| The Surgical Technologist | JULY 2022 310 American College of Obstetricians & Gynaecologists guidelines that recommend thromboprophylaxis for all patients with Csections who have at least one major indication or two minor indications for anticoagulation (159). The three major indications are previous VTE, body mass index (BMI) > 35, and thrombophilia. The minor indications are preeclampsia, hypertension, diabetes, peripartum infection, and other comorbidities (145, 159–163). Since guidelines are dynamic, the inclusion of COVID-19 as a minor indication seems reasonable. However, it would also be judicious to refer to the spectrum of diseases whereby women with severe COVID-19 are included in the group of patients with major indications for anticoagulation such that they would receive six weeks thromboprophylaxis. This paradigm has been useful in the most recent literature and serves as a template for applications to the other disciplines. Since there is sparse literature regarding the guidance of thromboprophylaxis and treatment of the peripartum COVID19 patient, surgeons must rely on consensus recommendations from interim guidelines. These recommendations for peripartum anticoagulation and thromboprophylaxis have been extrapolated from the COVID-19 literature for nonpregnant patients. Interim guidelines have been published by many organizations with specific references to pregnant women (164–166). Orthopaedics Similar to obstetric patients, there is a spectrum of risk for developing postoperative VTE as a function of COVID-19 illness severity in patients undergoing orthopaedic surgery. Significant literature has demonstrated the benefit of serial VHAs to predict postoperative VTE (167–169). Therefore, for a disease which, by its very nature presents with a hypercoagulopathic state manifested clinically by increased VTEs and arterial thromboses, the use of VHAs in this COVID-19 population is a logical extension. While consensus recommendations have been proposed to optimize safety for patients undergoing elective surgery after previously being diagnosed with COVID-19, adjunctive VHAs may enhance these guidelines to better predict VTE and guide anticoagulant therapy postoperatively (131, 170–172). Early intervention tends to be optimal for fracture fixation, but timing of surgery is historically complicated in patients with hemostatic derangement such as that which is induced in the post-COVID-19 patient. Decreased time between hip fracture and surgery correlates with decreased morbidity and mortality. FIGURE 4 | Prototype spectrum of COVID-19-associated coagulopathy used to assess the patient’s coagulopathy with thromboelastography (TEG) and plasma microclot analysis. Shown above is an example of correlation between the most hypercoagulable delta (B.1.617.1) variant, intermediate hypercoagulable omicron (B.1.1.529) variant, and physiologic TEGs with corresponding plasma microclot analyses. Using Thioflavin-T as afluorescent marker specifically for microclot staining, fluorescence microscopy demonstrates microclots in plasma with representative examples of different degrees of microclot formation as related to delta (A), omicron (B), and physiologic (C) TEGs. Previously described, Stage 1 to 4 is a qualitative numerical scoring system where a score of 4 is given for significant and widespread microclot formation and a score of 1 is given for minimal microclot formation (78, 119). In this figure, delta variant (A) equals stage 4, omicron (nonhospitalized patient) (B) is stage 3, normal physiologic non-infected individual (C) is stage 2. A hypocoagulable state either from anticoagulation of the COVID-19 patient or due to naturally acquired disease from COVID-19-associated coagulopathy is stage 1 (not pictured). Patients with Long COVID also demonstrate microclot formation, which may be used to assess platelet dysfunction and surgical candidacy in this group of patients (77, 78, 119). The omicron variant (BA.1 sub-lineage) was detected by polymerase chain reaction (PCR) based on S-gene target failure (SGTF) as a proxy for variant status (https://www.science.org/doi/ 10.1126/science.abn4543) (120). The TaqPath COVID-19 Combo Kit® (Thermo Fisher Scientific) identifies SARS-CoV-2 infections by detecting 3 viral gene regions, E, RdRP, and Ngene. The laboratory reported positive cycle threshold of 32 cycles for both the E gene, 35 for RdRP and 34 for the Ngene. Positive N gene with negative S gene (SGTF) is an acceptable proxy of the BA.1 variant when the gold-standard whole genome sequencing is not done. The PCR result combined with reported case counts and known genomic epidemiology of the 4th wave in South Africa has been used to track changes in transmission over time for the BA.1 variant (121, 122). Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 10 2022 | Volume 9 | Article 889999
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