Does pulmonary embolism in critically ill COVID-19 patients worsen the in-hospital mortality: A meta-analysis

Pulmonary embolism impacts clinical outcomes of intubated patients with acute respiratory distress syndrome related to COVID-19

BACKGROUND

Pulmonary embolism (PE) in critically ill patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 is a major complication which might impact survival. We aimed to determine the prevalence of PE and assess its impact of PE on clinical outcomes in intubated patients with ARDS due to COVID-19.

METHODS

All intubated patients with ARDS due to COVID-19 admitted to the intensive care unit (ICU) of Geneva University Hospitals between March 9, 2020, and May 31, 2022, were included. A retrospective analysis was conducted on the occurrence of PE and its association with clinical outcomes. The primary outcome was ventilator-free days during the first 28 days after ICU admission. Linear regressions were performed to investigate the association between PE and outcomes.

RESULTS

Among the 370 intubated patients with ARDS related to COVID-19, 58 (15.7%) presented with PE. Patients with PE had significantly fewer ventilator-free days than patients without PE (median (IQR) of 3 (0-11) days versus 12 (0-19) days; p < 0.001). Mortality did not differ significantly between groups (12/58 [20.7%] of patients with PE versus 71/312 [22.8%] of patients without PE; p = 0.72). Duration of IMV, and ICU and hospital LOS were significantly longer among patients with PE. The need for ECMO support was similar among both groups.

CONCLUSIONS

The occurrence of PE in patients with ARDS due to COVID-19 had a significant impact on clinical outcomes. They had fewer ventilator-free days, longer duration of IMV, and longer ICU and hospital lengths of stay. However, pulmonary embolism was not associated with higher mortality.

ETHICS APPROVAL

Ethical committee of Geneva (BASEC #: 2020-00917).

Pulmonary embolism in hospitalized COVID-19 patients: Short- and long-term clinical outcomes

Introduction

Pulmonary embolism (PE) is a frequent complication in COVID-19. However, the influence of PE on the prognosis of COVID-19 remains unclear as previous studies were affected by misclassification bias. Therefore, we evaluated a cohort of COVID-19 patients whom all underwent systematic screening for PE (thereby avoiding misclassification) and compared clinical outcomes between patients with and without PE.

Materials and methods

We included all COVID-19 patients who were admitted through the ED between April 2020 and February 2021. All patients underwent systematic work-up for PE in the ED using the YEARS-algorithm. The primary outcome was a composite of in-hospital mortality and ICU admission. We also evaluated long-term outcomes including PE occurrence within 90 days after discharge and one-year all-cause mortality.

Results

637 ED patients were included in the analysis. PE was diagnosed in 46 of them (7.2%). The occurrence of the primary outcome did not differ between patients with PE and those without (28.3% vs. 26.9%, p = 0.68). The overall rate of PE diagnosed in-hospital (after an initial negative PE screening in the ED) and in the first 90 days after discharge was 3.9% and 1.2% respectively. One-year all-cause mortality was similar between patients with and without PE (26.1% vs. 24.4%, p = 0.83).

Conclusions

In a cohort of COVID-19 patients who underwent systematic PE screening in the ED, we found no differences in mortality rate and ICU admissions between patients with and without PE. This may indicate that proactive PE screening, and thus timely diagnosis and treatment of PE, may limit further clinical deterioration and associated mortality in COVID-19 patients.

Impact of Alteplase on Mortality in Critically Ill Patients with COVID-19 and Pulmonary Embolism

COVID-19 is an independent risk factor for pulmonary embolism (PE). Little is known about alteplase therapy in this patient group. A retrospective study analyzed 74 patients with PE and acute respiratory distress syndrome (ARDS) due to COVID-19 who were hospitalized in the intensive care unit in 2021. Patients with or without confirmed right heart thrombi (RHT) were treated with unfractionated heparin or alteplase. The mortality rate in patients with RHT treated with heparin was 100% compared to 37.9% and 55.2% in those treated with alteplase without RHT and alteplase with RHT, respectively. The risk of death in the alteplase group increased with delayed thrombolysis (p = 0.009, odds ratio (OR) = 1.73 95% CI (confidence interval) 1.14-2.62), increased D-dimer concentration (p = 0.02, OR = 1.43 95% CI 1.06-1.93), and decreased PaO₂/FiO₂ ratio (p = 0.001, OR = 0.56 95% CI 0.41-0.78). The receiver operating characteristic method determined that a 1-day delay in thrombolytic treatment, D-dimer concentration >5.844 mg/L, and PaO₂/FiO₂ <144 mmHg predicted a fatal outcome. The risk of death in patients with severe COVID-19 with ARDS and PE increases with higher D-dimer levels, decreased PaO₂/FiO₂, and delayed thrombolytic treatment. Thrombolysis seems to be treatment of choice in severe COVID-19 with PE and RHT. It should be carried out as soon as possible after the diagnosis is established.

To Study the Correlation of Clinical Severity and Cytokine Storm in COVID-19 Pulmonary Embolism Patients by Using Computed Tomography Pulmonary Angiography (CTPA) Qanadli Clot Burden Scoring System

BACKGROUND

Pulmonary embolism (PE) is a fatal form of venous thromboembolism (VTE), with an overall untreated mortality of up to 30%. Greater than 50% of patients with lower extremity proximal DVT have concurrent PE at presentation. VTE has been seen in up to one-third of patients with COVID-19 infections requiring intensive care unit (ICU) admission. The objective of this study is to determine the correlation between CT pulmonary angiography, pulmonary embolism clot burden, and the Qanadli scoring system with clinically severe COVID-19 pneumonia and cytokine storm.

MATERIAL AND METHOD

153 COVID-19 hospitalized patients who underwent CT pulmonary angiography (CTPA) for likely PE on pretest probability modified Wells criteria were enrolled. COVID-19 pneumonia was classified as URTI (upper respiratory tract infection), mild, severe, and critical COVID pneumonia. For data analysis, we categorized into two groups: (1) the non-severe group included URTI and mild pneumonia, and (2) the severe group included severe and critical pneumonia. We used the Qanadli scoring system to assess the PE percentages of pulmonary vascular obstruction using CTPA.  Results: 41.8% (64) of COVID-19 patients were diagnosed with pulmonary embolism (PE) on CTPA. The majority of 51.6% of pulmonary vascular occlusions using the Qanadli scoring system for pulmonary embolism were at segmental arterial levels. Out of 104 COVID-19 cytokine storm patients, 45 (43%) were associated with pulmonary embolism. Overall, a 25% (16) mortality rate was observed in COVID-19 patients with pulmonary embolism.

DISCUSSION

The pathogenesis of hypercoagulability in COVID-19 may include direct endothelial cell invasion by the virus, microvascular inflammation, endothelial exocytosis, and endotheliitis. A meta-analysis of 71 studies to investigate the occurrence of PE on CTPA in COVID-19 patients found 48.6% in ICU settings and 65.3% of patients have clots in the peripheral pulmonary vasculature.

CONCLUSIONS

There is a significant correlation between pulmonary embolism and high clot burden Qanadli CTPA scores, as well as between the severity of COVID-19 pneumonia and mortality. The association between critically ill COVID-19 pneumonia and pulmonary embolism may result in higher mortality and a poor prognostic marker.

Association of thrombosis and mortality in patients with COVID-19 infections: a hospital-based observational study

Objective

A hospital-based cross-sectional study on COVID-19 confirmed patients was conducted at the Aga Khan University Hospital, Karachi, Pakistan, from April to June 2021. Presence of thrombosis in these patients was compared with mortality. Platelet counts and D-dimer was also compared among survivor and non-survivor to identify the marker for severity of the disease.

Results

Sixty-six patients were enrolled in the study and the mean age of the patients was 62.3 years and 45 patients (68.2%) were male. Pulmonary embolism was identified in 32 patients (48.5%) while non-pulmonary thrombosis occurred in 5 of the admitted patients (7.6%). In our study, mortality occurred in 34 patients (51.5%). Pulmonary embolism was identified in 20 recovered patients (62.5%) and 10 patients died (p value 0.03). Four patients (80%) with non-pulmonary thrombosis were non-survivors (p value 0.05). Median platelets were 73 in non-survivors and 109.5 in survivors (p value < 0.01). Both the groups had a median D-dimer of 3.8 (p value 0.024).

Conclusion

Based on our study, we conclude that COVID-19 infection has the potential to cause hypercoagulable states. It increases the risk of thrombosis and with thrombosis it has a higher mortality rate. Thrombocytopenia is a biomarker with an adverse prognosis in these patients.

Effect of heparin treatment on pulmonary embolism and in-hospital death in unvaccinated COVID-19 patients without overt deep vein thrombosis

Background

Pulmonary embolism (PE) without overt deep vein thrombosis (DVT) was common in hospitalized coronavirus-induced disease (COVID)-19 patients and represented a diagnostic, prognostic, and therapeutic challenge. The aim of this study was to analyze the prognostic role of PE on mortality and the preventive effect of heparin on PE and mortality in unvaccinated COVID-19 patients without overt DVT.

Methods

Data from 401 unvaccinated patients (age 68 ± 13 years, 33% females) consecutively admitted to the intensive care unit or the medical ward were included in a retrospective longitudinal study. PE was documented by computed tomography scan and DVT by compressive venous ultrasound. The effect of PE diagnosis and any heparin use on in-hospital death (primary outcome) was analyzed by a classical survival model. The preventive effect of heparin on either PE diagnosis or in-hospital death (secondary outcome) was analyzed by a multi-state model after having reclassified patients who started heparin after PE diagnosis as not treated.

Results

Median follow-up time was 8 days (range 1–40 days). PE cumulative incidence and in-hospital mortality were 27% and 20%, respectively. PE was predicted by increased D-dimer levels and COVID-19 severity. Independent predictors of in-hospital death were age (hazards ratio (HR) 1.05, 95% confidence interval (CI) 1.03–1.08, p < 0.001), body mass index (HR 0.93, 95% CI 0.89–0.98, p = 0.004), COVID-19 severity (severe versus mild/moderate HR 3.67, 95% CI 1.30–10.4, p = 0.014, critical versus mild/moderate HR 12.1, 95% CI 4.57–32.2, p < 0.001), active neoplasia (HR 2.58, 95% CI 1.48–4.50, p < 0.001), chronic obstructive pulmonary disease (HR 2.47; 95% CI 1.15–5.27, p = 0.020), respiratory rate (HR 1.06, 95% CI 1.02–1.11, p = 0.008), heart rate (HR 1.03, 95% CI 1.01–1.04, p < 0.001), and any heparin treatment (HR 0.35, 95% CI 0.18–0.67, p = 0.001). In the multi-state model, preventive heparin at prophylactic or intermediate/therapeutic dose, compared with no treatment, reduced PE risk and in-hospital death, but it did not influence mortality of patients with a PE diagnosis.

Conclusions

PE was common during the first waves pandemic in unvaccinated patients, but it was not a negative prognostic factor for in-hospital death. Heparin treatment at any dose prevented mortality independently of PE diagnosis, D-dimer levels, and disease severity.

COVID-19-associated Coagulopathy and Thromboembolism: Determination of their Patterns and Risk Factors as Predictors of Mortality Among Severe COVID-19 Patients

BACKGROUND

Corona virus disease 2019 (COVID-19) is associated with coagulopathy (CAC) and venous thromboembolism (VTE). These are well-reported complications of COVID-19 infection. Earlier publications have shown that CAC and thromboembolism are predictors of mortality among COVID-19 patients with severe disease.

MATERIAL AND METHODS

A prospective study was conducted in the Intensive Care Unit (ICU) where all confirmed COVID-19 patients were enrolled and followed until death or ICU discharge. CAC, VTE, along with all comorbidities were recorded. Predictors of mortality were determined by univariate and multivariate regression.

RESULTS

Among 261 patients with COVID-19, 48.3% survived and 51.7% died. CAC was present in 53.2% and 76.3% of the survivors and non-survivors, respectively (p<0.001); 89 patients (31.4%) had VTE (p=0.36) and 11 patients (4.2%) had arterial thrombosis (p=0.76) among survivors and non-survivors. Age between 71-80 years (p=0.009), male gender (p=0.045), CAC (p<0.001), comorbidities like chronic kidney disease (CKD, p=0.013), chronic obstructive pulmonary disease (COPD, p=0.001) and asthma (p=0.046), were significant predictors of mortality.

CONCLUSION

A severe complication of COVID-19 is CAC, such as sepsis-induced coagulopathy, overt disseminated-coagulopathy and VTE. Old age, various comorbidities (e.g. COPD, CKD or asthma), CAC, VTE (pulmonary embolism) and coagulation parameters with critical severity score (D-dimers, platelets, prothrombin time) and the SOFA (Sequential Organ Failure Assessment) score were significant predictors of mortality among COVID-19 patients.

The Use of Vancomycin Versus Teicoplanin in Treating Febrile Neutropenia: A Meta-Analysis and Systematic Review

Background and objective

The efficacy of vancomycin vs. teicoplanin for the successful treatment of febrile neutropenia (FN) has been a subject of debate in the medical community. In light of this, we performed a systematic review and meta-analysis to compare these two medications in the treatment of patients with FN in terms of treatment success and adverse events.

Data source and study design

We conducted a search of major electronic databases [MEDLINE (PubMed, Ovid), Google Scholar, clinicaltrial.org], which returned 10 studies with 1,630 patients (vancomycin: 788; teicoplanin: 842) for analysis. An unadjusted odds ratio (OR) with a 95% confidence interval (CI) was calculated for all studies, as well as separate sub-analyses of randomized controlled trials (RCTs) and retrospective studies.

Results

The average age of patients ranged from 37 to 57 years in the vancomycin group and 31 to 57 years in the teicoplanin group (n=9 studies). Over half of the patients in both groups were male (vancomycin: 55.6%; teicoplanin: 57.7%; n=9 studies). Both overall evaluation and sub-analyses revealed that both treatments were comparable in terms of treatment success, nephrotoxicity, and red man syndrome. The vancomycin group was more likely to develop skin rashes (OR: 2.49; 95% CI: 1.28-4.83). The heterogeneity for all analyses ranged from 0-47.4%.

Conclusion

Our analysis showed that vancomycin and teicoplanin showed comparable results in terms of successful treatment of FN. Adverse effects such as nephrotoxicity and red man syndrome were also comparable between the two treatment groups.