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CASE REPORTS
Year : 2022  |  Volume : 15  |  Issue : 7  |  Page : 103-105  

Anticoagulant therapy post-COVID in the perioperative setting: Bountiful of choices, indefinite treatment plans- A case report


Department of Anesthesiology, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India

Date of Submission10-Nov-2021
Date of Decision06-Feb-2022
Date of Acceptance21-Feb-2022
Date of Web Publication11-Jul-2022

Correspondence Address:
Balasubramaniam Gayathri
B102 Newry Shrenika Jayachandran Nagar 1st Main Road Jalladanpet, Chennai - 600 100, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_879_21

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  Abstract 


A post-COVID patient with a high D-dimer Value (>5000 IU) was posted for total knee replacement. She was on multiple anticoagulants including the novel oral anticoagulants that started to reduce thrombotic risk. This case highlights the importance of continuing the anticoagulants and provides insights on the proper timing to stop and restart various anticoagulants after surgery in post-COVID patients.

Keywords: Anticoagulation, D-Dimer, post COVID


How to cite this article:
Gayathri B, Krishnamoorthy K, Lakshmikanthan C, Yuvashree M. Anticoagulant therapy post-COVID in the perioperative setting: Bountiful of choices, indefinite treatment plans- A case report. Med J DY Patil Vidyapeeth 2022;15, Suppl S1:103-5

How to cite this URL:
Gayathri B, Krishnamoorthy K, Lakshmikanthan C, Yuvashree M. Anticoagulant therapy post-COVID in the perioperative setting: Bountiful of choices, indefinite treatment plans- A case report. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Sep 28];15, Suppl S1:103-5. Available from: https://www.mjdrdypv.org/text.asp?2022/15/7/103/350688




  Introduction Top


A 67-year-old female, hypertensive and diabetic, was posted for total knee replacement surgery. She was affected with COVID-19 3 months back. She was afebrile and had no symptoms suggestive of long COVID syndrome. Her heart rate was 86/min, regular BP 134/74 mm Hg. Her Hb was 10.3 g%, total count 4650 with 87.3% neutrophils, 24% lymphocytes, and platelet count of 1, 32, 400. Her creatinine was 0.6 with normal electrolyte values. Her liver function and thyroid function were normal. Her Hba1C was 9.5, Prothrombin time- 13 with INR-1.0, Activated partial thromboplastin time-31, bleeding time 1 min and 30 s, and clotting time 2 min and 30 s. Her D-Dimer value was 2520 IU with a normal lower limb Doppler study. As her SpO2 on air was 94%, CT pulmonary angiography (CTPA) was advised, which was normal, and the patient was assessed under American Society of Anaesthesiologist ASA physical status 3. Initially, while in the hospital for evaluation, she was on orokinase, low-molecular-weight heparin (LMWH), and aspirin. She was discharged home on novel oral anticoagulant (NOAC) apixaban 5 mg bd after stopping LMWH due to a urinary infection. After 21 days, the patient stopped apixaban on her own as D-dimer was 640 IU. After a week just before surgery, her D-Dimer was >5000 IU, and she was again started on LMWH 0.4 mL SC bd [Table 1]. Surgery was done under SA with ddductor canal block. The postoperative period was uneventful, and the patient was discharged after a week with T. apixiban 5 mg BD.
Table 1: D-dimer, anticoagulants received by patient and events

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  Discussion Top


Viral infections provoke systemic inflammatory response and cause an imbalance between the procoagulant and anticoagulant homeostatic mechanisms [Figure 1]. Multiple pathogenic mechanisms are involved, including endothelial dysfunction and tissue factor pathway activation. Liam et al.[1] reviewed 150 COVID patients at a median of 80.5 days after the initial diagnosis. Clinical examination, chest X-ray, and 6-min walk test and coagulation and inflammatory markers were assessed. They observed that increased D-dimer levels (>500 ng/mL) were observed in 25.3% of the patients up to 4 months after infection.
Figure 1: Formation of D-dimer

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The medical fraternity is challenged now with the burden of post-COVID patients, with varied symptoms. Patients coming for elective procedures post-COVID with high D-dimer values with or without anticoagulant prophylaxis is a common phenomenon. Various studies have identified markedly elevated D-dimer as one of the predictors of mortality.[2],[3],[4] Al-Samkari et al.[3] demonstrated that elevated D-dimer was predictive of coagulation-associated complications (D-dimer >2500 ng/mL, the adjusted odds ratio for thrombosis, 6.79 [95% CI, 2.39–19.30]; critical illness, and death. Zhou et al.[4] showed that elevated D-dimer levels (>1 g/L) were strongly associated with in-hospital death (OR 18.4 95% CI 2.6–128.6, P = 0.003). In patients needing critical care support, Huang et al.[5] showed that D-dimer levels on admission were higher (median [range] D-dimer level 2400 ng/mL [600–14,400)]) than those patients who did not require it (median [range] D-dimer level 0·5 ng/nL [300–800], P = 0·0042).

Currently, there is no validated scheme on the dose and timing of the use of antithrombotic drugs for prophylaxis. Results from several trials are expected to provide us with guidelines on the protocol for anticoagulation post-COVID [Table 2].
Table 2: Anti-coagulant trials in post COVID patients[6]

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The drugs commonly being prescribed are unfractionated heparin and low-molecular weight-heparin (LMWH) when patients are admitted in the active phase and novel oral anticoagulants (NOACs), commonly apixaban and rivaroxaban, in the chronic post-COVID phase. The European Heart Rhythm Association has provided a practical guide on the use of new oral anticoagulants in patients; the second update of which gives guidelines on treatment protocols of NOACs,[7] which are apt to be followed for elective surgeries [Table 3]. In emergency situations, it is recommended to send the whole coagulation panel prothrombin time, partial thromboplastin time (PT/APTT), anti-Factor Xa levels and diluted Thrombin time (dTT) and reverse NOAC if necessary.
Tabl 3: Practical guide on the use of NOACs in elective surgeries

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An expert panel survey by Ferrandis et al.[8] suggested postponing nononcologic surgery for at least 1 month from a negative reverse transcription-polymerase chain reaction (RTPCR), ensuring thromboprophylaxis. Increasing thromboprophylaxis to intermediate levels up to 100 IU/Kg of LMWH if surgery is planned during the first month. Adding mechanical devices like compression stockings up to the resumption of ambulation is also recommended.[9] Global surgery collaborative suggests delaying surgery by 7 weeks wherever possible, following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, with an observation that patients with ongoing symptoms ≥7 weeks from the time of diagnosis may benefit from further delay.[10]

Our patient had elevated D-Dimer levels when she presented 3 months after COVID. She had mild disease and was not on anticoagulants during the active phase. The main concerns in patients with high D-Dimer values are deep vein thrombosis (DVT) and pulmonary embolism, which was carefully averted by anticoagulation.


  Conclusion Top


Right now, we have bountiful choices for anticoagulation, but the treatment plans are indefinite in post-COVID patients with elevated D-dimer. Timely anticoagulation, deferring before surgery, and restarting helps in preventing perioperative thrombotic complications.

Acknowledgements

Nil.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Liam T, Helen F, Dyer A, Martin-Loeches I. Prolonged elevation of D-dimer levels in convalescent COVID-19 patients is independent of the acute phase response. J Thromb Haemost 2021;19:1064-70.  Back to cited text no. 1
    
2.
Townsend L, Fogarty H, Dyer A, Martin-Loeches I, Bannan C, Nadarajan P, et al. Prolonged elevation of D-dimer levels in convalescent COVID-19 patients is independent of the acute phase response. J Thromb Haemost 2021;19:1064-70.  Back to cited text no. 2
    
3.
Al-Samkari H, Karp Leaf RS, Dzik WH, Carlson JC, Fogerty AE, Waheed A. COVID-19 and coagulation: Bleeding and thrombotic manifestations of SARS-CoV-2 infection. Blood 2020;136:489-500.  Back to cited text no. 3
    
4.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 4
    
5.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 5
    
6.
Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat Med 2021;27:601-15.  Back to cited text no. 6
    
7.
Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, et al. The 2018 European heart rhythm association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018;39:1330-93.  Back to cited text no. 7
    
8.
Ferrandis R, Llau JV, Afshari A, Douketis JD, Gómez-Luque A, Samama CM. Management of perioperative thromboprophylaxis for surgery following COVID-19: An expert-panel survey. Br J Anaesth 2021;127:e143-5.  Back to cited text no. 8
    
9.
Lobo D, Devys JM. Timing of surgery following SARS-CoV-2 infection: An international prospective cohort study. Anaesthesia 2022;77:110.  Back to cited text no. 9
    
10.
COVIDSurg Collaborative, GlobalSurg Collaborative. Timing of surgery following SARS-CoV-2 infection: An international prospective cohort study. Anaesthesia 2021;76:748-58.  Back to cited text no. 10
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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