effects of other cardiovascular risk factors 14. Furthermore, conventional coagulation tests (CCTs) are limited by their inability to assess clot strength, fibrinogen functionality and fibrinolysis 15. Conversely, ROTEM provides a more rapid and comprehensive assessment of whole blood clot formation allowing for a complete view of the entire coagulation cascade, and has been shown a better tool for monitoring coagulation profiles than CCTs 16,17. As can be seen in Figure 2, FIBTEM-MCF and P-fibrinogen are highly correlated in COVID-19 patients, whereas EXTEM-MCF supplies information that differs from D-dimer at an early disease stage. If individuals at risk of developing COVID-19 related thromboses are identified at an early stage, enhanced prophylaxis with LMWH may decrease mortality in this group of patients 6,18. It is feasible that ROTEM could be applied for this purpose. Whether the ROTEM data will have better predictive characteristics compared with CCTs do, however, remain to be shown. Sepsis is known to exert a complex effect on the coagulation system, generally affecting all aspects of clot formation, kinetic activity and clot development...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  4. Version published to 10.1101/2020.06.11.20128710v1 on medRxiv