Letter to the Editor
SEDAR-SEMICYUC consensus on the management of haemostasis disorders in severe COVID-19 patients
Consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes COVID-19 graves
J.V. Llaua,b,
, R. Ferrandisa,c, P. Sierraa,d, F. Hidalgoa,e, C. Cassinelloa,f, A. Gómez-Luquea,g, M. Quintanah,i, R. Amezagah,j, M. Geroih,k, A. Serranoh,l, P. Marcosh,m
Corresponding author
a Sociedad Española de Anestesiología-Reanimación y Terapéutica del Dolor (SEDAR), Spain
b Hospital Universitari Doctor Peset, Valencia, Spain
c Hospital Universitari i Politècnic La Fe, Valencia, Spain
d Fundació Puigver, Barcelona, Spain
e Clínica Universidad de Navarra, Pamplona, Spain
f Hospital Universitario Miguel Servet, Zaragoza, Spain
g Hospital Universitario Virgen de la Victoria, Málaga, Spain
h Sociedad Española de Medicina Intensiva, Crítica y de Unidades Coronarias (SEMICYUC), Spain
i Hospital Universitario La Paz-Carlos III, Madrid, Spain
j Hospital Universitario Son Espases, Palma de Mallorca, Spain
k Hospital Universitario de Burgos, Burgos, Spain
l Hospital Clínico Universitario, Valencia, Spain
m Hospital Germans Trias i Pujol, Badalona, Spain
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"apellidos" => "Marcos" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">m</span>" "identificador" => "aff0065" ] ] ] ] "afiliaciones" => array:13 [ 0 => array:3 [ "entidad" => "Sociedad Española de Anestesiología-Reanimación y Terapéutica del Dolor (SEDAR), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Universitari Doctor Peset, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Fundació Puigver, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Clínica Universidad de Navarra, Pamplona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Hospital Universitario Virgen de la Victoria, Málaga, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Sociedad Española de Medicina Intensiva, Crítica y de Unidades Coronarias (SEMICYUC), Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Hospital Universitario La Paz-Carlos III, Madrid, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Hospital Universitario Son Espases, Palma de Mallorca, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Hospital Universitario de Burgos, Burgos, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Hospital Clínico Universitario, Valencia, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Hospital Germans Trias i Pujol, Badalona, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes COVID-19 graves" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2375 "Ancho" => 3333 "Tamanyo" => 750726 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Schematic representation of the recommendations for the management of anticoagulants and antiplatelet drugs in severe COVID-19 patients.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ASA: acetylsalicylic acid; DOAC: direct oral anticoagulant; AVK: anti-vitamin K; DD: D dimer; VTED: venous thromboembolic disease; AF: atrial fibrillation; GFR: glomerular filtration rate; FIB: fibrinogen; LMWH: low molecular weight heparin; UFH: unfractionated heparin; NR: normal range; HIT: heparin-induced thrombocytopenia; IMV: invasive mechanical ventilation; NIMV: noninvasive mechanical ventilation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Infection due to the SARS-CoV-2 coronavirus, which causes COVID-19, tends to predispose patients to hypercoagulability, with an increased risk of thrombotic disease of a multifactor origin. In view of the need to establish a series of recommendations for the management of coagulation disorders in severe COVID-19 patients, the working groups of the Spanish Society of Anesthesia-Resuscitation and Pain Therapy (<span class="elsevierStyleItalic">Sociedad Española de Anestesiología-Reanimación y Terapéutica del Dolor</span> [SEDAR]) and the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (<span class="elsevierStyleItalic">Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias</span> [SEMICYUC]) decided to join our forces and knowledge and develop a consensus document with the aim of providing guidelines for dealing with these patients. As the result of intense work, with the posterior participation of review committees from both Societies, a manuscript was developed that has just been published by the <span class="elsevierStyleItalic">Revista Española de Anestesiología y Reanimación</span> (REDAR).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> For different reasons unrelated to the authors, joint and simultaneous publication in <span class="elsevierStyleSmallCaps">Medicina Intensiva</span> has not been possible. We believe that the most important aspect of any article – and particularly of a consensus document – is its diffusion for knowledge and subsequent clinical application in those cases where it is indicated. We therefore would like to highlight some essential aspects of the mentioned document (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and invite those readers who are interested to consult the full open-access original on the website of the REDAR.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Thrombotic risk in COVID-19 patients:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Assessment of thrombotic and bleeding risk is recommended in all COVID-19 patients in which the seriousness of the disease requires admission to hospital.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">Thrombophylaxis is recommended in all admitted patients, with low molecular weight heparin (LMWH) being the drug of choice.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">In those patients in which a procoagulant profile is confirmed, elevation of the LMWH dose from prophylactic (40-60 mg sc/24 h) to intermediate levels (100 IU/kg/24 h) is suggested, particularly in patients admitted to the Intensive Care Unit (ICU) and subjected to mechanical ventilation.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Elevation of the LMWH dose from intermediate to therapeutic levels (150 IU/kg/24 h or 100 IU/kg/12 h) is suggested in those cases where pulmonary thromboembolism is suspected (e.g., sudden worsening of oxygenation or a sharp and unexplained drop in blood pressure) and no firm diagnosis can be established.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Testing to confirm pulmonary thromboembolism is recommended in suspect cases due to progression of the hemostatic parameters (fundamentally D dimer) or on the basis of the clinical course of the patient, whenever possible. If confirmation is established, anticoagulation with LMWH is recommended as standard treatment.</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">Adjustment of anticoagulant and antiplatelet medication:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">The maintenance of anticoagulation is recommended where required, preferably prescribing LMWH at therapeutic doses.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">The maintenance of antiplatelet treatment is recommended, administering acetylsalicylic acid in those patients where needed, and it is advisable to replace clopidogrel with prasugrel in those cases requiring dual therapy.</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">Interpretation of the hemostasis tests:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">It is advisable not to administer hemostatic agents to correct the coagulation test data in the absence of significant bleeding.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">In situations of active bleeding, when the administration of hemostatic agents proves necessary, the use of plasma as first choice is suggested versus prothrombin complex concentrates, due to the lack of experience and safety data.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Routine protocols for the management of bleeding are recommended in COVID-19 patients with severe acute hemorrhage.</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">We would like to end by underscoring the importance of the early detection and optimum management of hemostatic disorders in severe COVID-19 patients. In our opinion, the establishment of consensuses endorsed by scientific societies allows a better approach to patient management, and should be promoted whenever possible.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Llau JV, Ferrandis R, Sierra P, Hidalgo F, Cassinello C, Gómez-Luque A, et al. Consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes COVID-19 graves. Med Intensiva. 2021;45:567–568.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2375 "Ancho" => 3333 "Tamanyo" => 750726 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Schematic representation of the recommendations for the management of anticoagulants and antiplatelet drugs in severe COVID-19 patients.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ASA: acetylsalicylic acid; DOAC: direct oral anticoagulant; AVK: anti-vitamin K; DD: D dimer; VTED: venous thromboembolic disease; AF: atrial fibrillation; GFR: glomerular filtration rate; FIB: fibrinogen; LMWH: low molecular weight heparin; UFH: unfractionated heparin; NR: normal range; HIT: heparin-induced thrombocytopenia; IMV: invasive mechanical ventilation; NIMV: noninvasive mechanical ventilation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Reference" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:1 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recomendaciones de consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes graves con infección por COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.V. Llau" 1 => "R. Ferrandis" 2 => "P. Sierra" 3 => "F. Hidalgo" 4 => "C. Cassinello" 5 => "A. Gómez-Luque" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2020" "volumen" => "67" "paginaInicial" => "391" "paginaFinal" => "399" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004500000009/v2_202201010839/S2173572721001417/v2_202201010839/en/main.assets" "Apartado" => array:4 [ "identificador" => "64604" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004500000009/v2_202201010839/S2173572721001417/v2_202201010839/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572721001417?idApp=WMIE" ]
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