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Semin Thromb Hemost 2022; 48(07): 850-857
DOI: 10.1055/s-0042-1756304
Review Article

Low-Molecular-Weight Heparin Resistance and Its Viscoelastic Assessment in Critically Ill COVID-19 Patients

Johannes Bösch
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Christopher Rugg
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Volker Schäfer
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Philipp Lichtenberger
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Nikolai Staier
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Benjamin Treichl
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Sasa Rajsic
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Andreas Peer
2   Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria
,
Wolfgang Schobersberger
3   Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT – Private University for Health Sciences and Health Technology, Hall i.T., Austria
,
Dietmar Fries
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
,
Mirjam Bachler
1   Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
3   Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT – Private University for Health Sciences and Health Technology, Hall i.T., Austria
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Abstract

Critically ill COVID-19 patients present an inflammatory and procoagulant status with a high rate of relevant macro- and microvascular thrombosis. Furthermore, high rates of heparin resistance have been described; yet, individualized anticoagulation by drug monitoring has not been sufficiently researched. We analyzed data from critically ill COVID-19 patients treated at Innsbruck Medical University Hospital with routinely adapted low-molecular-weight heparin (LMWH) doses according to anti-Xa peak levels, and regularly performed ClotPro analyses (a viscoelastic hemostatic whole blood test). A total of 509 anti-Xa peak measurements in 91 patients were categorized as below (<0.008 IU/mL/mg), within (0.008–0–012 IU/mL/mg) or above (> 0.012 IU/mL/mg) expected ranges with respect to the administered LMWH doses. Besides intergroup comparisons, correlations between anti-Xa levels and ClotPro clotting times (CTs) were performed (226 time points in 84 patients). Anti-Xa peak levels remained below the expected range in the majority of performed measurements (63.7%). Corresponding patients presented with higher C-reactive protein and D-dimer but lower antithrombin levels when compared with patients achieving or exceeding the expected range. Consequently, higher enoxaparin doses were applied in the sub-expected anti-Xa range group. Importantly, 47 (51.6%) patients switched between groups during their intensive care unit (ICU) stay. Anti-Xa levels correlated weakly with IN test CT and moderately with Russell's viper venom (RVV) test CT. Critically ill COVID-19 patients present with a high rate of LMWH resistance but with a variable LMWH response during their ICU stay. Therefore, LMWH–anti-Xa monitoring seems inevitable to achieve adequate target ranges. Furthermore, we propose the use of ClotPro's RVV test to assess the coagulation status during LMWH administration, as it correlates well with anti-Xa levels but more holistically reflects the coagulation cascade than anti-Xa activity alone.

Keywords

COVID-19 - critically ill - heparin resistance - anti-Xa - viscoelastic test


Publication History

Article published online:
29 September 2022

© 2022. Thieme. All rights reserved.

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