Results
The demographics and laboratory values of eight hospitalized children diagnosed with SARS-CoV-2 infection are shown in Table 1. Average age was 12.9 years, with equal gender distribution and 38% were overweight or obese (BMI >25 kg/m2 or >30 kg/m2 respectively). Seventy-five percent required oxygen supplementation and 63% required ICU admission. Central lines in 25% remained in place for an average of 6 days; half of the patients were treated with hydroxychloroquine and 25% received Remdesivir (compassionate use, Gilead Sciences). Prophylactic enoxaparin (0.5 mg/kg/dose subcutaneously every 12 hours) was initiated in patients based on institutional adult guidelines of oxygen requirement, and elevated D-dimer levels. It was escalated to therapeutic enoxaparin (1 mg/kg/dose subcutaneously every 12 hours) in 63 % of patients for clinical deterioration with increasing hypoxia requiring admission to intensive care and/ or ventilator support. Anti-Xa levels were monitored only in the presence of deteriorating renal function or thrombocytopenia to reduce clinical staff exposure. There were no observed bleeding complications, thromboembolic complications or deaths.
Abnormal laboratory data expressed as means included lymphopenia (37.5%), mild thrombocytopenia (13 %), prolonged PT (50 %), elevated ferritin (37%) and C-reactive protein (88%). Elevations in D-dimer levels (75%), and fibrinogen (88 %) were observed on the day ROTEM was drawn for analyses.
ROTEM analysis (Table 2) showed a predominance of hypercoagulable profiles with elevated EXTEM MCF (50%), elevated INTEM MCF (38%), and both elevated FIBTEM A10/20 and elevated FIBTEM MCF (in 75% of patients), which is comparable to that seen in adults. Averages and ranges cannot be reported due to variability of age-based reference ranges in pediatrics10. There was no statistically significant correlation between fibrinogen and EXTEM MCF (p=0.116), INTEM MCF (p=0.232) or FIBTEM MCF (p=0.130) on the day ROTEM was obtained, nor was there correlation of d-dimer levels with these parameters [d-dimer and EXTEM MCF (p=0.949), INTEM MCF (p=0.731) or FIBTEM MCF (p=0.748)]. However, we observed that all patients admitted to the ICU had a 3 to 10-fold elevation in D-dimer levels, and a 2- fold elevation in fibrinogen levels and 80 % of the patients had elevated FIBTEM parameters.