COVID-19 Infection-Related Coagulopathy and Viscoelastic Methods: A Paradigm for Their Clinical Utility in Critical Illness

Argirios E. Tsantes 1,*, Andreas G. Tsantes 1 , Styliani I. Kokoris 1 , Stefanos Bonovas 2,3 , Frantzeska Frantzeskaki 4 , Iraklis Tsangaris 4 and Petros Kopterides 5

1 Laboratory of Hematology and Blood Bank Unit, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens

2 Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini

3 Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy

4 Second Department of Critical Care, “Attikon” University Hospital, Medical School, National and Kapodistrian University of Athens,

5 Intensive Care Unit, Excela Health Westmoreland Hospital, Greensburg,

Abstract: Hypercoagulability and thrombosis remain a challenge to diagnose and treat in severe COVID-19 infection. The ability of conventional global coagulation tests to accurately reflect in vivo hypo- or hypercoagulability is questioned. The currently available evidence suggests that markedly increased D-dimers can be used in identifying COVID-19 patients who may need intensive care unit (ICU) admission and close monitoring or not. Viscoelastic methods (VMs), like thromboelastography (TEG) and rotational thromboelastometry (ROTEM), estimate the dynamics of blood coagulation. The evaluation of coagulopathy by VMs in severe COVID-19 infection seems an increasingly attractive option. Available evidence supports that COVID-19 patients with acute respiratory failure suffer from severe hypercoagulability rather than consumptive coagulopathy often associated with fibrinolysis shutdown. However, the variability in definitions of both the procoagulant profile and the clinical outcome assessment, in parallel with the small sample sizes in most of these studies, do not allow the establishment of a clear association between the hypercoagulable state and thrombotic events. VMs can effectively provide insight into the pathophysiology of coagulopathy, detecting the presence of hypercoagulability in critically ill COVID-19 patients. However, it remains unknown whether the degree of coagulopathy can be used in order to predict the outcome, establish a diagnosis or guide anticoagulant therapy.