Acute COVID-19, Clinical Pathway — All Settings

Anticoagulation

General Information

  • Review contraindications to anticoagulation and Mechanical Prophylaxis listed below Assess renal function:
    • If renal impairment (CrCl < 30 mL/min) consider unfractionated heparin (UFH).
  • When enoxaparin is initiated, follow Xa level targets as below.
  • Refer to MIS-C Pathway or Kawaski Pathway for anticoagulation recommendations as indicated for the individual patient presentation.
  • For patients who would otherwise be discharged home but remain hospitalized, follow routine VTE Prophylaxis.
Anticoagulation Recommendations for Patients Critically Ill with Acute Symptoms of COVID-19 Infection Admitted to the PICU
Age < 12 years
and
*Normal renal function
and
No contraindications
  • Mechanical Prophylaxis
  • Sequential compression devices there is an applicable size
  • +
  • Chemoprophylaxis if patient requires a central venous catheter and/or intubation
  • Enoxaparin
    • < 3 mo: 0.75 mg/kg/dose subQ q12 h
    • ≥ 3 mo: 0.5 mg/kg/dose subQ q12 h (max initial dose: 60 mg subQ q12h)
  • Goal anti-Xa: 0.2-0.4 units/mL
Age ≥ 12 years
and
*Normal renal function
and
No contraindications
  • Mechanical Prophylaxis
  • Sequential compression devices
  • +
  • Chemoprophylaxis
  • Enoxaparin 0.5 mg/kg/dose subQ q 12 hrs (max initial dose: 60 mg subQ q12h)
  • Goal anti-Xa: 0.2-0.4 units/mL
* If renal impairment (CrCl < 30 mL/min) consider unfractionated heparin (UFH)
Anticoagulation Recommendations for Patients with Acute Symptoms of COVID-19 Admitted to an inpatient special treatment room
Age < 12 years
and
No Contraindications
  • Mechanical Prophylaxis
  • Sequential compression devices if there is an applicable size
  • +
  • Chemoprophylaxis
  • Generally not indicated
  • Consult Hematology if increased concern for VTE (beyond COVID19 + status) to determine need for anticoagulation
Age ≥ 12 years
and
*Normal renal function
and
No contraindications
  • Mechanical Prophylaxis
  • Sequential compression devices
  • +
  • Chemoprophylaxis
  • Enoxaparin 0.5 mg/kg/dose subQ q 12 hrs (max initial dose: 60 mg subQ q12h)
  • Goal anti-Xa: 0.2-0.4 units/mL
* If renal impairment (CrCl < 30mL/min) consider unfractionated heparin (UFH)
Review Contraindications to Mechanical and Chemoprophylaxis
Absolute Contraindications to Mechanical Prophylaxis
  • Distal/peripheral IV access: i.e. IV in foot
  • Suspected or existing deep vein thrombosis
  • Skin conditions affecting extremity
    • (i.e., dermatitis, burn)
  • Acute fracture (Can use device on unaffected extremity)
  • No appropriate size pneumatic sequential compression device (SCD) available
  • Lower extremity conditions which result in significant pain with compression
    • i.e., solid tumor, vaso-occlusive episode in sickle cell disease
  • Surgical or anesthesia contraindication to sequential compression during a procedure
Absolute contraindications to anticoagulation
  • Intracranial hemorrhage
  • Acute stroke/brain ischemia
  • Ongoing and uncontrolled bleeding
  • Uncorrected coagulopathy
  • Incomplete spinal cord injury with suspected or known paraspinal hematoma
  • Allergy to UFH or enoxaparin
  • Platelet count < 50,000/mcl
  • Epidural – discuss with anesthesia prior to initiating pharmacologic prophylaxis
  • Patient is likely to require an invasive procedure within the next 24 hours
  • Congenital bleeding disorder
  • Uncontrolled severe hypertension
  • Intracranial mass