| The Surgical Technologist | JULY 2022 308 during the hypercoagulable stages of the disease, the fibrinolytic and therapeutic effect may be greater than those reported in the recent literature. Also, when administered later in the course of the disease—as the cytokine storm recedes—the patients may be prone to hemorrhage similar to anticoagulated COVID-19 patients (17, 101). Therapeutic anticoagulation and thromboprophylaxis for the hospitalized COVID-19 surgical patient vary substantially. Recommendations have been made from adherence to standard VTE prophylactic guidance to intermediate or therapeutic dosing for moderately ill COVID-19 patients (85, 86). The preferred agents have been enoxaparin with antiXa monitoring or unfractionated heparin with either activated partial thromboplastin time (aPTT) or anti-Xa guidance. This heterogeneity is based on large multiplatform randomized controlled trials (RCTs) as well as society consensus statements. Recent guidelines and consensus statements have considered conditional support for therapeutic and/or intermediate heparinoid thromboprophylaxis for moderately ill COVID-19 patients not requiring high-flow oxygen (Table 1) (24–26, 85, 86, 99, 102–104). The importance of this foundational literature has been highlighted by observations that clinicians find it difficult to practice medicine during the COVID-19 pandemic bereft of RCTs to guide treatment (105). Therefore, reliance on categorization of hemostatic phenotype by VHAs fulfills the criteria of personalized-based medicine as a guidance for anticoagulation and thromboprophylaxis for the COVID-19 surgical patient. For elective cases, a high incidence of patients discharged from the hospital have VTEs within 90 days of discharge from COVID-19 (16). In addition, a subsection of the population who have COVID-19 and have undergone surgery have a markedly elevated rate of VTEs (9). Because of the absence of specific RCTs recommending postoperative DVT prophylaxis in this group of patients, use of Elective Surgery Acuity Scale (ESAS) guidelines as well as co-morbidities and adjunctive VHA analysis would allow for postoperative DVT prophylaxis similar to that which has been recommended for the postCOVID discharged patient. Specifically, the recommendations vary from 10 mg rivaroxaban for 35 days, 2.5 mg apixaban b.i.d. for 35 days, or for patients with normal renal function, 40 mg enoxaparin for 35 days (102, 106, 107). Specific comorbid analysis using conventional coagulation tests with adjunctive TEG-guided anticoagulation for COVID-19 patients with and without macrothrombosis has demonstrated the ability of the TEG to assist in the prediction of bleeding and clotting in this group of patients (17, 108). Similarly, the large RCTs which have demonstrated therapeutic benefit of heparinoids in moderately ill COVID-19 patients would be refined by the addition of VHAs to guide anticoagulant therapy (17, 85, 86, 109). As has been shown, so-called “intermediate” and therapeutic anticoagulation has been found to protect patients with moderately severe COVID-19 pneumonitis (86). Surgeons will find themselves during the acute and subacute period considering emergent and semi-emergent procedures for patients on anticoagulation not just for known macrothromboses but also for the specific antiviral and antiinflammatory functions of heparinoids in these patients (85, 86, 109). In addition to conventional coagulation tests, anticoagulation for these patients is facilitated by adjunctive hemostatic monitoring with VHAs (17, 20–22). The sequelae of Long COVID may be a function of residual endothelial damage from the SARS-CoV-2 endothelial cell invasion (88, 110). As such, thromboprophylaxis for postoperative convalescent COVID-19 patients should draw from strategies to manage acute COVID-19 patients along with the strategies for non-COVID-19 patients undergoing elective surgery. Viscoelastic Hemostatic Assays and Plasma Fluorescent Microclot Analysis as Precision-based Tools to Contextualize COVID-19-associated Immuno-thrombosis Surgeons—because of their more than half century experience with TEG/ROTEM to diagnose and treat coagulopathies in liver transplantation, cardiac surgery, and trauma—have been TABLE 1 | Salient society recommendations on anticoagulant dosing for acute COVID-19 patients. Society Outpatient Inpatient Intensive Care Unit Post-discharge American Society of Hematology (February 2, 2022) (24) Thromboprophylaxis not recommended For patients without VTE, standard prophylactic dose with LMWH or UFH For patients without VTE, standard prophylactic dose with LMWH or UFH Thromboprophylaxis not recommended American College of Chest Physicians (CHEST) Guideline (February 12, 2022) (25) Not addressed Conditional recommendation: For patients without VTE, therapeutic dose with LMWH or UFH For patients without VTE, standard prophylactic dose with LMWH or UFH Not addressed National Institutes of Health (NIH) Guidelines (February 24, 2022) (26) Not addressed Therapeutic dose heparin only for patients hospitalized on low-flow oxygen For hospitalized patients without VTE and not requiring oxygen or requiring high-flow device or NIV, standard prophylactic dose with LMWH or UFH For patients without VTE, standard prophylactic dose with LMWH or UFH Thromboprophylaxis not recommended Abbreviations: LMWH, low molecular weight heparin; UFH, unfractionated heparin; VTE, venous thromboembolism. Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 8 2022 | Volume 9 | Article 889999
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