TEG Max Clot Strength is Consistently Elevated and May Be Predictive of COVID-19 Status at the Time of ICU Admission

  1. Shaun Lawicki
  2. Katherine Wang
  3. Bing Han
  4. Gordon Love

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Abstract

Background

Hypercoagulability is becoming widely recognized as a major complication of COVID-19 infection as evidenced by high levels of fibrinogen degradation products and microthrombi identified within the lungs and kidneys of autopsy specimens from these patients. We report thromboelastography (TEG) testing on a cohort of patients with suspected COVID-19 infection at the time of admission to the intensive care unit.

Methods

TEG testing was performed using the TEG 6s analyzer near or at the time of ICU admission. We also report the results of other coagulation or inflammatory related indices such as platelet count, prothrombin time, fibrinogen, D-dimer, C-reactive protein, ferritin, and procalcitonin. All laboratory testing was performed at the discretion of the attending physician in the course of normal patient care and retrospectively reviewed.

Results

We found that maximum clot strength was consistently elevated in COVID-19 patients while normal in all patients found to be negative. We did not encounter significant prolongations of coagulation assays outside of those expectedly prolonged by heparin therapy nor was meeting the criteria for disseminated intravascular coagulation encountered.

Conclusions

We postulate that elevated maximum clot strength by TEG testing is predictive of COVID-19 status as within our cohort this perfectly predicted patients’ COVID-19 status despite a high level of suspicion in negative patients with normal TEG results. While these results require a larger cohort for confirmation, we feel that TEG testing could improve confidence in COVID-19 testing results in suspected patients possibly allowing for earlier de-escalation of infectious precautions and personal protective equipment utilization.

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  1. ScreenIT

    SciScore for 10.1101/2020.04.30.20076703: (What is this?)

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

    Table 1: Rigor

    Institutional Review Board StatementIRB: This study received an institutional review board (IRB) exemption from the Louisiana State University Health Science Center New Orleans IRB and approval from the Research Review Committee of UMCNO.
    Randomizationnot detected.
    Blindingnot detected.
    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:
    Although our results could prove useful for limiting unnecessary retesting and possibly earlier de-escalation of infectious precautions with subsequent saving on precious personal protective equipment, we recognize that our findings have several limitations. First, our sample size is small especially our group of COVID-19 negative patients making it difficult to predict how consistent elevated maximum clot strength may be predictive in a larger cohort or at a different time in patients’ hospital courses since all our patients were admitted to the ICU at the time of TEG testing. It is noteworthy that one of our COVID-19 positive patients did receive TEG testing at the time of original presentation over a week before ICU admission when symptoms were still mild-moderate, and this was normal. Second, we have not been able to perform more esoteric coagulation studies in these patients, so we are unable to do anything other than speculate on the underlying mechanism of these elevated maximum clot strengths. Since both functional fibrinogen and rapid TEG maximum clot strengths are elevated it is unknown if these abnormalities are due to increased platelet function/activation, elevated fibrinogen production, increased thrombin generation (locally in the lung or systemically), or a combination of all three. It has also been reported that the TEG functional fibrinogen assay does not eliminate the platelet contribution to maximum clot strength completely.6 Finally, TEG results where ava...

    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.
    • Thank you for including a protocol registration statement.

    About SciScore

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  2. Version published to 10.1101/2020.04.30.20076703v1 on medRxiv