Overcoming bleeding events related to extracorporeal membrane oxygenation in COVID-19

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024: significance of guidelines developed for each underlying disease

Disseminated intravascular coagulation (DIC) is a severe condition characterized by systemic, persistent activation of coagulation in the presence of an underlying disease, leading to the formation of microthrombi in small blood vessels. In DIC, fibrinolysis is also activated alongside coagulation, but the extent of fibrinolysis varies significantly depending on the underlying condition. The classification of DIC types is crucial not only for understanding the pathophysiology involved, but also for selecting appropriate treatment strategies. Internationally, DIC is often associated with sepsis, typically presenting with ischemic organ damage. However, it is important to recognize that some forms of DIC exhibit minimal ischemic organ damage but severe bleeding symptoms. When diagnosing and treating DIC, considering the underlying condition and disease type can lead to better clinical outcomes. This underscores the need for DIC management guidelines that are based on an understanding of the underlying disease. The newly released "Clinical Practice Guidelines for Management of Disseminated Intravascular Coagulation in Japan 2024" offer the first comprehensive guidelines for detailed management based on specific underlying conditions, providing a groundbreaking contribution to the global DIC clinical community.

Coagulation Abnormalities and Clinical Complications in Children With SARS-CoV-2: A Systematic Review of 48,322 Patients

Given the limited information on the coagulation abnormalities of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in pediatric patients, we designed a systematic review to evaluate this topic. A comprehensive literature search was conducted for "SARS-CoV-2," "coagulopathy," and "pediatrics." Two authors independently screened the articles that the search returned for bleeding, thrombosis, anticoagulant and/or antiplatelet usage, and abnormal laboratory markers in pediatric patients with SARS-CoV-2, and the authors then extracted the relevant data. One hundred twenty-six publications were included. Thirty-four (27%) studies reported thrombotic complications in 504 patients. Thirty-one (25%) studies reported bleeding complications in 410 patients. Ninety-eight (78%) studies reported abnormal laboratory values in 6580 patients. Finally, 56 (44%) studies reported anticoagulant and/or antiplatelet usage in 3124 patients. The variety of laboratory abnormalities and coagulation complications associated with SARS-CoV-2 presented in this review highlights the complexity and variability of the disease presentation in infants and children.

Coagulopathy and Fibrinolytic Pathophysiology in COVID-19 and SARS-CoV-2 Vaccination

Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is frequently complicated by thrombosis. In some cases of severe COVID-19, fibrinolysis may be markedly enhanced within a few days, resulting in fatal bleeding. In the treatment of COVID-19, attention should be paid to both coagulation activation and fibrinolytic activation. Various thromboses are known to occur after vaccination with SARS-CoV-2 vaccines. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can occur after adenovirus-vectored vaccination, and is characterized by the detection of anti-platelet factor 4 antibodies by enzyme-linked immunosorbent assay and thrombosis in unusual locations such as cerebral venous sinuses and visceral veins. Treatment comprises high-dose immunoglobulin, argatroban, and fondaparinux. Some VITT cases show marked decreases in fibrinogen and platelets and marked increases in D-dimer, suggesting the presence of enhanced-fibrinolytic-type disseminated intravascular coagulation with a high risk of bleeding. In the treatment of VITT, evaluation of both coagulation activation and fibrinolytic activation is important, adjusting treatments accordingly to improve outcomes.

Spontaneous tension hemothorax in a severe COVID-19 patient receiving ECMO therapy: The other side of COVID-19-associated coagulopathy

As opposed to widely recognized Coronavirus Disease 2019 (COVID-19)-associated thrombotic events, the unusual but serious bleeding complications in COVID-19 patients are worth-mentioned. Here, we describe a 44-year-old man afflicted by COVID-19 pneumonia with acute respiratory distress syndrome (ARDS) and submassive pulmonary embolism. The patient's condition initially improved with the prescription of ECMO, tocilizumab, and hemoadsorption, however, he later developed spontaneous tension hemothorax, which is considered rare but devastating in the setting of COVID-19. While the exact pathogenesis of COVID-19-associated bleeding events remains poorly understood, we aim to highlight the other aspect of coagulation dysfunction potentially caused by COVID-19.

Delayed retroperitoneal hemorrhage during extracorporeal membrane oxygenation in COVID-19 patients: A case report and literature review

BACKGROUND

Retroperitoneal hemorrhage (RPH) is a rare and severe complication in patients undergoing extracorporeal membrane oxygenation (ECMO). Clinical diagnosis is difficult.

CASE SUMMARY

Three cases of RPH patients with corona virus disease-19 (COVID-19) were included in this study. All three suffered from respiratory failure, were treated with veno-venous or veno-arterial-venous ECMO, and experienced RPH during ECMO treatment. Two of the COVID-19 cases were diagnosed after the patients experienced abdominal pain. The other patient exhibited decreases in the ECMO circuit flow rate and hemoglobin level. Two cases were treated by transcatheter arterial embolization, and one was treated conservatively. The hemorrhage in each of the three cases did not deteriorate. Satisfactory treatment results were achieved for the three patients because of prompt diagnosis and treatment.

CONCLUSION

Although the incidence of RPH during ECMO treatment is low, the risk is increased by anticoagulant use and local mechanical injury. If declines in blood flow velocity and hemoglobin are detected, RPH should be considered, and prompt aggressive therapy should be started.

Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome

Hemostatic changes induced by extracorporeal membrane oxygenation (ECMO) support have been yet poorly documented in coronavirus-19 (COVID-19) patients who have a baseline complex hypercoagulable state. In this prospective monocentric study of patients with severe acute respiratory distress syndrome (ARDS) rescued by ECMO, we performed longitudinal measurements of coagulation and fibrinolysis markers throughout the course of ECMO support in 20 COVID-19 and 10 non-COVID-19 patients. Blood was sampled before and then 24 hours, 7, and 14 days after ECMO implantation. Clinical outcomes were prospectively assessed until discharge from the intensive care unit or death. The median age of participants was 47 (35-56) years, with a median body mass index of 30 (27-35) kg/m², and a Sepsis-related Organ Failure Assessment score of 12 (8-16). Baseline levels of von Willebrand factor, fibrinogen, factor VIII, prothrombin F1 + 2, thrombin-antithrombin, D-dimer, and plasminogen activator inhibitor-1 (PAI-1) were elevated in both COVID-19 and non-COVID-19 ARDS patients, indicating that endothelial activation, endogenous thrombin generation, and fibrinolysis shutdown occur in all ARDS patients before ECMO implantation. From baseline to day 7, thrombin generation (prothrombin F1 + 2, p < 0.01) and fibrin formation markers (fibrin monomers, p < 0.001) significantly increased, further resulting in significant decreases in platelet count (p < 0.0001) and fibrinogen level (p < 0.001). PAI-1 levels significantly decreased from baseline to day 7 (p < 0.0001) in all ARDS patients. These changes were more marked in COVID-19 patients, resulting in 14 nonfatal and 3 fatal bleeding. Additional studies are warranted to determine whether monitoring of thrombin generation and fibrinolysis markers might help to early predict bleeding complications in COVID-19 patients supported by ECMO.