High D dimers and low global fibrinolysis coexist in COVID19 patients: what is going on in there?

Backgroud COVID-19 coagulopathy linked to increased D-dimer levels has been associated with high mortality (Fei Z et al in Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Lancet (London, England) 395(10229):1054-62, 2020) While D-dimer is accepted as a disseminated intravascular coagulation marker, rotational thromboelastometry (ROTEM) also detects fibrinolysis (Wright FL et al in Fibrinolysis shutdown correlates to thromboembolic events in severe COVID-19 infection J Am Coll Surg (2020) Available from https :// pubme d ncbi nlm nih gov/32422 349/ [cited 14 Jun 2020];Schmitt FCF et al in Acute fibrinolysis shutdown occurs early in septic shock and is associated with increased morbidity and mortality: results of an observational pilot study Ann Intensive Care 9(1):19, 2019) We describe the ROTEM profile in severely ill COVID-19 patients and compare it with the standard laboratory coagulation test Methods Adult patients diagnosed with COVID-19 admitted to the ICU were prospectively enrolled after Ethics Committee approval (HCB/2020/0371) All patients received venous thromboembolism prophylaxis;those on therapeutic anticoagulation were excluded The standard laboratory coagulation test and ROTEM were performed simultaneously at 24-48 h after ICU admission Sequential organ failure assessment (SOFA), disseminated intravascular coagulation (DIC) and sepsis-induced coagulopathy (SIC) scores were calculated at sample collection Results Nineteen patients were included with median SOFA-score of 4 (2-6), DIC-score of 1 (0-3) and SIC-score of 1 8 (0 9) Median fibrinogen, D-dimer levels and platelet count were 6 2 (4 8-7 6 g/L), 1000 (600-4200 ng/ml) and 236 (136-364 10 9 /L), respectively Clot firmness was above the normal range in the EXTEM and FIBTEM tests while clot lysis was decreased There was no significant correlation between ROTEM or D-dimer parameters and the SOFA score Conclusion In COVID-19 patients, the ROTEM pattern was characterized by a hypercoagulable state with decreased fibrino-lytic capacity despite a paradoxical increase in D-dimer levels We suggest that, in COVID-19 patients, the lungs could be the main source of D-dimer, while a systemic hypofibrinolytic state coexists This hypothesis should be confirmed by future studies