Anticoagulation for COVID19 Patients admitted to Intensive Care Units

Aims of the Guidance
  1. This protocol is intended to standardize the anticoagulation management for critically-ill patients with COVID19 pneumonia requiring admission to intensive care unit.
Indications:
  1. Adult patients admitted to Intensive Care Unit with COVID19 Pneumonia OR as per your local guidance for high risk patients.
Contraindication:
  1. Patients with active bleeding.
  2. Platelets less than 50,000 per microliter.
  3. Fibrinogen level less than 1.5 gram per liter.
Protocol

  1. LOW-RISK GROUP: D-Dimer less than 1.2 mg/L
  2. If CrCl ≥ 30 ml/min
    1. Enoxaparin 40 mg subcutaneous once daily for patients with weight < 90 kg.
    2. Enoxaparin 60 mg subcutaneous once daily for patients with weight ≥ 90 kg.
  3. If CrCl < 30 ml/min
    1. Dalteparin 5,000 units subcutaneous once daily for patients with weight < 90 kg.
    2. Dalteparin 7,500 units subcutaneous once daily for patients with weight ≥ 90 kg.
  4. For patients on Renal Replacement Therapy (RRT),
    1. Unfractionated Heparin 5000 units subcutaneous every 12 hours.

  1. INTERMEDIATE-RISK GROUP: D-Dimer ≥ 1.2 mg/L and P/F ratio < 200
  2. If CrCl ≥ 30 ml/min
    1. Enoxaparin 40 mg subcutaneous every 12 hours for patients with weight < 90 kg.
    2. Enoxaparin 60 mg subcutaneous every 12 hours for patients with weight ≥ 90 kg.
  3. If CrCl < 30 ml/min,
    1. Dalteparin 7,500 units subcutaneous once daily for patients with weight < 90 kg.
    2. Dalteparin 10,000 units subcutaneous once daily for patients with weight ≥ 90 kg.
  4. For patients on Renal Replacement Therapy,
    1. Unfractionated Heparin 5000 units subcutaneous every 8 hours.

  1. HIGH-RISK GROUP: D-Dimer ≥ 1.2 mg/L, P/F ratio < 100, acutely worsening oxygenation or increasing dead space or rapid increase in D-Dimer ( ≥ 5 folds in 48 hours).
  2. If CrCl ≥ 30 ml/min,
    1. Administer Enoxaparin 1 mg/kg subcutaneous every 12 hours.
  3. If CrCl < 30 ml/min,
    1. Administer Dalteparin 100 units/kg subcutaneous every 12 hours.
  4. For patients on Renal Replacement Therapy,
    1. Administer Unfractionated Heparin intravenous infusion at 18 units/kg/hour targeting aPTT as per protocol.
MONITORING PATIENTS RECEIVING ANTICOAGULATION
  1. For low-risk patients:
    1. Receiving LMWH (Enoxaparin or Dalteparin), target Anti-Factor Xa level of 0.2-0.4 units/ml. Blood sample to be collected for analysis 4 hours after the 3rd dose.
  2. For intermediate-risk patients
    1. Receiving LMWH (Enoxaparin or Dalteparin), target Anti-Factor Xa level of 0.4-0.6 units/ml. Blood sample to be collected for analysis 4 hours after the 3rd dose.
  3. For high-risk patients
    1. Rreceiving LMWH (Enoxaparin or Dalteparin), target Anti- Factor Xa level of 0.6-1.0 units/ml. Blood sample to be collected for analysis 4 hours after the 3rd dose.
  4. For all patients assess bleeding risk daily (platelet count < 50,000 per microliter, fibrinogen level < 1.5 gm/L).
Algorithm
References
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