Enhanced thromboprophylaxis in critically ill patients with COVID-19 infection

Patients with severe SARS-CoV-2 infection have been shown to have abnormal coagulation parameters and are at increased risk of thromboembolism. The optimal thromboprophylaxis regimen that minimizes thrombosis without increased risk of serious bleeding is uncertain. To describe the efficacy and safety of increased intensity (enhanced) thromboprophylaxis in patients with COVID-19 admitted to the medical intensive care unit (MICU). This is a retrospective cohort analysis of patients with a diagnosis of COVID-19 admitted to the MICU of an urban safety net hospital. With the exception of patients being supported with extracorporeal membrane oxygenation or on chronic anticoagulation who received therapeutic dosing of anticoagulation, thromboprophylaxis was given as either enoxaparin or unfractionated heparin in doses higher than those recommended for standard prophylaxis, but lower than those used for therapeutic anticoagulation. Of the 120 patients managed with an enhanced thromboprophylaxis protocol, 6 (5%) experienced thromboembolism as a result of their COVID-19 disease (1 pulmonary embolus, 4 deep vein thromboses, and 1 arterial embolism). Four patients experienced major bleeding while receiving therapeutic anticoagulation. In critically ill patients with COVID-19, increased intensity (enhanced) thromboprophylaxis appears to be effective at preventing clinically significant thromboembolic events without an increased risk of serious bleeding. •In COVID-19 critical illness standard anticoagulation prophylaxis may not provide adequate protection against thrombosis.•Enhanced thromboprophylaxis uses anticoagulant doses higher than standard prophylaxis but less than therapeutic anticoagulation.•Only 6 (5%) of 120 critically ill patients managed with enhanced thromboprophylaxis had thrombotic complications and none had serious bleeding.•In COVID-19 critical illness, intermediate dose prophylaxis may offer protection against thrombosis without causing increased risk of bleeding.