• Janice Wang, Negin Hajizadeh, and Linda Shore-Lesserson.
• Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Feinstein Institute for Medical Research, 410 Lakeville Rd, Suite 105, New Hyde Park, NY, 11042, USA. Electronic address: jwang@northwell.edu.
• J. Cardiothorac. Vasc. Anesth. 2022 Aug 1; 36 (8 Pt A): 253625432536-2543.

ObjectiveTo develop a practical thromboelastograph guided (TEG) anticoagulation protocol to guide the management of COVID-19 critically ill patients.DesignAn inter disciplinary team reviewed the current literature on hypercoagulability in critically ill COVID-19 patients, clinical management practices and challenges with high rates of thrombotic events despite anticoagulant therapies.SettingThe largest tertiary care hospital within the Northwell Health System in New York.PatientsCOVID-19 invasively mechanically ventilated patients in Medical Intensive Care Unit Settings.MethodsTEG was monitored in critically ill COVID-19 patients. Patterns were reviewed to guide the development of a treatment protocol leveraging TEG parameters to select anticoagulant therapy. Three patients are reported to highlight TEG profiles that led to the development of the algorithm. Clinical trajectory and treatment decisions were extracted retrospectively from the Electronic Health Record, with input from the intensivists. Anticoagulant use, laboratory and TEG values, and venous/arterial lower extremity (LE) ultrasound results were recorded.Main ResultsThese patients demonstrated hypercoagulable TEG results despite prophylactic or therapeutic dosages of unfractionated heparin or low-molecular-weight heparin (LMHW). TEG surveillance identified functional fibrinogen and maximum amplitude in high-risk patients with hyper inflammatory markers. Anticoagulation assessment, TEG parameters, and LE ultrasound monitoring for venous and arterial thrombus were used to construct an algorithm to guide and escalate anticoagulant therapy.ConclusionsTEG provides patient-specific evidence for a hypercoagulable state in patients receiving all types of anticoagulant therapy. The proposed TEG algorithm guides anticoagulation management decisions to maintain or escalate anticoagulant dose and/or change choice of anticoagulant. A TEG algorithm may help negotiate the potential harm/benefit balance of full-dose anticoagulation in critically ill COVID-19 patients, by allowing for a more individualized approach that goes beyond the review of activated partial thromboplastin time (aPTT) levels.Copyright © 2021 Elsevier Inc. All rights reserved.

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