More severe hypercoagulable state in acute COVID-19 pneumonia as compared to other pneumonia.

OBJECTIVE: To conduct a comprehensive evaluation of coagulation profiles - via traditional and whole blood thromboelastometry tests - in COVID-19 positive vs. COVID-19 negative patients admitted to medical wards for acute pneumonia. PATIENTS AND METHODS: We enrolled all consecutive patients admitted to Internal Medicine wards of Padova University Hospital between 7 March and 30 April 2020 for COVID-19-related pneumonia (cases) vs. non-COVID-19 pneumonia (controls). A group of healthy subjects acted as baseline for thromboelastometry parameters. RESULTS: Fifty-six cases (mean age 64±15 yrs, M/F 37/19) and 56 controls (mean age 76±11 yrs, M/F 35/21) were enrolled. Cases and controls showed markedly hypercoagulable thromboelastometry profiles vs. healthy subjects, mainly characterized by a significantly shorter propagation phase of coagulation (Clot Formation Time, CFT) and significantly increased maximum clot firmness (MCF) (p <0.001 in all comparisons). COVID-19 patients with pneumonia had significantly shorter CFT and higher MCF (p <0.01 and <0.05, respectively in all comparisons) vs. controls. CONCLUSION: Patients admitted to internal medicine wards for COVID-19 pneumonia presented a markedly prothrombotic state, which seems peculiar to COVID-19 rather than pneumonia itself.

More Severe Hypercoagulable State in Acute COVID-19 Pneumonia as Compared With Other Pneumonia.

OBJECTIVE: To conduct a comprehensive evaluation of coagulation profiles-via traditional and whole blood thromboelastometry tests-in coronavirus disease 2019 (COVID-19)-positive vs COVID-19-negative patients admitted to medical wards for acute pneumonia. PATIENTS AND METHODS: We enrolled all consecutive patients admitted to internal medicine wards of Padova University Hospital between 7 March and 30 April, 2020, for COVID-19-related pneumonia (cases) vs non-COVID-19 pneumonia (controls). A group of healthy individuals acted as baseline for thromboelastometry parameters. RESULTS: Fifty-six cases (mean age, 64±15 years; male/female, 37/19) and 56 controls (mean age, 76±11 years; male/female, 35/21) were enrolled. Cases and controls exhibited markedly hypercoagulable thromboelastometry profiles vs healthy individuals, mainly characterized by a significantly shorter propagation phase of coagulation (clot formation time) and significantly increased maximum clot firmness (P<.001 for all comparisons). Patients with COVID-19 pneumonia had significantly shorter clot formation time and higher maximum clot firmness (P<.01 and P<.05, respectively, for all comparisons) than did controls. CONCLUSION: Patients admitted to internal medicine wards for COVID-19 pneumonia presented a markedly prothrombotic state, which seems peculiar to COVID-19 rather than pneumonia itself.

Clinico-epidemiology and management of Russell's viper (Daboia russelii) envenoming in dogs in Sri Lanka.

INTRODUCTION: Russell's viper envenoming in dogs is a significant problem in Sri Lanka. The current study focused on investigating clinical profile, laboratory findings of three selected tests and to develop a treatment strategy with Indian polyvalent Anti-Venom Serum (AVS). It was also intended to report adverse effects and complications caused by both Russell's viper venom (RVV) and AVS in Russell's Viper (RV) envenomed dogs. OBJECTIVE: To evaluate and report the clinical manifestations, to find out the minimum effective vials of AVS and to record AVS induced adverse reactions of RV envenoming in dogs. MATERIALS AND METHODS: A prospective study was conducted on Russell's viper bitten dogs (n = 65) admitted to the Veterinary Teaching Hospital (VTH) in Sri Lanka. Indian polyvalent AVS was used to treat all the envenomed dogs. The number of vials of AVS that was administered to a patient was decided upon by a second degree polynomial model with a number of vials of AVS in the X axis verses Prothrombine Time (PT), Activated Partial Thromboplastine Time (aPTT) and Clotting Time (CT) in the Y axis respectively. RESULTS: Varying degrees of pain were exhibited by all the victim dogs. Mild swelling and necrosis at the site of bite was seen in 54% (n = 35) and 37% (n = 24) of dogs respectively. Prolonged values of, PT, aPTT and CT were seen from all the RV envenomed dogs. The mean leukocyte count in these dogs was 39.79 × 103/µL (normal range; 4-20 × 103/µL) (IQR:29.05 × 103/µL-45.92 × 103/µL). Statistical analysis showed that the initial vials of 7 AVS would be the minimum required vials. Therefore, a range of 6-15 AVS vials in total were administered to these dogs and in 7.6% (n = 5) of dogs, the results of PT, aPTT and CT became normal with 6 AVS vials at 32-97 minutes. Acute Renal Failure (ARF) was detected from 29% (n = 19) of dogs as a complication. CONCLUSIONS: Systemic clinical signs of haemorrhagic lesions, cardio respiratory toxicities were common in Russell's viper envenomed dogs. Initially 6 vials of AVS must be administered. AVS induced reactions were reported commonly. Russell's viper envenoming was found to be lethal in dogs.

Thromboelastography for Assessing the Risk of Bleeding in Patients With Cirrhosis-Moving Closer.

BACKGROUND AND AIMS: Conventional coagulation tests (CCTs) in patients with cirrhosis only assess procoagulant factors and are poor predictors of bleeding risk. In spite of this knowledge, they are routinely used prior to invasive procedures, and attempts are made to correct these abnormalities before invasive procedures. These practices are not supported by the evidence and are harmful to the patients. METHODS: This prospective study included 150 patients of cirrhosis undergoing invasive procedures. CCTs [bleeding time (BT), clotting time (CT), international normalized ratio (INR), activated partial thromboplastin time (aPTT) and platelet count], thromboplastin generation time (TGT) and thromboelastography (TEG) were done in all patients, and they were observed for post procedural bleeding. None of the patients received prophylactic transfusion before the procedure. RESULTS: BT, CT and TGT were normal in all 150 patients. One of 150 patients developed clinically significant post procedural bleeding. No statistically significant association was seen among INR, aPTT, platelet count and Child class with bleeding. TEG values (R time and MA value) were normal in 61% and 75% patients respectively in spite of abnormal CCTs in most of them. Comparison of abnormal TEG values (R time and MA value) with INR and platelet count, respectively, in patients with no bleeding showed a statistically significant lower percentage of abnormal values of R time and MA value compared to INR and platelet count. CONCLUSION: Abnormal CCTs in patients of cirrhosis do not predict bleeding risk. TEG may be useful in patients undergoing invasive procedures to assess bleeding risk and prevents erroneous prophylactic transfusions.

Assessing Coagulation by Rotational Thromboelastometry (ROTEM) in Rivaroxaban-Anticoagulated Blood Using Hemostatic Agents.

Introduction The use of direct oral anticoagulants (DOACs) such as rivaroxaban (Xarelto) is increasingly common. However, therapies for reversing anticoagulation in the event of hemorrhage are limited. This study investigates the ability of hemostatic agents to improve the coagulation of rivaroxaban-anticoagulated blood, as measured by rotational thromboelastometry (ROTEM). Hypothesis/Problem If a chitosan-based hemostatic agent (Celox), which works independently of the clotting cascade, is applied to rivaroxaban-anticoagulated blood, it should improve coagulation by decreasing clotting time (CT), decreasing clot formation time (CFT), and increasing maximum clot firmness (MCF). If a kaolin-based hemostatic agent (QuikClot Combat Gauze), which works primarily by augmenting the clotting cascade upstream of factor Xa (FXa), is applied to rivaroxaban-anticoagulated blood, it will not be effective at improving coagulation. METHODS: Patients (age >18 years; non-pregnant) on rivaroxaban, presenting to the emergency department (ED) at two large, university-based medical centers, were recruited. Subjects (n=8) had blood drawn and analyzed using ROTEM with and without the presence of a kaolin-based and a chitosan-based hemostatic agent. The percentage of patients whose ROTEM parameters responded to the hemostatic agent and percent changes in coagulation parameters were calculated. RESULTS: Data points analyzed included: CT, CFT, and MCF. Of the samples treated with a kaolin-based hemostatic agent, seven (87.5%) showed reductions in CT, eight (100.0%) showed reductions in CFT, and six (75.0%) showed increases in MCF. The average percent change in CT, CFT, and MCF for all patients was 32.5% (Standard Deviation [SD]: 286; Range:-75.3 to 740.7%); -66.0% (SD:14.4; Range: -91.4 to -44.1%); and 4.70% (SD: 6.10; Range: -4.8 to 15.1%), respectively. The corresponding median percent changes were -68.1%, -64.0%, and 5.2%. Of samples treated with a chitosan-based agent, six (75.0%) showed reductions in CT, three (37.5%) showed reductions in CFT, and five (62.5%) showed increases in MCF. The average percent changes for CT, CFT, and MCF for all patients were 165.0% (SD: 629; Range:-96.9 to 1718.5%); 139.0% (SD: 174; Range: -83.3 to 348.0%); and -8.38% (SD: 32.7; Range:-88.7 to 10.4%), respectively. The corresponding median percent changes were -53.7%, 141.8%, and 3.0%. CONCLUSIONS: Rotational thromboelastometry detects changes in coagulation parameters caused by hemostatics applied to rivaroxaban-anticoagulated blood. These changes trended in the direction towards improved coagulability, suggesting that kaolin-based and chitosan-based hemostatics may be effective at improving coagulation in these patients. Bar J , David A , Khader T , Mulcare M , Tedeschi C . Assessing coagulation by rotational thromboelastometry (ROTEM) in rivaroxaban-anticoagulated blood using hemostatic agents. Prehosp Disaster Med. 2017;32(5):580-587.