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Quick reference for evaluation and management of COVID-19-associated hypercoagulability

Evaluations and monitoring
Inpatients	Initial PT, aPTT, fibrinogen, D-dimer; frequency of monitoring depends on acuity and trend in values Diagnostic imaging studies if feasible for clinically suspected DVT or PE; consult PERT team Alternative evaluations if standard imaging studies are not feasible
Outpatients	Routine coagulation testing is not required
Management
Abnormal coagulation studies	Use for prognostic information and level of care Do not intervene solely based on coagulation abnormalities
VTE prophylaxis	Individualized risk-benefit assessment to determine dosing; prophylactic dosing preferred for ICU patients; therapeutic dosing preferred for non-ICU inpatients Dose adjustments may be made for increased body weight or decreased kidney function LMW heparin is generally preferred over other anticoagulants Thromboprophylaxis is generally not continued following discharge, with rare exceptions Thromboprophylaxis is generally not used in outpatients, with rare exceptions
VTE treatment	Therapeutic (full-dose) anticoagulation for documented VTE or high suspicion for VTE Initiate in hospital per standard protocols Continue for at least 3 months Unfractionated heparin preferred for unstable patients with organ dysfunction LMW heparin or a DOAC (apixaban or rivaroxaban) can be used for stable patients without organ dysfunction Reserve fibrinolytic agents (eg, tPA) for limb-threatening DVT, massive PE, acute stroke, or acute MI; consult PERT or stroke team
Clotting in vascular catheters or extracorporeal circuits*	Therapeutic (full-dose) anticoagulation Standard protocols for continuous renal replacement therapy or ECMO
Bleeding	Similar to individuals without COVID-19 Transfusions for anemia or thrombocytopenia using appropriate transfusion thresholds Anticoagulant reversal and/or discontinuation for anticoagulant-associated bleeding Specific treatments (eg, factor replacement) for underlying bleeding disorders Avoid antifibrinolytic agents in individuals with acute decompensated DIC^¶

Refer to UpToDate for discussions of COVID-19 management. Resources are also available from the International Society on Thrombosis and Haemostasis (https://onlinelibrary.wiley.com/doi/10.1111/jth.14853), the American Society of Hematology (https://www.hematology.org/covid-19/covid-19-and-coagulopathy), and the American College of Cardiology (https://www.acc.org/latest-in-cardiology/articles/2020/04/17/14/42/thrombosis-and-coronavirus-disease-2019-covid-19-faqs-for-current-practice).

COVID-19: coronavirus disease 2019; PT: prothrombin time; aPTT: activated partial thromboplastin time; DVT: deep vein thrombosis; PE: pulmonary embolism; PERT: pulmonary embolism response team; VTE: venous thromboembolism; ICU: intensive care unit; tPA: tissue plasminogen activator; MI: myocardial infarction; ECMO: extracorporeal membrane oxygenation; DIC: disseminated intravascular coagulation.

* Includes continuous renal replacement therapy (hemodialysis), ECMO, or other extracorporeal circuits.

¶ Acute decompensated DIC is associated with clinical bleeding and/or thrombosis and laboratory findings including prolonged PT and aPTT, thrombocytopenia, and hypofibrinogenemia. Antifibrinolytic agents (tranexamic acid and epsilon aminocaproic acid) are avoided because they may tip the balance towards thrombosis. Refer to UpToDate for details.

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