Comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with COVID 1
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REVIEW
Open Access
Comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with COVID 19: implications for clinical practice and future investigations Adam Flaczyk1, Rachel P. Rosovsky2*, Clay T. Reed3, Brittany K. Bankhead-Kendall4, Edward A. Bittner1 and Marvin G. Chang5*
Abstract Critically ill patients with COVID-19 are at increased risk for thrombotic complications which has led to an intense debate surrounding their anticoagulation management. In the absence of data from randomized controlled clinical trials, a number of consensus guidelines and recommendations have been published to facilitate clinical decisionmaking on this issue. However, substantive differences exist between these guidelines which can be difficult for clinicians. This review briefly summarizes the major societal guidelines and compares their similarities and differences. A common theme in all of the recommendations is to take an individualized approach to patient management and a call for prospective randomized clinical trials to address important anticoagulation issues in this population. Keywords: COVID-19, Coronavirus, Thrombosis, Anticoagulation, Venous thromboembolism, Hematologic monitoring, Therapeutic anticoagulation
Introduction COVID-19-associated coagulopathy [1] is well established in COVID-19 patients and is marked by a state of profound inflammation with endothelial dysfunction, abnormal flow dynamics, platelet activation, and hypercoagulability resulting in higher rates of thrombotic complications such as deep venous thrombosis (DVT), pulmonary embolism (PE), and microvasculature thrombosis [2–5]. Given the evidence that COVID-19 patients * Correspondence: [email protected]; [email protected] 2 Division of Hematology and Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA 5 Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA Full list of author information is available at the end of the article
are at increased risk for thrombotic complications, a number of consensus guidelines and recommendations are now available to facilitate clinical decision-making. However, these guidelines are limited by their lack of data from randomized controlled clinical trials. This review provides an overview of major societal guidelines and recommendations that focus on prevention, monitoring, and treatment of COVID-19-associated coagulopathy (CAC). In addition, the similarities and differences between the guidelines are highlighted, and their implications for practice are explored. Lastly, proposed topics for future consideration and study are offered.
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a
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