Scott Gottlieb retweeted this conversation on Twitter regarding blood clots. Posting as an FYI for the Docs and to get the opinions of those treating patients with COvID19.

I might include nephrology in that group as well, a lot of these folks are requiring CRRT and advanced avid/base management.

Appreciate the responses.

I'm Heme/Onc and I don't THINK what she thinks is true. I have not seen a COVID pt but I see clots ALL the time. That's what Heme does.

Not dissecting the original tweet but find the suggestion of hypercoagulability interesting. Have seen a patient that required TPA for presumed PE. Dvt was verified.

Yes the irony. Today lost one to a huge PE. Covid pos. Probably something to this. But I don't think it's the main mechanism of these patients dying.

I've been thinking about this a lot lately. It would explain the profound hypoxia without the presence of ARDS at least in some patients initially with good lung compliance. I've also seen some theories regarding it creating a functional hemoglobinopathy affecting oxygen delivery. Not sure how we could increase oxygen delivery, however. Have you all been getting TEGs on these patients?

https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173

PikesPeakAg said:

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Not dissecting the original tweet but find the suggestion of hypercoagulability interesting. Have seen a patient that required TPA for presumed PE. Dvt was verified.

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watch, now everyone with a cough will get a CTA

When it comes to coronavirus, I've wondered about my dad who's Factor V Leiden has always led to secondary complications when he's had health issues, would come into play.

jac4 said:

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Pelayo said:

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PikesPeakAg said:

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Not dissecting the original tweet but find the suggestion of hypercoagulability interesting. Have seen a patient that required TPA for presumed PE. Dvt was verified.

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watch, now everyone with a cough will get a CTA

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As a radiologist, I wondered if that ever stopped.

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Ha!

We have observed an awful lot of thrombotic complications in patients with COVID19 who are critically ill in our ICUs: clotted central lines and dialysis catheters, clotted dialysis filters, DVTs/PTEs, strokes. We've also observed a high rate of acute renal failure in normotensive patients and a few cases of sudden, unexplained cardiomyopathy which have led us to speculate about microthrombi. Not able to put it all together yet but participating in a 2-hour teleconference about this tomorrow morning with experts in thromboembolic disease from around the country.

Infection_Ag11 said:

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I agree with everything except "most" deaths being due to clots. We are finding more DVTs in these patients than would normally be expected, and anything with this degree of systemic inflammation is going to be very pro-thrombotic, but the leading causes of death are pretty clearly refractory hypoxia from ARDS and left heart failure likely due to myocarditis. I'm sure a bunch of these patients have pulmonary emboli as well and done may very well be coding from massive PEs but I can't support the claim that it's likely a huge percentage of those dying.

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Agree 100%. I am sure the risk of DVT is higher in patients given the high cytokine storm, thus why their CRPs are through the roof....however I doubt this is the major cause of death. I still believe ARDS and shock are the major causes.....not a large saddle PE. I would assume 40mg lovenox sq qd, would be sufficient, however obviously we are still learning things by the day. There has been some autopsys that show covid can cause endothelial myocardial sloughing---->microvascular occlusion, thus higher anticoagulation may be beneficial? Still, so much to learn.

For the ER docs and cards out there. EF 40%, covid +, mild CAD

Marcus Aurelius said:

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Yes the irony. Today lost one to a huge PE. Covid pos. Probably something to this. But I don't think it's the main mechanism of these patients dying.

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Just curious about patient's clinical course if you don't mind sharing.... COVID + pt whom also was found to have PE early on, or a patient covid + whom deteriorated later in the ICU? In the ER we are seeing a lot of covid + pts, and to be honest we are trying to avoid CT when possible because each covid + patient then requires an hour long clean in the scanner afterwards. Begs the question, should hypotensive covid + patients just get full dose tpa if they are on the brink of coding? Treat like a massive PE.

She was admitted for worsened MS symptoms 3/9. Contracted COID nosocomial. Disturbing.

damn

Doug Ross said:

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For the ER docs and cards out there. EF 40%, covid +, mild CAD

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Every time I think I miss my general medicine days in residency I see something like this, remember the 2 AM sphincter puckering and suddenly I'm good again.

Doug Ross said:

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For the ER docs and cards out there. EF 40%, covid +, mild CAD

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Wow. Are you saying the cath showed mild cad or he had a history of mild cad when he presented?

Quote:

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Begs the question, should hypotensive covid + patients just get full dose tpa if they are on the brink of coding? Treat like a massive PE.

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It does. Tough without more data.

Infection_Ag11 said:

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Doug Ross said:

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For the ER docs and cards out there. EF 40%, covid +, mild CAD

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Every time I think I miss my general medicine days in residency I see something like this, remember the 2 AM sphincter puckering and suddenly I'm good again.

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I can honestly say I don't miss much of anything about residency, and it's been two decades. Fellowship was another story.