Fibrinolysis Shutdown Correlation with Thromboembolic Events in Severe COVID-19 Infection

J Am Coll Surg. 2020 Aug;231(2):193-203.e1. doi: 10.1016/j.jamcollsurg.2020.05.007. Epub 2020 May 15.


Background: COVID-19 predisposes patients to a prothrombotic state with demonstrated microvascular involvement. The degree of hypercoagulability appears to correlate with outcomes; however, optimal criteria to assess for the highest-risk patients for thrombotic events remain unclear; we hypothesized that deranged thromboelastography measurements of coagulation would correlate with thromboembolic events.

Study design: Patients admitted to an ICU with COVID-19 diagnoses who had thromboelastography analyses performed were studied. Conventional coagulation assays, d-dimer levels, and viscoelastic measurements were analyzed using a receiver operating characteristic curve to predict thromboembolic outcomes and new-onset renal failure.

Results: Forty-four patients with COVID-19 were included in the analysis. Derangements in coagulation laboratory values, including elevated d-dimer, fibrinogen, prothrombin time, and partial thromboplastin time, were confirmed; viscoelastic measurements showed an elevated maximum amplitude and low lysis of clot at 30 minutes. A complete lack of lysis of clot at 30 minutes was seen in 57% of patients and predicted venous thromboembolic events with an area under the receiver operating characteristic curve of 0.742 (p = 0.021). A d-dimer cutoff of 2,600 ng/mL predicted need for dialysis with an area under the receiver operating characteristic curve of 0.779 (p = 0.005). Overall, patients with no lysis of clot at 30 minutes and a d-dimer > 2,600 ng/mL had a venous thromboembolic event rate of 50% compared with 0% for patients with neither risk factor (p = 0.008), and had a hemodialysis rate of 80% compared with 14% (p = 0.004).

Conclusions: Fibrinolysis shutdown, as evidenced by elevated d-dimer and complete failure of clot lysis at 30 minutes on thromboelastography predicts thromboembolic events and need for hemodialysis in critically ill patients with COVID-19. Additional clinical trials are required to ascertain the need for early therapeutic anticoagulation or fibrinolytic therapy to address this state of fibrinolysis shutdown.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Betacoronavirus
  • Blood Coagulation Tests*
  • COVID-19
  • Coronavirus Infections / blood*
  • Coronavirus Infections / physiopathology
  • Coronavirus Infections / therapy
  • Female
  • Fibrin Clot Lysis Time
  • Fibrin Fibrinogen Degradation Products / analysis
  • Fibrinolysis / physiology*
  • Humans
  • Intensive Care Units
  • Male
  • Middle Aged
  • Pandemics
  • Partial Thromboplastin Time
  • Pneumonia, Viral / blood*
  • Pneumonia, Viral / physiopathology
  • Pneumonia, Viral / therapy
  • Renal Dialysis
  • Risk Factors
  • SARS-CoV-2
  • Thrombelastography
  • Thromboembolism / blood*
  • Thromboembolism / diagnosis*
  • Thromboembolism / physiopathology
  • Thromboembolism / therapy


  • Fibrin Fibrinogen Degradation Products
  • fibrin fragment D