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Trebuian CI, Marza AM, Cindrea AC, Petrica A, Onea S, Sutoi D, Barsac C, Crintea-Najette I, Popa D, Chioibas R, Mederle OA. Risk Assessment of Venous Thromboembolism among Septic Shock Patients: Single versus Concurrent Insertion of Central Venous Catheters. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:785. [PMID: 38792968 PMCID: PMC11123159 DOI: 10.3390/medicina60050785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: Thrombosis is a serious complication experienced by some hospitalized patients. While concurrent placement of two catheters (CVCs) in the same central vein offers several benefits in clinical settings, we aimed to investigate the role of this procedure in relation to the risk of thrombosis. Materials and Methods: Over a two-year retrospective analysis, we examined 114 patients with septic shock caused by a pulmonary infection, who underwent the insertion of one or more central lines into a central vein during their ICU stay. Logistic regression models were employed to assess the correlation between the Caprini risk score, the placement of two CVCs in the same vein, COVID-19 infection and the risk of venous thromboembolism (VTE). Results: In total, 53% of the patients underwent the concurrent insertion of two CVCs. The placement of two CVCs in the same vein appears to elevate the VTE risk by 2.5 times (95% CI: 1.03-6.12). Logistic regression analysis indicated that hemodialysis catheters amplify the VTE risk by nearly five times, even when accounting for a series of factors (95% CI: 1.86-12.31). Conclusions: Our study suggests that the elevated risk of VTE is likely associated with the insertion of the hemodialysis catheters rather than solely the presence of two concurrent catheters.
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Affiliation(s)
- Cosmin Iosif Trebuian
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Department of Anesthesia and Intensive Care, Emergency County Hospital, 320210 Resita, Romania
| | - Adina Maria Marza
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital, 300079 Timisoara, Romania
| | - Alexandru Cristian Cindrea
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital, 300079 Timisoara, Romania
| | - Alina Petrica
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Emergency Department, “Pius Brinzeu” Emergency Clinical County Hospital, 300736 Timisoara, Romania
| | - Stefania Onea
- Clinic of Anesthesia and Intensive Care, “Pius Brinzeu” Emergency Clinical County Hospital, 300736 Timisoara, Romania;
| | - Dumitru Sutoi
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Clinic of Anesthesia and Intensive Care, “Pius Brinzeu” Emergency Clinical County Hospital, 300736 Timisoara, Romania;
| | - Claudiu Barsac
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Clinic of Anesthesia and Intensive Care, “Pius Brinzeu” Emergency Clinical County Hospital, 300736 Timisoara, Romania;
| | - Iulia Crintea-Najette
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital, 300079 Timisoara, Romania
| | - Daian Popa
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital, 300079 Timisoara, Romania
| | - Raul Chioibas
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
| | - Ovidiu Alexandru Mederle
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.I.T.); (A.C.C.); (A.P.); (D.S.); (C.B.); (I.C.-N.); (D.P.); (R.C.); (O.A.M.)
- Emergency Department, Emergency Clinical Municipal Hospital, 300079 Timisoara, Romania
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Youness M, Mansour S, Sakr F, Olabi S, Atwi S, Martinez IY, El Khatib S, Hallit S, Salameh P, Malaeb D, Hosseini H. Odds and associated factors for thrombosis development among Lebanese COVID-19 patients: a case-control retrospective study. J Pharm Policy Pract 2024; 17:2319743. [PMID: 38505825 PMCID: PMC10950289 DOI: 10.1080/20523211.2024.2319743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
Background Thromboembolism is reported to be up to 27% in COVID-19 patients due to SARS-CoV-2 infection. Dysregulated systemic inflammation and various patient traits play a vital role in thrombosis progression. Purpose To assess odds and associated factors for thrombosis development among Lebanese COVID-19 patients. Methods This was a case-control retrospective study conducted in January-May 2021. Patients infected with COVID-19 and developed thrombosis were classified as cases and patients who were thrombosis-free identified as control. A questionnaire assessed socio-demographics, clinical parameters, and WHO COVID-19 disease severity. Results Among 267 patients, 26 (9.7%) developed thrombosis and the majority of thrombosis 34.6% was myocardial infarction, and the least (3.8%) was for catheter-related thrombosis. Results showed that the risk of thrombosis development is higher in patients with previous thromboembolic event (OR = 9.160) and previous intake of anti-hypertensive medications at home (OR = 3.116). However, females (OR = 0.330; CI: 0.118-0.925), intake of anticoagulants during hospital admission (OR = 0.126; CI: 0.053-0.300) and non-severe COVID-19 were at lower thrombosis risk (OR = 0.273). Patients who developed thromboembolic events had longer hospital stay (OR = 0.077). Conclusion Patients with COVID-19 and thromboembolism were at higher risk of mortality as compared to patients with COVID-19 but without thromboembolism. The use of anticoagulants significantly reduced the risk for thromboembolism.
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Affiliation(s)
- Mahmoud Youness
- Research Department, Beirut Cardiac Institute, Beirut, Lebanon
| | - Sara Mansour
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Fouad Sakr
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Samer Olabi
- Rafic Hariri University Hospital, Beirut, Lebanon
| | - Sarah Atwi
- Rafic Hariri University Hospital, Beirut, Lebanon
| | | | - Sami El Khatib
- Department of Biomedical Sciences, Lebanese International University, Bekaa, Lebanon
- Center for Applied Mathematics and Bioinformatics (CAMB), Gulf University for Science and Technology, Mubarak Al-Abdullah, Kuwait
| | - Souheil Hallit
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
| | - Pascale Salameh
- INSPECT-LB: Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Beirut, Lebanon
- Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
- Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
- School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Diana Malaeb
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Hassan Hosseini
- Neurology Department, Henri Mondor Hospital, AP-HP, Creteil, France
- UPEC-University Paris-Est, Creteil, France
- RAMSAY SANTÉ, HPPE, Champigny sur Marne, France
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Bakhsh E. The Benefits and Imperative of Venous Thromboembolism Risk Screening for Hospitalized Patients: A Systematic Review. J Clin Med 2023; 12:7009. [PMID: 38002623 PMCID: PMC10672497 DOI: 10.3390/jcm12227009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Venous thromboembolism (VTE) is a major preventable condition in hospitalized patients globally. This systematic review evaluates the effectiveness and clinical significance of venous thromboembolism (VTE) risk-screening protocols in preventing VTE events among hospitalized patients. Databases, including PubMed, Embase and Cochrane, were searched without date limits for studies comparing outcomes between hospitalized patients who did and did not receive VTE risk screening using standard tools. Twelve studies, enrolling over 139,420 patients, were included. Study quality was assessed using the ROBVIS tool. The results were summarized narratively. The findings show significant benefits of using VTE risk screening versus usual care across various outcomes. Using recommended tools, like Caprini, Padua and IMPROVE, allowed for the accurate identification of high-risk patients who benefited most from prevention. Formal screening was linked to much lower VTE rates, shorter hospital stays, fewer deaths and better use of preventive strategies matched to estimated clot risk. This review calls for the widespread adoption of VTE risk screening as an important safety step for at-risk hospital patients. More high-quality comparative research is needed to validate screening tools in different settings and populations. In summary, VTE risk screening is essential for healthcare systems to reduce life-threatening VTE events and improve patient outcomes through properly targeted preventive methods.
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Affiliation(s)
- Ebtisam Bakhsh
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia
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Lobastov K, Urbanek T, Stepanov E, Lal BK, Marangoni J, Krauss ES, Cronin M, Dengler N, Segal A, Welch HJ, Gianesini S, Chen X, Caprini JA. The Thresholds of Caprini Score Associated With Increased Risk of Venous Thromboembolism Across Different Specialties: A Systematic Review. Ann Surg 2023; 277:929-937. [PMID: 36912040 DOI: 10.1097/sla.0000000000005843] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/18/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Estimation of the specific thresholds of the Caprini risk score (CRS) that are associated with the increased incidence of venous thromboembolism (VTE) across different specialties, including identifying the highest level of risk. BACKGROUND Accurate risk assessment remains an important but often challenging aspect of VTE prophylaxis. One well-established risk assessment model is CRS, which has been validated in thousands of patients from many different medical and surgical specialties. METHODS A search of MEDLINE and the Cochrane Library was performed in March 2022. Manuscripts that reported on (1) patients admitted to medical or surgical departments and (2) had their VTE risk assessed by CRS and (3) reported on the correlation between the score and VTE incidence, were included in the analysis. RESULTS A total of 4562 references were identified, and the full text of 202 papers was assessed for eligibility. The correlation between CRS and VTE incidence was reported in 68 studies that enrolled 4,207,895 patients. In all specialties, a significant increase in VTE incidence was observed in patients with a CRS of ≥5. In most specialties thresholds of ≥7, ≥9, and ≥11 to 12 were associated with dramatically increased incidences of VTE. In COVID-19, cancer, trauma, vascular, general, head and neck, and thoracic surgery patients with ≥9 and ≥11 to 12 scores the VTE incidence was extremely high (ranging from 13% to 47%). CONCLUSION The Caprini score is being used increasingly to predict VTE in many medical and surgical specialties. In most cases, the VTE risk for individual patients increases dramatically at a threshold CRS of 7 to 11.
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Affiliation(s)
- Kirill Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Eugeniy Stepanov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Brajesh K Lal
- University of Maryland School of Medicine, Baltimore, MD
| | | | - Eugene S Krauss
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - MaryAnne Cronin
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Nancy Dengler
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Ayal Segal
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Harold J Welch
- Division of Vascular Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Xiaolan Chen
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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5
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Fanning JP, Weaver N, Fanning RB, Griffee MJ, Cho SM, Panigada M, Obonyo NG, Zaaqoq AM, Rando H, Chia YW, Fan BE, Sela D, Chiumello D, Coppola S, Labib A, Whitman GJR, Arora RC, Kim BS, Motos A, Torres A, Barbé F, Grasselli G, Zanella A, Etchill E, Usman AA, Feth M, White NM, Suen JY, Li Bassi G, Peek GJ, Fraser JF, Dalton H. Hemorrhage, Disseminated Intravascular Coagulopathy, and Thrombosis Complications Among Critically Ill Patients with COVID-19: An International COVID-19 Critical Care Consortium Study. Crit Care Med 2023; 51:619-631. [PMID: 36867727 PMCID: PMC10089926 DOI: 10.1097/ccm.0000000000005798] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
OBJECTIVES To determine the prevalence and outcomes associated with hemorrhage, disseminated intravascular coagulopathy, and thrombosis (HECTOR) complications in ICU patients with COVID-19. DESIGN Prospective, observational study. SETTING Two hundred twenty-nine ICUs across 32 countries. PATIENTS Adult patients (≥ 16 yr) admitted to participating ICUs for severe COVID-19 from January 1, 2020, to December 31, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS HECTOR complications occurred in 1,732 of 11,969 study eligible patients (14%). Acute thrombosis occurred in 1,249 patients (10%), including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial ischemia, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic strokes. Hemorrhagic complications were reported in 579 patients (4.8%), including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, 77 (13%) with pulmonary hemorrhage, and 68 (12%) with hemorrhage associated with extracorporeal membrane oxygenation (ECMO) cannula site. Disseminated intravascular coagulation occurred in 11 patients (0.09%). Univariate analysis showed that diabetes, cardiac and kidney diseases, and ECMO use were risk factors for HECTOR. Among survivors, ICU stay was longer (median days 19 vs 12; p < 0.001) for patients with versus without HECTOR, but the hazard of ICU mortality was similar (hazard ratio [HR] 1.01; 95% CI 0.92-1.12; p = 0.784) overall, although this hazard was identified when non-ECMO patients were considered (HR 1.13; 95% CI 1.02-1.25; p = 0.015). Hemorrhagic complications were associated with an increased hazard of ICU mortality compared to patients without HECTOR complications (HR 1.26; 95% CI 1.09-1.45; p = 0.002), whereas thrombosis complications were associated with reduced hazard (HR 0.88; 95% CI 0.79-0.99, p = 0.03). CONCLUSIONS HECTOR events are frequent complications of severe COVID-19 in ICU patients. Patients receiving ECMO are at particular risk of hemorrhagic complications. Hemorrhagic, but not thrombotic complications, are associated with increased ICU mortality.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Natasha Weaver
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Robert B Fanning
- Northern Hospital, Northern Health, Melbourne, VIC, Australia
- Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Matthew J Griffee
- Department of Anesthesiology and Perioperative Medicine, Sections of Critical Care and Perioperative Echocardiography, University of Utah, Salt Lake City, UT
- Department of Anesthesiology, Anesthesiology Service, Veteran Affairs Medical Center, Salt Lake City, UT
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Neuroscience Critical Care, Department of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mauro Panigada
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
| | - Nchafatso G Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Initiative to Develop African Research Leaders (IDeAL)/KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
| | - Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
- Department of Medicine, Georgetown University, Washington, DC
| | - Hannah Rando
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bingwen Eugene Fan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Haematology, Tan Tock Seng Hospital, Singapore
- Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore
| | - Declan Sela
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, Aziende Socio Sanitarie Territoriali (ASST) Santi Paolo e Carlo, San Paolo University Hospital of Milan, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, Aziende Socio Sanitarie Territoriali (ASST) Santi Paolo e Carlo, San Paolo University Hospital of Milan, Milan, Italy
| | - Ahmed Labib
- Medical Intensive Care Unit, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Bo S Kim
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anna Motos
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Division of Cardiac Surgery, Department of Surgery, Case Western Reserve University, Cleveland, OH
| | - Antoni Torres
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Division of Cardiac Surgery, Department of Surgery, Case Western Reserve University, Cleveland, OH
- Centro de Investigación Biomedica En Red - Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Ferran Barbé
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Servei de Pneumologia, Hospital Clinic, University of Barcelona, Spain
| | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
- Institució Catalana de Recerca i Estudis Avançats, Spain
| | - Alberto Zanella
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
- Institució Catalana de Recerca i Estudis Avançats, Spain
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Asad Ali Usman
- Translational Research in Respiratory Medicine, Respiratory Department, Hospital Universitari Aranu de Vilanova and Santa Maria, IRBLleida, Leida, Spain
| | - Maximilian Feth
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nicole M White
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - Giles J Peek
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Heidi Dalton
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
- Congenital Heart Centre, University of Florida, Gainesville, FL
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Pan J, Bonow RH, Temkin N, Robinson EF, Sekhar LN, Levitt MR, Lele AV. Incidence and Risk Model of Venous Thromboembolism in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 172:e418-e427. [PMID: 36657716 DOI: 10.1016/j.wneu.2023.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a significant source of morbidity and mortality in hospitalized patients. We describe our experience with VTE prophylaxis and treatment in patients with aneurysmal subarachnoid hemorrhage (aSAH), risk factors for VTE, and a hazard model describing the daily risk of VTE. METHODS A retrospective cohort study was performed on patients with aSAH admitted from 2014 to 2018. Patients were screened for VTE based on clinical suspicion. Demographics, perioperative data, and in-hospital data were assessed as risk factors for VTE using survival analysis with death as a competing risk. RESULTS Among 485 patients, the overall incidence of VTE, deep vein thrombosis, and pulmonary embolism were 5.6%, 4.3%, and 2.3%, respectively. Increasing length of stay in the intensive care unit (hazard ratio [HR], 1.79; P < 0.0001; 95% confidence interval [CI], 1.49-2.16) and ventilation immediately after aneurysm treatment was associated with VTE (HR, 8.87; P < 0.01; 95% CI, 1.86-42.38). Hunt and Hess grade was negatively associated with VTE (HR, 0.61; P = 0.045; 95% CI, 0.37-1.00) due to its increased association with the competing risk of death (HR, 2.57; P < 0.0001; 95% CI, 1.89-3.49). The adjusted 4-year cumulative incidence for VTE is 11.1% and at mean day of hospital discharge is 5.4%. Treatment of VTEs with anticoagulation and/or inferior vena cava filter placement was not associated with immediate complications. CONCLUSIONS We describe the largest single-institution cohort of VTEs in aSAH patients. Our hazard model quantifies the cumulative incidence of VTEs during the course of hospitalization. We suggest a standardized protocol for screening, prophylaxis, and treatment of VTEs in this patient population.
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Affiliation(s)
- James Pan
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert H Bonow
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA; Harborview Injury Prevention Research Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA; Harborview Injury Prevention Research Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ellen F Robinson
- Quality Improvement, Harborview Medical Center, Seattle, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Abhijit V Lele
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA; Harborview Injury Prevention Research Center, University of Washington School of Medicine, Seattle, Washington, USA.
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7
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Kumar SVRB, Elango I, Balasubramanian K, Nair SV, Ramasamy A, Kathir C. Renal Allograft Cortical Necrosis in a COVID-19 Positive Patient. Indian J Nephrol 2023; 33:125-127. [PMID: 37234436 PMCID: PMC10208533 DOI: 10.4103/ijn.ijn_3_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/15/2022] [Indexed: 11/04/2022] Open
Abstract
The incidence of acute kidney injury (AKI) has been reported to be higher in kidney transplant recipients infected with SARS-CoV-2 compared with the general population. Here, we report a case of cortical necrosis in the graft kidney due to COVID infection in a patient with stable graft function over the years. The patient was started on hemodialysis and treated with steroids, and anticoagulants for COVID infection. Later, he had gradual improvement in his graft function and became dialysis independent on follow up.
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Affiliation(s)
- SVR Bipin Kumar
- Department of Nephrology, Saveetha Medical College Hospital, Tamil Nadu, India
| | - Indumathi Elango
- Department of Nephrology, Saveetha Medical College Hospital, Tamil Nadu, India
| | | | - Sanjeev V. Nair
- Department of Nephrology, Saveetha Medical College Hospital, Tamil Nadu, India
| | - Ashok Ramasamy
- Department of Nephrology, Saveetha Medical College Hospital, Tamil Nadu, India
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Liu Y, Feng X, Tang Y, Sun Y, Pu X, Feng X. Clinical characteristics of venous thromboembolism onset from severe high altitude pulmonary edema in plateau regions. Thromb J 2023; 21:22. [PMID: 36855176 PMCID: PMC9973235 DOI: 10.1186/s12959-023-00469-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/20/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND To investigate venous thromboembolism (VTE) in hospitalized patients with severe high altitude pulmonary edema (HAPE), we performed a single center retrospective study to evaluate its clinical characteristics, prognosis, and potential thromboprophylaxis strategies in a large referral and treatment center in plateau regions. METHODS We studied a total of 18 patients with severe HAPE from January 1, 2012 to December 31, 2021. Demographic and clinical data, laboratory data, including ultrasound scans of the lower extremities and cardiac ultrasound, and computed tomographic pulmonary angiography (CTPA) variables were obtained, and comparisons were made between groups with and without VTE. RESULTS Of the 18 patients hospitalized with severe HAPE (age 43 (range, 34-54) years, 14 [77.8%] men), 7 patients developed VTE (38.9%), including 5 with deep vein thrombosis (DVT) and pulmonary embolism (PE), 2 of whom had DVT only. Eighteen patients are all firstly rapid ascent to high altitudes which the mean altitude was 3700 m (3656-4050 m). Compared with patients who did not have VTE, patients with VTE had a longer time in hospital (13 [11, 19] versus 9 [7, 12]; P = 0.027), respiratory failure (6 [85.7%] versus 2 [18.2%]; P = 0.013), the shortened APTT (21.50 [19.00, 27.50] versus 26.30 [24.80, 30.10]; P = 0.044) and the higher level of D-dimer (7.81 [4.62, 9.60] versus 2.90 [1.75, 3.37]; P = 0.003). The proportion of thromboprophylaxis is too low in our cohort which 2 of 18 (11.1%) patients were given VTE prophylaxis. There was no statistically significant difference between the VTE and non-VTE groups (0 [0.0%] versus 2 [18.2%]; P = 0.497). CONCLUSIONS The prevalence of VTE is high in hospitalized patients with severe high altitude pulmonary edema (HAPE). Prophylaxis for venous thromboembolism may be protective in severe HAPE patients after admission. Our data seem to suggest that VTE is probably an additional prognostic factors in patients with severe HAPE.
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Affiliation(s)
- Yanmin Liu
- grid.469564.cDepartment of Cardiology, Qinghai Provincial People’s Hospital, 2 Gonghe Road, Chengdong District, Xining, Qinghai Province 810007 China ,grid.263761.70000 0001 0198 0694Suzhou Medical College of Soochow University, 199 RenAi Road, Suzhou Industrial Park, Suzhou, Jiangsu Province 215123 China
| | - Xinwei Feng
- grid.262246.60000 0004 1765 430XCollege of Medicine, Qinghai University, 16 Kunlun Road, Chengxi District, Xining, Qinghai Province 810001 China
| | - Yongxue Tang
- grid.262246.60000 0004 1765 430XCollege of Medicine, Qinghai University, 16 Kunlun Road, Chengxi District, Xining, Qinghai Province 810001 China
| | - Yanqiu Sun
- The Department of Radiology, Qinghai Provincial People's Hospital, 2 Gonghe Road, Chengdong District, Xining, Qinghai Province, 810007, China.
| | - Xiaoyan Pu
- College of Medicine, Qinghai University, 16 Kunlun Road, Chengxi District, Xining, Qinghai Province, 810001, China.
| | - Xiaokai Feng
- Department of Respiratory and Critical Care Medicine, Qinghai Provincial People's Hospital, 2 Gonghe Road, Chengdong District, Xining, Qinghai Province, 810007, China. .,Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, China.
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9
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Li L, Zhen J, Huang L, Zhou J, Yao L, Xu L, Zhang W, Zhang G, Chen Q, Cheng B, Gong S, Cai G, Jiang R, Yan J. The risk factors for deep venous thrombosis in critically ill older adult patients: a subgroup analysis of a prospective, multicenter, observational study. BMC Geriatr 2022; 22:977. [PMID: 36536310 PMCID: PMC9764582 DOI: 10.1186/s12877-022-03599-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Older adult patients mainly suffer from multiple comorbidities and are at a higher risk of deep venous thrombosis (DVT) during their stay in the intensive care unit (ICU) than younger adult patients. This study aimed to analyze the risk factors for DVT in critically ill older adult patients. METHODS This was a subgroup analysis of a prospective, multicenter, observational study of patients who were admitted to the ICU of 54 hospitals in Zhejiang Province from September 2019 to January 2020 (ChiCTR1900024956). Patients aged > 60 years old on ICU admission were included. The primary outcome was DVT during the ICU stay. The secondary outcomes were the 28- and 60-day survival rates, duration of stay in ICU, length of hospitalization, pulmonary embolism, incidence of bleeding events, and 60-day coagulopathy. RESULTS A total of 650 patients were finally included. DVT occurred in 44 (2.3%) patients. The multivariable logistic regression analysis showed that age (≥75 vs 60-74 years old, odds ratio (OR) = 2.091, 95% confidence interval (CI): 1.308-2.846, P = 0.001), the use of analgesic/sedative/muscarinic drugs (OR = 2.451, 95%CI: 1.814-7.385, P = 0.011), D-dimer level (OR = 1.937, 95%CI: 1.511-3.063, P = 0.006), high Caprini risk score (OR = 2.862, 95%CI: 1.321-2.318, P = 0.039), basic prophylaxis (OR = 0.111, 95%CI: 0.029-0.430, P = 0.001), and physical prophylaxis (OR = 0.322, 95%CI: 0.109-0.954, P = 0.041) were independently associated with DVT. There were no significant differences in 28- and 60-day survival rates, duration of stay in ICU, total length of hospitalization, 60-day pulmonary embolism, and coagulation dysfunction between the two groups, while the DVT group had a higher incidence of bleeding events (2.6% vs. 8.9%, P < 0.001). CONCLUSION In critically ill older adult patients, basic prophylaxis and physical prophylaxis were found as independent protective factors for DVT. Age (≥75 years old), the use of analgesic/sedative/muscarinic drugs, D-dimer level, and high Caprini risk score were noted as independent risk factors for DVT. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR1900024956).URL: http://www.chictr.org.cn/listbycreater.aspx .
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Affiliation(s)
- Li Li
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Junhai Zhen
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Liquan Huang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of Chinese Medicine, 54 Youdian Road, Hangzhou, 310013 China
| | - Jia Zhou
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Lina Yao
- grid.411634.50000 0004 0632 4559Department of Critical Care Medicine, Ningbo Yinzhou People’s Hospital, 58 Zhoumeng North Road, Yinzhou, Ningbo City, 315100 China
| | - Lingen Xu
- Department of Critical Care Medicine, Xinchang Hospital of Traditional Chinese Medicine, 188 Jiufeng Road, Xinchang, Shaoxing City, 312500 China
| | - Weimin Zhang
- grid.452237.50000 0004 1757 9098Department of Critical Care Medicine, Dongyang People’s Hospital, 60 Wuning West Road, Dongyang, Jinhua City, 322100 China
| | - Gensheng Zhang
- grid.412465.0Department of Critical Care Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009 China
| | - Qijiang Chen
- Department of Critical Care Medicine, Ninghai First Hospital, 142 Taoyuan Middle Road, Ninghai, Ningbo City, 315600 China
| | - Bihuan Cheng
- grid.268099.c0000 0001 0348 3990Department of Critical Care Medicine, The 2nd School of Medicine, Wenzhou Medical University, 109 West Xueyuan Road, Wenzhou, 325027 China
| | - Shijin Gong
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Guolong Cai
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
| | - Ronglin Jiang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of Chinese Medicine, 54 Youdian Road, Hangzhou, 310013 China
| | - Jing Yan
- grid.417400.60000 0004 1799 0055Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013 China
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10
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Sochet AA, Havlicek EE, Faustino EVS, Goldenberg NA. Mechanical Ventilation and Hospital-Acquired Venous Thromboembolism Among Critically Ill Children. Hosp Pediatr 2022; 12:1099-1109. [PMID: 36349533 DOI: 10.1542/hpeds.2022-006697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To estimate the occurrence of, and evaluate associations between, hospital-acquired venous thromboembolism (HA-VTE) and invasive mechanical ventilation (MV) among children hospitalized in the PICU. METHODS We performed a multicenter, retrospective cohort study comparing HA-VTE frequencies among subjects <18 years of age hospitalized in the PICU from January 2018 through December 2019 among 47 participating centers, via the Pediatric Health Information Systems registry. We excluded perinatal encounters, those with VTE present at admission, and those with observational status. The primary outcome was the proportion of HA-VTE events before hospital discharge, including extremity deep venous thrombosis, pulmonary embolism, and organ-specific deep venous thrombosis. The HA-VTE frequencies were compared using χ2 tests. The association between HA-VTE and MV was investigated via multivariable logistic regression, adjusting for previously described VTE risk factors. RESULTS Of the 205 231 PICU encounters identified for study, 70 829 (34.5%) underwent MV. The occurrence of HA-VTE was 2.2% and was greater among children who received, versus did not receive, MV (4.4% versus 1.1%, P < .001). Multivariable logistic regression revealed significant association between MV and HA-VTE (odds ratio 2.51, 95% confidence interval 2.33-2.69; P < .001). CONCLUSIONS In this multicenter, retrospective, registry-based cohort study, HA-VTE were diagnosed in 2.2% of critically-ill children, and after adjustment for central venous catheterization, MV independently increased the risk of HA-VTE 2.5-fold. These findings warrant prospective validation to inform the design of future risk-stratified clinical trials of thromboprophylaxis in critically-ill children.
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Affiliation(s)
- Anthony Alexander Sochet
- Divisions of Critical Care Medicine.,Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida.,Departments of Anesthesiology.,Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | | | - Neil Andrew Goldenberg
- Hematology, Department of Medicine, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Departments of Medicine.,Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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11
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The Incidence of Venous Thromboembolism in Critically Ill Patients with SARS-CoV-2 Infection Compared with Critically Ill Influenza and Community-Acquired Pneumonia Patients: A Retrospective Chart Review. Med Sci (Basel) 2022; 10:medsci10020030. [PMID: 35736350 PMCID: PMC9231025 DOI: 10.3390/medsci10020030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/10/2022] [Accepted: 06/06/2022] [Indexed: 01/08/2023] Open
Abstract
The rate of venous thromboembolism in COVID-19 patients has been reported to be 30% (deep vein thrombosis 20% and pulmonary embolism 18%). This has been shown to be higher in COVID-19 patients admitted to the ICU. Prophylactic anticoagulation may be sufficient at ward level, but not in intensive care. A retrospective chart review was undertaken in a large university hospital. The review included 276 patients from COVID-19 Wave 1, COVID-19 Wave 2, influenza, and community-acquired pneumonia groups. The timeframe included patients admitted between 23 February 2014 and 12 May 2021. Clinical characteristics, outcomes, blood results, rates of venous thromboembolism, and anticoagulation status were recorded. The incidence of venous thromboembolism in COVID-19 Wave 1, COVID-19 Wave 2, influenza, and community-acquired pneumonia was 10.91%, 13.69%, 13.33%, and 6.81%, respectively (p = 0.481). The incidence of pulmonary embolism was 7.27%, 10.95%, 3.33%, and 5.68%, respectively (p = 0.350). The incidence of deep vein thrombosis was 5.45%, 5.48%, 10.00%, and 1.14%, respectively (p = 0.117). Although most patients were prophylactically anticoagulated, venous thromboembolism still occurred. Venous thromboembolism remains an important differential to consider in critically ill COVID-19 patients. The current literature does not advise therapeutic anticoagulation for thromboprophylaxis in the ICU.
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12
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Permpikul C, Chaiyasoot W, Panitchote A. Incidence of proximal deep vein thrombosis in medical critical care patients. Thromb J 2022; 20:5. [PMID: 35123485 PMCID: PMC8817527 DOI: 10.1186/s12959-022-00363-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 01/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background Approximately 13-31% of medical critical care patients develop deep vein thrombosis (DVT). However, there are very few reports regarding the incidence of DVT among Asian patients without routine prophylaxis. The objectives of this study were to assess the prevalence and incidence proportion of proximal DVT in Thai medical critical care patients not receiving thrombosis prophylaxis. Methods We conducted a prospective cohort study in medical critical care patients admitted to Siriraj Hospital, Thailand between November 2008 and November 2009. Patients were screened for proximal DVT by duplex ultrasonography performed 48 h, 7, 14 and 28 days after admission. Primary outcomes were prevalence and incidence proportion of DVT. Factors associated with the development of proximal DVT were evaluated by multivariate analysis. Results Of the 158 patients enrolled in the study, 25 had proximal DVT (15.8%). Nine patients (5.7%) had DVT on the first test at 48 h, while 10 (6.3%), 2 (1.3%) and 4 (2.5%) patients had developed DVT on days 7, 14, and 28, respectively. Thus, the prevalence at the beginning of the study was 5.7% (95%CI 2.6-10.5) and the incidence proportion was 10.1% (95%CI 5.9-15.9). The multivariate analysis showed that age (odds ratio [OR] per 1-year increase was 1.04, 95% confidence interval [CI] 1.01-1.07), female gender (OR 4.05, 95%CI 1.51-12.03), femoral venous catheter (OR 11.18, 95%CI 3.19-44.83), and the absence of platelet transfusion (OR 0.07, 95%CI 0.003-0.43) were associated with the development of proximal DVT. Patients with proximal DVT had a longer hospital length of stay (22 days [IQR 11-60] vs. 14 days [7-23], p = 0.03) and spent more time on mechanical ventilation (10 days (3.3-57) vs. 6 days (3-12), p = 0.053) than patients without DVT. Patient mortality was not affected by the presence of DVT (52% vs. 38.3%, p = 0.29). Conclusions Routine thromboprophylaxis is not used in our institution and the prevalence and incidence proportion of proximal DVT in Asian medical critical care patients were both substantial. Patients with older age, female gender, an intravenous femoral catheter, and the absence of platelet transfusion all had a higher chance of developing proximal DVT.
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13
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Karajizadeh M, Zand F, Sharifian R, Nikandish R, Vazin A, Davoodian L, Nasimi S. Experience with Pharmacological Prophylaxis for Venous Thromboembolism in Surgical ICUs in Tertiary Care Hospitals in Southwest Asia. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03299-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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14
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Li R, Jiang J, Song Y, Zhang J, Wu Y, Wu L, Zhu X, Zeng L. Prognostic Nomogram for Predicting Lower Extremity Deep Venous Thrombosis in Neurointensive Care Unit Patients: A Prospective Observational Study. Front Neurol 2022; 12:761029. [PMID: 35153974 PMCID: PMC8831723 DOI: 10.3389/fneur.2021.761029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/23/2021] [Indexed: 11/24/2022] Open
Abstract
Background Deep venous thrombosis (DVT) of the lower extremities is one of the common complications for neurointensive care unit patients, which leads to increased morbidity and mortality. The purpose of our study was to explore risk factors and develop a prognostic nomogram for lower extremity DVT in neurointensive care unit patients. Methods We prospectively collected and analyzed the clinical data of 420 neurointensive care unit patients who received treatment in our institution between January 2018 and September 2019. Stepwise logistic regression was used to select predictors. R software was used to develop the prognostic nomogram. The performance of the nomogram was validated using a validation cohort of patients with data collected between October 2019 and March 2020. Results Among 420 patients, 153 (36.4%) had lower extremity DVT and five (1.2%) had both DVT and pulmonary embolism (PE) in our study. Logistic regression analysis indicated that age [odds ratio (OR): 1.050; 95% confidence interval (CI): 1.029–1.071; P < 0.001], Glasgow Coma Scale (GCS) score (OR: 0.889; 95% CI: 0.825–0.959; P = 0.002), D-dimer level (OR: 1.040; 95% CI: 1.008–1.074; P = 0.014), muscle strength (OR: 2.424; 95% CI: 1.346–4.366; P = 0.003), and infection (OR: 1.778; 95% CI: 1.034–3.055; P = 0.037) were independent predictors for lower extremity DVT. These predictors were selected to be included in the nomogram model. The area under the curve values in the primary cohort and validation cohort were 0.817 (95% CI: 0.776–0.858) and 0.778 (95% CI: 0.688–0.868), respectively, and respective Brier scores were 0.167 and 0.183. Conclusion Age, GCS score, D-dimer level, muscle strength, and infection are independent predictors for lower extremity DVT. The nomogram is a reliable and convenient model to predict the development of lower extremity DVT in neurointensive care unit patients.
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Affiliation(s)
- Rongqing Li
- Neurointensive Care Unit, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jinxia Jiang
- Department of Emergency, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yu Song
- Department of Neurosurgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jianan Zhang
- Neurointensive Care Unit, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yawen Wu
- Neurointensive Care Unit, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lingzhi Wu
- Neurointensive Care Unit, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoping Zhu
- Department of Nursing, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Xiaoping Zhu
| | - Li Zeng
- Neurointensive Care Unit, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Li Zeng
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15
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S. Aleidan F, Albilal S, Alammari M, Al Sulaiman K, Alassiri M, Abdel Gadir A. Does carbapenem-resistant enterobacteriaceae infection drive venous thromboembolism in patients admitted to intensive care units receiving prophylactic anticoagulants? JOURNAL OF APPLIED HEMATOLOGY 2022. [DOI: 10.4103/joah.joah_151_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Tufano A, Rendina D, Abate V, Casoria A, Marra A, Buonanno P, Galletti F, Di Minno G, Servillo G, Vargas M. Venous Thromboembolism in COVID-19 Compared to Non-COVID-19 Cohorts: A Systematic Review with Meta-Analysis. J Clin Med 2021; 10:jcm10214925. [PMID: 34768445 PMCID: PMC8584903 DOI: 10.3390/jcm10214925] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background: A high incidence of venous thromboembolism (VTE) is reported in hospitalized COVID-19 patients, in particular in patients admitted to the intensive care unit (ICU). In patients with respiratory tract infections, including influenza A (H1N1), many studies have demonstrated an increased incidence of thromboses, but evidence is lacking regarding the risk difference (RD) of the occurrence of VTE between COVID-19 and non-COVID-19 patients. Methods: In this systematic review with meta-analysis, we evaluated the RD of the occurrence of VTE, pulmonary embolism (PE), and deep venous thrombosis (DVT) between COVID-19 and other pulmonary infection cohorts, in particular H1N1, and in an ICU setting. We searched for all studies comparing COVID-19 vs. non-COVID-19 regarding VTE, PE, and DVT. Results: The systematic review included 12 studies and 1,013,495 patients. The RD for VTE in COVID-19 compared to non-COVID-19 patients was 0.06 (95% CI 0.11–0.25, p = 0.011, I2 = 97%), and 0.16 in ICU (95% CI 0.045–0.27, p = 0.006, I2 = 80%). The RD for PE between COVID-19 and non-COVID-19 patients was 0.03 (95% CI, 0.006–0.045, p = 0.01, I2 = 89%). The RD for PE between COVID-19 and non-COVID-19 patients was 0.021 in retrospective studies (95% CI 0.00–0.04, p = 0.048, I2 = 92%) and 0.11 in ICU studies (95% CI 0.06–0.16, p < 0.001, I2 = 0%). Conclusions: The growing awareness and understanding of a massive inflammatory response combined with a hypercoagulable state that predisposes patients to thrombosis in COVID-19, in particular in the ICU, may contribute to a more appropriate strategy of prevention and earlier detection of the thrombotic events.
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Affiliation(s)
- Antonella Tufano
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.T.); (D.R.); (V.A.); (A.C.); (F.G.); (G.D.M.)
| | - Domenico Rendina
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.T.); (D.R.); (V.A.); (A.C.); (F.G.); (G.D.M.)
| | - Veronica Abate
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.T.); (D.R.); (V.A.); (A.C.); (F.G.); (G.D.M.)
| | - Aniello Casoria
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.T.); (D.R.); (V.A.); (A.C.); (F.G.); (G.D.M.)
| | - Annachiara Marra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.M.); (P.B.); (G.S.)
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.M.); (P.B.); (G.S.)
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.T.); (D.R.); (V.A.); (A.C.); (F.G.); (G.D.M.)
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.T.); (D.R.); (V.A.); (A.C.); (F.G.); (G.D.M.)
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.M.); (P.B.); (G.S.)
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.M.); (P.B.); (G.S.)
- Correspondence:
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Cui N, Jiang C, Chen H, Zhang L, Feng X. Prevalence, risk, and outcome of deep vein thrombosis in acute respiratory distress syndrome. Thromb J 2021; 19:71. [PMID: 34645471 PMCID: PMC8511290 DOI: 10.1186/s12959-021-00325-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 10/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few data exist on deep vein thrombosis (DVT) in patients with acute respiratory distress syndrome (ARDS), a group of heterogeneous diseases characterized by acute hypoxemia. STUDY DESIGN AND METHODS We retrospectively enrolled 225 adults with ARDS admitted to the Beijing Chao-Yang Hospital and the First Affiliated Hospital of Shandong First Medical University between 1 January 2015 and 30 June 2020. We analyzed clinical, laboratory, and echocardiography data for groups with and without DVT and for direct (pulmonary) and indirect (extrapulmonary) ARDS subgroups. RESULTS Ninety (40.0%) patients developed DVT. Compared with the non-DVT group, patients with DVT were older, had lower serum creatinine levels, lower partial pressure of arterial oxygen/fraction of inspired oxygen, higher serum procalcitonin levels, higher Padua prediction scores, and higher proportions of sedation and invasive mechanical ventilation (IMV). Multivariate analysis showed an association between age, serum creatinine level, IMV, and DVT in the ARDS cohort. The sensitivity and specificity of corresponding receiver operating characteristic curves were not inferior to those of the Padua prediction score and the Caprini score for screening for DVT in the three ARDS cohorts. Patients with DVT had a significantly lower survival rate than those without DVT in the overall ARDS cohort and in the groups with direct and indirect ARDS. CONCLUSIONS The prevalence of DVT is high in patients with ARDS. The risk factors for DVT are age, serum creatinine level, and IMV. DVT is associated with decreased survival in patients with ARDS.
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Affiliation(s)
- Na Cui
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China
- Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Chunguo Jiang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China
- Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Hairong Chen
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Ji'nan, People's Republic of China
| | - Liming Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.
- Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China.
| | - Xiaokai Feng
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.
- Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China.
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18
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Cui N, Mi S, Jiang C, Sun W, Mao W, Zhang L, Feng X. Deep vein thrombosis in acute respiratory distress syndrome caused by bacterial pneumonia. BMC Pulm Med 2021; 21:264. [PMID: 34391407 PMCID: PMC8364306 DOI: 10.1186/s12890-021-01632-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 08/03/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by acute hypoxaemia, and few studies have reported the incidence of deep vein thrombosis (DVT) in direct ARDS caused by bacterial pneumonia. We performed a study to evaluate the prevalence, risk factors, prognosis and potential thromboprophylaxis strategies of DVT in these patients. Methods Ninety patients were included. Demographic, and clinical data, laboratory data and outcome variables were obtained, and comparisons were made between the DVT and non-DVT groups. Results Of the 90 patients, 40 (44.4%) developed lower extremity DVT. Compared with non-DVT patients, DVT patients had higher systemic inflammatory response syndrome (SIRS) scores, lower serum creatinine levels, higher D-dimer levels, and higher rates of sedative therapy and invasive mechanical ventilation (IMV). Multivariate analysis showed an association between the SIRS score (OR 3.803, P = 0.027), level of serum creatinine (OR 0.988, P = 0.001), IMV (OR 5.822, P = 0.002) and DVT. The combination of SIRS score, serum creatinine level and IMV has a sensitivity of 80.0% and a specificity of 74.0% for screening for DVT. The survival rate within 28 days after ARDS in the DVT group was significantly lower than that in the non-DVT group (P = 0.003). There was no difference in the prevalence of DVT between the 41 patients who received thromboprophylaxis and the 49 patients who did not receive thromboprophylaxis (41.5% vs 46.9%; P = 0.603). Conclusions The prevalence of DVT is high in hospitalized patients with direct ARDS caused by bacterial pneumonia and may be associated with adverse outcomes. The current thromboprophylaxis strategies may need to be further optimized.
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Affiliation(s)
- Na Cui
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Song Mi
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Chunguo Jiang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Wanlu Sun
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Wenping Mao
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Liming Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China. .,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China.
| | - Xiaokai Feng
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China. .,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China.
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19
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What Do We Know about Thromboprophylaxis and Its Monitoring in Critically Ill Patients? Biomedicines 2021; 9:biomedicines9080864. [PMID: 34440068 PMCID: PMC8389559 DOI: 10.3390/biomedicines9080864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is an important complication in patients hospitalized in intensive care units (ICU). Thromboprophylaxis is mainly performed with Low Molecular Weight Heparin (LMWH) and, in some specific patients, with Unfractionated Heparin (UFH). These intensive units are an environment where individual patient variability is extreme and where traditional antithrombotic protocols are frequently ineffective. This was known for a long time, but the hospitalization of many patients with COVID-19 inflammatory storms suddenly highlighted this knowledge. It is therefore reasonable to propose variable antithrombotic prevention protocols based initially on a series of individual criteria (weight, BMI, and thrombotic risks). Secondly, they should be adjusted by the monitoring of anticoagulant activity, preferably by measuring the anti-Xa activity. However, we still face unresolved questions, such as once- or twice-daily LMWH injections, monitoring at the peak and/or trough, and poorly defined therapeutic targets. Equally surprisingly, we observed a lack of standardization of the anti-Xa activity kits.
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20
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Zhang JC, Li T. Delayed retroperitoneal hemorrhage during extracorporeal membrane oxygenation in COVID-19 patients: A case report and literature review. World J Clin Cases 2021; 9:5203-5210. [PMID: 34307568 PMCID: PMC8283594 DOI: 10.12998/wjcc.v9.i19.5203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/21/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Retroperitoneal hemorrhage (RPH) is a rare and severe complication in patients undergoing extracorporeal membrane oxygenation (ECMO). Clinical diagnosis is difficult. CASE SUMMARY Three cases of RPH patients with corona virus disease-19 (COVID-19) were included in this study. All three suffered from respiratory failure, were treated with veno-venous or veno-arterial-venous ECMO, and experienced RPH during ECMO treatment. Two of the COVID-19 cases were diagnosed after the patients experienced abdominal pain. The other patient exhibited decreases in the ECMO circuit flow rate and hemoglobin level. Two cases were treated by transcatheter arterial embolization, and one was treated conservatively. The hemorrhage in each of the three cases did not deteriorate. Satisfactory treatment results were achieved for the three patients because of prompt diagnosis and treatment. CONCLUSION Although the incidence of RPH during ECMO treatment is low, the risk is increased by anticoagulant use and local mechanical injury. If declines in blood flow velocity and hemoglobin are detected, RPH should be considered, and prompt aggressive therapy should be started.
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Affiliation(s)
- Jing-Chen Zhang
- Department of Critical Care Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Tong Li
- Department of Critical Care Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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21
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Thondapu V, Montes D, Rosovsky R, Dua A, McDermott S, Lu MT, Ghoshhajra B, Hoffmann U, Gerhard-Herman MD, Hedgire S. Venous thrombosis, thromboembolism, biomarkers of inflammation, and coagulation in coronavirus disease 2019. J Vasc Surg Venous Lymphat Disord 2021; 9:835-844.e4. [PMID: 33188961 PMCID: PMC7657877 DOI: 10.1016/j.jvsv.2020.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/01/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) is associated with abnormal inflammatory and coagulation markers, potentially mediating thrombotic events. Our objective was to investigate the incidence, time course, laboratory features, and in-hospital outcomes of COVID-19 patients with suspected venous thromboembolism (VTE). METHODS A retrospective observational cohort study was conducted of patients hospitalized with COVID-19 who had undergone ultrasound imaging for suspected VTE from March 13 to May 18, 2020. The medical records of the included patients were reviewed for D-dimer, fibrinogen, prothrombin time, partial thromboplastin time, platelet count, C-reactive protein (CRP), and high-sensitivity troponin T at admission and at up to seven time points before and after ultrasound examination. The clinical outcomes included superficial venous thrombosis, deep vein thrombosis, pulmonary embolism, intubation, and death. Mixed effects logistic, linear, and Cox proportional hazards methods were used to evaluate the relationships between the laboratory markers and VTE and other in-hospital outcomes. RESULTS Of 138 patients who had undergone imaging studies, 44 (31.9%) had evidence of VTE. On univariable analysis, an elevated admission CRP (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; P = .02; per 10-U increase in CRP), platelet count (OR, 1.48; 95% CI, 1.04-2.12; P = .03; per 1000-U increase in platelet count), and male sex (OR, 2.64; 95% CI, 1.19-5.84; P = .02), were associated with VTE. However only male sex remained significant on multivariable analysis (OR, 2.37; 95% CI, 1.01-5.56; P = .048). The independent predictors of death included older age (hazard ratio [HR], 1.04; 95% CI, 1.00-1.07; P = .04), active malignancy (HR, 4.39; 95% CI, 1.39-13.91; P = .01), elevated admission D-dimer (HR, 1.016; 95% CI, 1.003-1.029; P = .02), and evidence of disseminated intravascular coagulation (HR, 4.81; 95% CI, 1.76-13.10; P = .002). CONCLUSIONS Male sex, elevated CRP, and elevated platelet count at admission were associated with VTE on univariable analysis. However, only male sex remained significant on multivariable analysis. Older age, active malignancy, disseminated intravascular coagulation, and elevated D-dimer at admission were independently associated with death for patients hospitalized with COVID-19.
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Affiliation(s)
- Vikas Thondapu
- Cardiovascular Imaging Research Center, Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Daniel Montes
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Rachel Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Anahita Dua
- Division of Vascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Shaunagh McDermott
- Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Brian Ghoshhajra
- Cardiovascular Imaging Research Center, Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Marie Denise Gerhard-Herman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sandeep Hedgire
- Cardiovascular Imaging Research Center, Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
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22
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Mansory EM, Srigunapalan S, Lazo-Langner A. Venous Thromboembolism in Hospitalized Critical and Noncritical COVID-19 Patients: A Systematic Review and Meta-analysis. TH OPEN 2021; 5:e286-e294. [PMID: 34240001 PMCID: PMC8260281 DOI: 10.1055/s-0041-1730967] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Venous thromboembolism (VTE) has been observed as a frequent complication in patients with severe novel coronavirus disease 2019 (COVID-19) infection requiring hospital admission. Aim This study was aimed to evaluate the epidemiology of VTE in hospitalized intensive care unit (ICU) and non-ICU patients. Materials and Methods PubMed was searched up to November 13, 2020, and updated in December 12, 2020. We included studies that evaluated the epidemiology of VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), in patients with COVID-19. Results A total of 91 studies reporting on 35,017 patients with COVID-19 was included. The overall frequency of VTE in all patients, ICU and non-ICU, was 12.8% (95% confidence interval [CI]: 11.103-14.605), 24.1% (95% CI: 20.070-28.280), and 7.7% (95% CI: 5.956-9.700), respectively. PE occurred in 8.5% (95% CI: 6.911-10.208), and proximal DVT occurred in 8.2% (95% CI: 6.675-9.874) of all hospitalized patients. The relative risk for VTE associated with ICU admission was 2.99 (95% CI: 2.301-3.887, p <0.001). DVT and PE estimated in studies that adopted some form of systematic screening were higher compared with studies with symptom-triggered screening. Analysis restricted to studies in the 5th quintile of sample size reported significantly lower VTE estimates. Conclusion This study confirmed a high risk of VTE in hospitalized COVID-19 patients, especially those admitted to the ICU. Nevertheless, sensitivity analysis suggests that previously reported frequencies of VTE in COVID-19 might have been overestimated.
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Affiliation(s)
- Eman M Mansory
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Hematology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Suthan Srigunapalan
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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23
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Fontelo P, Bastola MM, Zheng Z, Baik SH. A review of thromboembolic events in hospitalized COVID-19 patients. Thromb J 2021; 19:47. [PMID: 34187490 PMCID: PMC8240420 DOI: 10.1186/s12959-021-00298-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/15/2021] [Indexed: 12/23/2022] Open
Abstract
CONTEXT A higher incidence of thromboembolic disorders in COVID-19 has been reported by many clinicians worldwide. OBJECTIVE, DESIGN AND DATA SOURCES Selected studies found in PubMed that reported thromboembolic events were included for meta-analysis using weighted fixed and random effects. Data from 19 articles on cohort studies in patients diagnosed with COVID-19 and thromboembolic events, including thrombosis and embolism were included in this review. RESULTS The likelihood for developing thromboembolic disorders in hospitalized COVID-19 patients was 0.28 (95% CI 0.21-0.36). CONCLUSION This study further validates the increased risk of VTE in COVID-19 patients when compared to healthy, non-hospitalized people, and hospitalized patients. These findings will be useful to researchers and medical practitioners caring for COVID-19 patients.
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Affiliation(s)
- Paul Fontelo
- Applied Clinical Informatics Branch, Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA.
| | - Mrigendra M Bastola
- Applied Clinical Informatics Branch, Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA
| | - Zhaonian Zheng
- Applied Clinical Informatics Branch, Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA
| | - Seo Hyon Baik
- Applied Clinical Informatics Branch, Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA
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24
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Chang JC. COVID-19 Sepsis: Pathogenesis and Endothelial Molecular Mechanisms Based on "Two-Path Unifying Theory" of Hemostasis and Endotheliopathy-Associated Vascular Microthrombotic Disease, and Proposed Therapeutic Approach with Antimicrothrombotic Therapy. Vasc Health Risk Manag 2021; 17:273-298. [PMID: 34103921 PMCID: PMC8179800 DOI: 10.2147/vhrm.s299357] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
COVID-19 sepsis is characterized by acute respiratory distress syndrome (ARDS) as a consequence of pulmonary tropism of the virus and endothelial heterogeneity of the host. ARDS is a phenotype among patients with multiorgan dysfunction syndrome (MODS) due to disseminated vascular microthrombotic disease (VMTD). In response to the viral septicemia, the host activates the complement system which produces terminal complement complex C5b-9 to neutralize pathogen. C5b-9 causes pore formation on the membrane of host endothelial cells (ECs) if CD59 is underexpressed. Also, viral S protein attraction to endothelial ACE2 receptor damages ECs. Both affect ECs and provoke endotheliopathy. Disseminated endotheliopathy activates two molecular pathways: inflammatory and microthrombotic. The former releases inflammatory cytokines from ECs, which lead to inflammation. The latter initiates endothelial exocytosis of unusually large von Willebrand factor (ULVWF) multimers and FVIII from Weibel-Palade bodies. If ADAMTS13 is insufficient, ULVWF multimers activate intravascular hemostasis of ULVWF path. In activated ULVWF path, ULVWF multimers anchored to damaged endothelial cells recruit circulating platelets and trigger microthrombogenesis. This process produces "microthrombi strings" composed of platelet-ULVWF complexes, leading to endotheliopathy-associated VMTD (EA-VMTD). In COVID-19, microthrombosis initially affects the lungs per tropism causing ARDS, but EA-VMTD may orchestrate more complex clinical phenotypes, including thrombotic thrombocytopenic purpura (TTP)-like syndrome, hepatic coagulopathy, MODS and combined micro-macrothrombotic syndrome. In this pandemic, ARDS and pulmonary thromboembolism (PTE) have often coexisted. The analysis based on two hemostatic theories supports ARDS caused by activated ULVWF path is EA-VMTD and PTE caused by activated ULVWF and TF paths is macrothrombosis. The thrombotic disorder of COVID-19 sepsis is consistent with the notion that ARDS is virus-induced disseminated EA-VMTD and PTE is in-hospital vascular injury-related macrothrombosis which is not directly related to viral pathogenesis. The pathogenesis-based therapeutic approach is discussed for the treatment of EA-VMTD with antimicrothrombotic regimen and the potential need of anticoagulation therapy for coinciding macrothrombosis in comprehensive COVID-19 care.
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Affiliation(s)
- Jae C Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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25
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Al-Samkari H, Gupta S, Leaf RK, Wang W, Rosovsky RP, Brenner SK, Hayek SS, Berlin H, Kapoor R, Shaefi S, Melamed ML, Sutherland A, Radbel J, Green A, Garibaldi BT, Srivastava A, Leonberg-Yoo A, Shehata AM, Flythe JE, Rashidi A, Goyal N, Chan L, Mathews KS, Hedayati SS, Dy R, Toth-Manikowski SM, Zhang J, Mallappallil M, Redfern RE, Bansal AD, Short SAP, Vangel MG, Admon AJ, Semler MW, Bauer KA, Hernán MA, Leaf DE. Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19. Ann Intern Med 2021; 174:622-632. [PMID: 33493012 PMCID: PMC7863679 DOI: 10.7326/m20-6739] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival. DESIGN In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used. SETTING 67 hospitals in the United States. PARTICIPANTS Adults with COVID-19 admitted to a participating ICU. MEASUREMENTS Time to death, censored at hospital discharge, or date of last follow-up. RESULTS Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]). LIMITATION Observational design. CONCLUSION Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Hanny Al-Samkari
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Shruti Gupta
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
| | - Rebecca Karp Leaf
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Wei Wang
- Brigham and Women's Hospital, Boston, Massachusetts (W.W.)
| | - Rachel P Rosovsky
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Samantha K Brenner
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, New Jersey (S.K.B.)
| | - Salim S Hayek
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Hanna Berlin
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Rajat Kapoor
- Indiana University School of Medicine, Indianapolis, Indiana (R.K.)
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.S.)
| | - Michal L Melamed
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York (M.L.M.)
| | - Anne Sutherland
- Rutgers New Jersey Medical School, Newark, New Jersey (A.S.)
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.R.)
| | - Adam Green
- Cooper University Health Care, Camden, New Jersey (A.G.)
| | | | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and Northwestern University Feinberg School of Medicine, Chicago, Illinois (A.S.)
| | - Amanda Leonberg-Yoo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.L.)
| | - Alexandre M Shehata
- Hackensack Meridian Health Mountainside Medical Center, Glen Ridge, New Jersey (A.M.S.)
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, UNC School of Medicine, and Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina (J.E.F.)
| | - Arash Rashidi
- University Hospitals Cleveland Medical Center, Cleveland, Ohio (A.R.)
| | | | - Lili Chan
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - Kusum S Mathews
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - S Susan Hedayati
- University of Texas Southwestern Medical Center, Dallas, Texas (S.S.H.)
| | - Rajany Dy
- University Medical Center of Southern Nevada Hospital, University of Nevada, Las Vegas, Nevada (R.D.)
| | | | - Jingjing Zhang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (J.Z.)
| | - Mary Mallappallil
- Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York (M.M.)
| | - Roberta E Redfern
- ProMedica Research, ProMedica Toledo Hospital, Toledo, Ohio (R.E.R.)
| | - Amar D Bansal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (A.D.B.)
| | - Samuel A P Short
- University of Vermont Larner College of Medicine, Burlington, Vermont (S.A.S.)
| | - Mark G Vangel
- Massachusetts General Hospital Biostatistics Center, Boston, Massachusetts (M.G.V.)
| | | | - Matthew W Semler
- Vanderbilt University Medical Center, Nashville, Tennessee (M.W.S.)
| | - Kenneth A Bauer
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.A.B.)
| | - Miguel A Hernán
- Harvard T.H. Chan School of Public Health and Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts (M.A.H.)
| | - David E Leaf
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
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26
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Fontelo P, Bastola MM, Zheng Z, Baik SH. A Review of Thromboembolic Events in Hospitalized COVID-19 Patients. RESEARCH SQUARE 2021:rs.3.rs-393440. [PMID: 33851147 PMCID: PMC8043461 DOI: 10.21203/rs.3.rs-393440/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Context: A higher incidence of thromboembolic disorders in COVID-19 has been reported by many clinicians worldwide. Objective, Design and Data Sources: Selected studies found in PubMed that reported thromboembolic events were included for meta-analysis using weighted fixed and random effects. Data from 19 articles on cohort studies in patients diagnosed with COVID-19 and thromboembolic events, including thrombosis and embolism were included in this review. Results: The likelihood for developing thromboembolic disorders in hospitalized COVID-19 patients was 0.28 (95% CI 0.21â€"0.36). Conclusion: This study further validates the increased risk of VTE in COVID-19 patients when compared to healthy, non-hospitalized people, and hospitalized patients. These findings will be useful to researchers and medical practitioners caring for COVID-19 patients.
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27
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Al Raizah A, Al Askar A, Shaheen N, Aldosari K, Alnahdi M, Luhanga M, Alshuaibi T, Bajhmoum W, Alharbi K, Alsahari G, Algahtani H, Alrayes E, Basendwah A, Abotaleb A, Almegren M. High rate of bleeding and arterial thrombosis in COVID-19: Saudi multicenter study. Thromb J 2021; 19:13. [PMID: 33658062 PMCID: PMC7928187 DOI: 10.1186/s12959-021-00265-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/16/2021] [Indexed: 12/23/2022] Open
Abstract
Background Several observational studies have reported the rate of venous and arterial thrombotic events in patients infected with COVID-19, with conflicting results. The aim of this study was to estimate the rate of thrombotic and bleeding events in hospitalized patients diagnosed with Coronavirus disease 2019 (COVID-19). Methods This was a multicenter study of 636 patients admitted between 20 March 2020 and 31 May 2020 with confirmed COVID-19 in four hospitals. Results Over a median length of stay in the non-ICU group of 7 days and of 19 days in the ICU group, twelve patients were diagnosed with Venous thromboembolism (VTE) (1.8 %) (95 % CI, 1.1–3). The rate in the non-ICU group was 0.19 % (95 % CI, 0.04–0.84), and that in the ICU group was 10.3 % (95 % CI, 6.4–16.2). The overall rate of arterial event is 2.2 % (95 % CI, 1.4–3.3). The rates in the non-ICU and ICU groups were 0.94 % (95 % CI, 0.46–0.1.9) and 8.4 % (95 % CI, 5.0–14.0). The overall composite event rate was 2.9 % (95 % CI, 2.0–4.3). The composite event rates in the non-ICU and ICU groups were 0.94 % (95 % CI, 0.46–0.1.9) and 13.2 % (95 % CI, 8.7–19.5). The overall rate of bleeding is 1.7 % (95 % CI, 1.0–2.8). The bleeding rate in the non-ICU group was 0.19 % (95 % CI, 0.04–0.84), and that in the ICU group was 9.4 % (95 % CI, 5.7–15.1). The baseline D-dimer level was a significant risk factor for developing VTE (OR 1.31, 95 % CI, 1.08–1.57, p = 0.005) and composite events (OR 1.32, 95 % CI, 1.12–1.55, p = 0.0007). Conclusions In this study, we found that the VTE rates in hospitalized patients with COVID-19 might not be higher than expected. In contrast to the risk of VTE, we found a high rate of arterial and bleeding complications in patients admitted to the ICU. An elevated D-dimer level at baseline could predict thrombotic complications in COVID-19 patients and may assist in the identification of these patients. Given the high rate of bleeding, the current study suggests that the intensification of anticoagulation therapy in COVID-19 patients beyond the standard of care be pursued with caution and would best be evaluated in a randomized controlled study.
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Affiliation(s)
- Abdulrahman Al Raizah
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia. .,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. .,King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia.
| | - Ahmed Al Askar
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Naila Shaheen
- King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia.,Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Khalid Aldosari
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohamed Alnahdi
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Musumadi Luhanga
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO Box. 22490, 11426, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Turki Alshuaibi
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Wail Bajhmoum
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Khaled Alharbi
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Ghaida Alsahari
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Hadeel Algahtani
- Department of Medicine, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Eunice Alrayes
- Department of Medicine, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Abdulrahim Basendwah
- Oncology Division, Medicine Department, King Fahad Armed Forces Hospital, Jeddah, Mecca, Saudi Arabia
| | - Alia Abotaleb
- Oncology Division, Medicine Department, King Fahad Armed Forces Hospital, Jeddah, Mecca, Saudi Arabia
| | - Mosaad Almegren
- Department of Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
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Lapébie FX, Minville V, Ribes A, Combis B, Thery A, Geeraerts T, Silva S, Bura-Rivière A, Vardon-Bounes F. Systematic Screening for Deep Vein Thrombosis in Critically Ill Inpatients With COVID-19: Impact on the Incidence of Venous Thromboembolism. Front Med (Lausanne) 2021; 7:624808. [PMID: 33521028 PMCID: PMC7840698 DOI: 10.3389/fmed.2020.624808] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Several studies suggest an increased incidence of thrombosis in COVID-19 patients. However, evidence on how to prevent and even treat it is scarce. The aim of this study was to compare the cumulative incidence of venous thromboembolism (VTE) of two different methods for lower extremity deep vein thrombosis (LE-DVT) diagnosis: systematic vs. clinically guided complete compression venous ultrasonography (CCUS). We conducted a monocentric, prospective, open-label, non-randomized study. All consecutive patients admitted in three intensive care units (ICUs) of University Hospital of Toulouse for COVID-19 pneumonia were included: one performed systematic screening for LE-DVT, the others did not. The primary outcome was the 21-day cumulative incidence of VTE. The secondary end points were the 21-day cumulative incidences of major bleeding and death. Results: Among the 78 patients included, 27 (34.6%) underwent systematic screening for DVT 7 ± 2 days after ICU admission. Thirty-two patients (41.0%) were diagnosed with VTE, with a 21-day cumulative incidence of 42.3% (95% CI, 31.4–55.2), without difference between screened and non-screened patients (hazard ratio 1.45, 95% CI, 0.72–2.93). In the screened group, the frequency of isolated DVT was higher (25.9 vs. 5.9%, p-value = 0.027), but the frequency of pulmonary embolism was not reduced (25.9 vs. 29.4%, p-value = 0.745). The 21-day cumulative incidences of major bleeding and death were 9.6% (95% CI, 4.7–19.2) and 10.3% (95% CI, 5.0–20.8), respectively, without difference between the two groups. Conclusions: A systematic screening for DVT in patients hospitalized in ICU was not associated with a higher diagnosis of VTE or a reduced diagnosis of PE.
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Affiliation(s)
- François-Xavier Lapébie
- Department of Vascular Medicine, Toulouse University Hospital, Toulouse, France.,UMR 1027 INSERM, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Vincent Minville
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,UMR 1048 INSERM, I2MC, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Agnès Ribes
- UMR 1048 INSERM, I2MC, Toulouse III - Paul Sabatier University, Toulouse, France.,Laboratory of Hematology, Toulouse University Hospital, Toulouse, France
| | - Bertrand Combis
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France
| | - Arthur Thery
- Department of Vascular Medicine, Toulouse University Hospital, Toulouse, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,ToNIC (Toulouse Neuro-Imaging Center) INSERM, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Stein Silva
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,ToNIC (Toulouse Neuro-Imaging Center) INSERM, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Alessandra Bura-Rivière
- Department of Vascular Medicine, Toulouse University Hospital, Toulouse, France.,UMR 1031 INSERM, StromaLab, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Fanny Vardon-Bounes
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,UMR 1048 INSERM, I2MC, Toulouse III - Paul Sabatier University, Toulouse, France
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29
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Boyd S, Martin-Loeches I. The incidence of venous thromboembolism in critically ill patients with COVID-19 compared with critically ill non-COVID patients. Ir J Med Sci 2021; 190:1317-1320. [PMID: 33415688 PMCID: PMC7790472 DOI: 10.1007/s11845-020-02503-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/31/2020] [Indexed: 01/20/2023]
Abstract
Background COVID-19 is a novel coronavirus that is currently responsible for the global pandemic. It has been reported that up to 25% [1] of hospitalized patients with COVID-19 develop VTE (venous thromboembolism), and this can be as high as 31% in ICU patients with COVID-19 [2]. Aims To determine VTE rates in ICU patients with COVID compared to those admitted with influenza and a control group. Methods We performed a retrospective chart review of 113 patients admitted to ICU at our hospital. Patient characteristics, comorbidities, coagulation profile and prevalence of radiologically proven VTE were recorded and compared between groups. Results More males than females were found in each group. When groups were compared the mean age, BMI and cigarette smoking were similar, as was the incidence of diabetes, chronic obstructive pulmonary disease and chronic kidney disease. aPTT was higher in the COVID-19 (30.9 ± 3.7 SD) vs (12.8 ± 4.1 SD) the influenza group vs (15.2 ± 4.1 SD) in controls p < 0.001, but fibrinogen was lower 6.2 ± 1.6 SD vs 34.6 ± 14.0SD vs 30.8 ± 5.0 SD, respectively, p < 0.001. VTE rates in the COVID (13.2%) (DVT 5.3%, PE 10.5%) and influenza groups (15.8%) (DVT 13.2%, PE 2.6%) were similar but were higher than the control group (8.1%) (DVT 8.1%, PE 2.7%), but not significantly so (p = 0.5). Conclusions ICU patients with COVID-19 displayed an abnormal coagulation profile and a VTE rate that is similar to ICU patients with influenza. VTE occurred despite thromboprophylaxis and remains a pertinent differential to keep in mind.
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Affiliation(s)
- Sean Boyd
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland.
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland.,Trinity College Dublin, Dublin, Ireland.,Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, CIBERes, 08036, Barcelona, Spain
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30
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von Meijenfeldt FA, Havervall S, Adelmeijer J, Lundström A, Rudberg A, Magnusson M, Mackman N, Thalin C, Lisman T. Prothrombotic changes in patients with COVID-19 are associated with disease severity and mortality. Res Pract Thromb Haemost 2021; 5:132-141. [PMID: 33537537 PMCID: PMC7845083 DOI: 10.1002/rth2.12462] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Patients with severe coronavirus disease 2019 (COVID-19) are at significant risk of thrombotic complications. However, their prothrombotic state is incompletely understood. Therefore, we measured in vivo activation markers of hemostasis, plasma levels of hemostatic proteins, and functional assays of coagulation and fibrinolysis in plasma from patients with COVID-19 and determined their association with disease severity and 30-day mortality. METHODS We included 102 patients with COVID-19 receiving various levels of respiratory support admitted to general wards, intermediate units, or intensive care units and collected plasma samples shortly after hospital admission. RESULTS Patients with COVID-19 with higher respiratory support had increased in vivo activation of coagulation and fibrinolysis, as reflected by higher plasma levels of d-dimer, thrombin-antithrombin, and plasmin-antiplasmin complexes as compared to patients with no to minimal respiratory support and healthy controls. Moreover, the patients with COVID-19 with higher respiratory support exhibited substantial ex vivo thrombin generation and lower ex vivo fibrinolytic capacity, despite higher doses of anticoagulant therapy compared to less severely ill patients. Fibrinogen, factor VIII, and von Willebrand factor levels increased, and ADAMTS13 levels decreased with increasing respiratory support in patients with COVID-19. Low platelet count; low levels of prothrombin, antithrombin, and ADAMTS13; and high levels of von Willebrand factor were associated with short-term mortality. CONCLUSIONS Severe COVID-19 is associated with prothrombotic changes with increased in vivo activation of coagulation and fibrinolysis, despite anticoagulant therapy.
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Affiliation(s)
- Fien A. von Meijenfeldt
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Sebastian Havervall
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Annika Lundström
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Ann‐Sofie Rudberg
- Department of NeurologyDanderyd HospitalStockholmSweden
- Department of Clinical NeurosciencesKarolinska InstitutetStockholmSweden
| | - Maria Magnusson
- Clinical Chemistry and Blood Coagulation ResearchMMKDepartment of PediatricsDepartment of HematologyCLINTECKarolinska InstitutetKarolinska University HospitalStockholmSweden
| | - Nigel Mackman
- UNC Blood Research CenterDivision of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillNCUSA
| | - Charlotte Thalin
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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31
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Waite AAC, Hamilton DO, Pizzi R, Ageno W, Welters ID. Hypercoagulopathy in Severe COVID-19: Implications for Acute Care. Thromb Haemost 2020; 120:1654-1667. [PMID: 33368088 PMCID: PMC7869057 DOI: 10.1055/s-0040-1721487] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
COVID-19 was first described in late 2019 and has since developed into a pandemic affecting more than 21 million people worldwide. Of particular relevance for acute care is the occurrence of COVID-19-associated coagulopathy (CAC), which is characterised by hypercoagulability, immunothrombosis and venous thromboembolism, and contributes to hypoxia in a significant proportion of patients. This review describes diagnosis and treatment of CAC in the emergency department and in intensive care. We summarise the pathological mechanisms and common complications of CAC such as pulmonary thrombosis and venous thromboembolic events and discuss current strategies for thromboprophylaxis and therapeutic anti-coagulation in the acute care setting.
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Affiliation(s)
- Alicia A C Waite
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom.,Department of Intensive Care Medicine, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - David O Hamilton
- Department of Intensive Care Medicine, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Roberto Pizzi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ingeborg D Welters
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom.,Department of Intensive Care Medicine, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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32
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Brown SA, Zaharova S, Mason P, Thompson J, Thapa B, Ishizawar D, Wilkes E, Ahmed G, Rubenstein J, Sanchez J, Joyce D, Kalyanaraman B, Widlansky M. Pandemic Perspective: Commonalities Between COVID-19 and Cardio-Oncology. Front Cardiovasc Med 2020; 7:568720. [PMID: 33344513 PMCID: PMC7746643 DOI: 10.3389/fcvm.2020.568720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/06/2020] [Indexed: 12/15/2022] Open
Abstract
Overlapping commonalities between coronavirus disease of 2019 (COVID-19) and cardio-oncology regarding cardiovascular toxicities (CVT), pathophysiology, and pharmacology are special topics emerging during the pandemic. In this perspective, we consider an array of CVT common to both COVID-19 and cardio-oncology, including cardiomyopathy, ischemia, conduction abnormalities, myopericarditis, and right ventricular (RV) failure. We also emphasize the higher risk of severe COVID-19 illness in patients with cardiovascular disease (CVD) or its risk factors or cancer. We explore commonalities in the underlying pathophysiology observed in COVID-19 and cardio-oncology, including inflammation, cytokine release, the renin-angiotensin-aldosterone-system, coagulopathy, microthrombosis, and endothelial dysfunction. In addition, we examine common pharmacologic management strategies that have been elucidated for CVT from COVID-19 and various cancer therapies. The use of corticosteroids, as well as antibodies and inhibitors of various molecules mediating inflammation and cytokine release syndrome, are discussed. The impact of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) is also addressed, since these drugs are used in cardio-oncology and have received considerable attention during the COVID-19 pandemic, since the culprit virus enters human cells via the angiotensin converting enzyme 2 (ACE2) receptor. There are therefore several areas of overlap, similarity, and interaction in the toxicity, pathophysiology, and pharmacology profiles in COVID-19 and cardio-oncology syndromes. Learning more about either will likely provide some level of insight into both. We discuss each of these topics in this viewpoint, as well as what we foresee as evolving future directions to consider in cardio-oncology during the pandemic and beyond. Finally, we highlight commonalities in health disparities in COVID-19 and cardio-oncology and encourage continued development and implementation of innovative solutions to improve equity in health and healing.
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Affiliation(s)
- Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Svetlana Zaharova
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Peter Mason
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jonathan Thompson
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Bicky Thapa
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - David Ishizawar
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Erin Wilkes
- Department of Pharmacy, Froedtert Health and Medical College of Wisconsin, Milwaukee, WI, United States
| | - Gulrayz Ahmed
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jason Rubenstein
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joyce Sanchez
- Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI, United States
| | - David Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Michael Widlansky
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
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33
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Katneni UK, Alexaki A, Hunt RC, Schiller T, DiCuccio M, Buehler PW, Ibla JC, Kimchi-Sarfaty C. Coagulopathy and Thrombosis as a Result of Severe COVID-19 Infection: A Microvascular Focus. Thromb Haemost 2020; 120:1668-1679. [PMID: 32838472 PMCID: PMC7869056 DOI: 10.1055/s-0040-1715841] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/14/2020] [Indexed: 02/08/2023]
Abstract
Coronavirus disease of 2019 (COVID-19) is the clinical manifestation of the respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While primarily recognized as a respiratory disease, it is clear that COVID-19 is systemic illness impacting multiple organ systems. One defining clinical feature of COVID-19 has been the high incidence of thrombotic events. The underlying processes and risk factors for the occurrence of thrombotic events in COVID-19 remain inadequately understood. While severe bacterial, viral, or fungal infections are well recognized to activate the coagulation system, COVID-19-associated coagulopathy is likely to have unique mechanistic features. Inflammatory-driven processes are likely primary drivers of coagulopathy in COVID-19, but the exact mechanisms linking inflammation to dysregulated hemostasis and thrombosis are yet to be delineated. Cumulative findings of microvascular thrombosis has raised question if the endothelium and microvasculature should be a point of investigative focus. von Willebrand factor (VWF) and its protease, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13), play important role in the maintenance of microvascular hemostasis. In inflammatory conditions, imbalanced VWF-ADAMTS-13 characterized by elevated VWF levels and inhibited and/or reduced activity of ADAMTS-13 has been reported. Also, an imbalance between ADAMTS-13 activity and VWF antigen is associated with organ dysfunction and death in patients with systemic inflammation. A thorough understanding of VWF-ADAMTS-13 interactions during early and advanced phases of COVID-19 could help better define the pathophysiology, guide thromboprophylaxis and treatment, and improve clinical prognosis.
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Affiliation(s)
- Upendra K. Katneni
- Department of Pediatrics, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Aikaterini Alexaki
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, U.S. FDA, Silver Spring, Maryland, United States
| | - Ryan C. Hunt
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, U.S. FDA, Silver Spring, Maryland, United States
| | - Tal Schiller
- Diabetes, Endocrinology and Metabolic Disease Unit, Kaplan Medical Center, Rehovot, Israel
| | - Michael DiCuccio
- National Center of Biotechnology Information, National Institutes of Health, Bethesda, Maryland, United States
| | - Paul W. Buehler
- Department of Pediatrics, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Juan C. Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Chava Kimchi-Sarfaty
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, U.S. FDA, Silver Spring, Maryland, United States
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34
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Roncon L, Zuin M, Barco S, Valerio L, Zuliani G, Zonzin P, Konstantinides SV. Incidence of acute pulmonary embolism in COVID-19 patients: Systematic review and meta-analysis. Eur J Intern Med 2020; 82:29-37. [PMID: 32958372 PMCID: PMC7498252 DOI: 10.1016/j.ejim.2020.09.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) has been described as a frequent and prognostically relevant complication of COVID-19 infection. AIM We performed a systematic review and meta-analysis of the in-hospital incidence of acute PE among COVID-19 patients based on studies published within four months of COVID-19 outbreak. MATERIAL AND METHODS Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. We searched Medline, Scopus and Web of Science to locate all articles published up to August 1, 2020 reporting the incidence of acute PE (or lung thrombosis) in COVID-19 patients. The pooled in-hospital incidence of acute PE among COVID-19 patients was calculated using a random effects model and presenting the related 95% confidence interval (CI). Statistical heterogeneity was measured using the Higgins I2 statistic. RESULTS We analysed data from 7178 COVID-19 patients [mean age 60.4 years] included in twenty-three studies. Among patients hospitalized in general wards and intensive care unit (ICU), the pooled in-hospital incidence of PE (or lung thrombosis) was 14.7% of cases (95% CI: 9.9-21.3%, I2=95.0%, p<0.0001) and 23.4% (95% CI:16.7-31.8%, I2=88.7%, p<0.0001), respectively. Segmental/sub-segmental pulmonary arteries were more frequently involved compared to main/lobar arteries (6.8% vs18.8%, p<0.001). Computer tomography pulmonary angiogram (CTPA) was used only in 35.3% of patients with COVID-19 infection across six studies. CONCLUSIONS The in-hospital incidence of acute PE among COVID-19 patients is higher in ICU patients compared to those hospitalized in general wards. CTPA was rarely used suggesting a potential underestimation of PE cases.
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Affiliation(s)
- Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy.
| | - Marco Zuin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy; University of Ferrara, School of Medicine, Ferrara, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Luca Valerio
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Pietro Zonzin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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Gupta S, Hayek SS, Wang W, Chan L, Mathews KS, Melamed ML, Brenner SK, Leonberg-Yoo A, Schenck EJ, Radbel J, Reiser J, Bansal A, Srivastava A, Zhou Y, Sutherland A, Green A, Shehata AM, Goyal N, Vijayan A, Velez JCQ, Shaefi S, Parikh CR, Arunthamakun J, Athavale AM, Friedman AN, Short SAP, Kibbelaar ZA, Abu Omar S, Admon AJ, Donnelly JP, Gershengorn HB, Hernán MA, Semler MW, Leaf DE. Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US. JAMA Intern Med 2020; 180:1436-1447. [PMID: 32667668 PMCID: PMC7364338 DOI: 10.1001/jamainternmed.2020.3596] [Citation(s) in RCA: 633] [Impact Index Per Article: 158.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
Abstract
Importance The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19. Objectives To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19. Design, Setting, and Participants This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020. Exposures Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds. Main Outcomes and Measures The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes. Results A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (≥80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (≥40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (Pao2:Fio2<100 vs ≥300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2-4 vs 0: OR, 2.61; 95% CI, 1.30-5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46-4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs ≥100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies. Conclusions and Relevance This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Salim S. Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Wei Wang
- Department of Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S. Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michal L. Melamed
- Montefiore Medical Center, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Samantha K. Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, New Jersey
| | - Amanda Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Edward J. Schenck
- Divison of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine
| | - Yan Zhou
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Anne Sutherland
- Division of Pulmonary and Critical Care Medicine, Rutgers New Jersey Medical School, Newark
| | - Adam Green
- Cooper University Health Care, Camden, New Jersey
| | - Alexandre M. Shehata
- Department of Medicine, Hackensack Meridian Health Mountainside Medical Center, Glen Ridge, New Jersey
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St Louis, St Louis, Missouri
| | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chirag R. Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin Arunthamakun
- Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | | | - Allon N. Friedman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | | | | | - Samah Abu Omar
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - John P. Donnelly
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Miguel A. Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard–Massachusetts Institute of Technology Division of Health Sciences and Technology, Boston, Massachusetts
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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36
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Torres-Machorro A, Anguiano-Álvarez VM, Grimaldo-Gómez FA, Rodríguez-Zanella H, Cortina de la Rosa E, Mora-Canela S, Lerma C, García-Cruz E, Ramos-Enriquez Á, Ramirez-Marroquin S, Izaguirre-Ávila R, Rojas-Velasco G. Asymptomatic deep vein thrombosis in critically ill COVID-19 patients despite therapeutic levels of anti-Xa activity. Thromb Res 2020; 196:268-271. [PMID: 32927400 PMCID: PMC7462642 DOI: 10.1016/j.thromres.2020.08.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/26/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023]
Abstract
Clinical signs are not useful for detecting DVT in critically ill COVID-19 patients DVT occurs despite full dose anticoagulation in critically ill COVID-19 patients Severe COVID-19 patients present a high prevalence of bilateral DVT
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Affiliation(s)
| | | | | | | | | | - Sergio Mora-Canela
- Surgery Department, "Ignacio Chávez" National Institute of Cardiology, Mexico
| | - Claudia Lerma
- Echocardiography Department, "Ignacio Chávez" National Institute of Cardiology, Mexico
| | - Edgar García-Cruz
- Intensive Care Unit, "Ignacio Chávez" National Institute of Cardiology, Mexico
| | | | | | - Raúl Izaguirre-Ávila
- Haematology Department, "Ignacio Chávez" National Institute of Cardiology, Mexico
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37
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Zermatten MG, Pantet O, Gomez F, Schneider A, Méan M, Mazzolai L, Hugli O, Bart PA, Papadimitriou-Olivgeris M, Alberio L. Utility of D-dimers and intermediate-dose prophylaxis for venous thromboembolism in critically ill patients with COVID-19. Thromb Res 2020; 196:222-226. [PMID: 32916564 PMCID: PMC7442003 DOI: 10.1016/j.thromres.2020.08.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/03/2020] [Accepted: 08/17/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Maxime G Zermatten
- Department of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Olivier Pantet
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Francisco Gomez
- Department of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Antoine Schneider
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Marie Méan
- Department of Internal Medicine, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lucia Mazzolai
- Department of Angiology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Pierre-Alexandre Bart
- Department of Internal Medicine, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Matthaios Papadimitriou-Olivgeris
- Department of Infectious Diseases, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland; Department of Hospital Preventive Medicine, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Department of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland.
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38
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COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection. Blood 2020; 136:489-500. [PMID: 32492712 PMCID: PMC7378457 DOI: 10.1182/blood.2020006520] [Citation(s) in RCA: 879] [Impact Index Per Article: 219.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/24/2020] [Indexed: 01/08/2023] Open
Abstract
Patients with coronavirus disease 2019 (COVID-19) have elevated D-dimer levels. Early reports describe high venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC) rates, but data are limited. This multicenter retrospective study describes the rate and severity of hemostatic and thrombotic complications of 400 hospital-admitted COVID-19 patients (144 critically ill) primarily receiving standard-dose prophylactic anticoagulation. Coagulation and inflammatory parameters were compared between patients with and without coagulation-associated complications. Multivariable logistic models examined the utility of these markers in predicting coagulation-associated complications, critical illness, and death. The radiographically confirmed VTE rate was 4.8% (95% confidence interval [CI], 2.9-7.3), and the overall thrombotic complication rate was 9.5% (95% CI, 6.8-12.8). The overall and major bleeding rates were 4.8% (95% CI, 2.9-7.3) and 2.3% (95% CI, 1.0-4.2), respectively. In the critically ill, radiographically confirmed VTE and major bleeding rates were 7.6% (95% CI, 3.9-13.3) and 5.6% (95% CI, 2.4-10.7), respectively. Elevated D-dimer at initial presentation was predictive of coagulation-associated complications during hospitalization (D-dimer >2500 ng/mL, adjusted odds ratio [OR] for thrombosis, 6.79 [95% CI, 2.39-19.30]; adjusted OR for bleeding, 3.56 [95% CI, 1.01-12.66]), critical illness, and death. Additional markers at initial presentation predictive of thrombosis during hospitalization included platelet count >450 × 109/L (adjusted OR, 3.56 [95% CI, 1.27-9.97]), C-reactive protein (CRP) >100 mg/L (adjusted OR, 2.71 [95% CI, 1.26-5.86]), and erythrocyte sedimentation rate (ESR) >40 mm/h (adjusted OR, 2.64 [95% CI, 1.07-6.51]). ESR, CRP, fibrinogen, ferritin, and procalcitonin were higher in patients with thrombotic complications than in those without. DIC, clinically relevant thrombocytopenia, and reduced fibrinogen were rare and were associated with significant bleeding manifestations. Given the observed bleeding rates, randomized trials are needed to determine any potential benefit of intensified anticoagulant prophylaxis in COVID-19 patients.
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39
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Al-Ani F, Chehade S, Lazo-Langner A. Thrombosis risk associated with COVID-19 infection. A scoping review. Thromb Res 2020; 192:152-160. [PMID: 32485418 PMCID: PMC7255332 DOI: 10.1016/j.thromres.2020.05.039] [Citation(s) in RCA: 260] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Infection by the 2019 novel coronavirus (COVID-19) has been reportedly associated with a high risk of thrombotic complications. So far information is scarce and rapidly emerging. METHODS We conducted a scoping review using a single engine search for studies assessing thrombosis and coagulopathy in COVID-19 patients. Additional studies were identified by secondary review and alert services. RESULTS Studies reported the occurrence of venous thromboembolism and stroke in approximately 20% and 3% of patients, respectively. A higher frequency seems to be present in severely ill patients, in particular those admitted to intensive care units. The thrombotic risk is elevated despite the use of anticoagulant prophylaxis but optimal doses of anticoagulation are not yet defined. Although an increase of biomarkers such as D-dimer has been consistently reported in severely ill COVID-19, the optimal cut-off level and prognostic value are not known. DISCUSSION A number of pressing issues were identified by this review, including defining the true incidence of VTE in COVID patients, developing algorithms to identify those susceptible to develop thrombotic complications and severe disease, determining the role of biomarkers and/or scoring systems to stratify patients' risk, designing adequate and feasible diagnostic protocols for PE, establishing the optimal thromboprophylaxis strategy, and developing uniform diagnostic and reporting criteria.
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Affiliation(s)
- Fatimah Al-Ani
- Department of Medicine, Division of Hematology, Western University, London, ON, Canada
| | - Samer Chehade
- Department of Medicine, Division of Hematology, Western University, London, ON, Canada
| | - Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
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40
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Zhang L, Feng X, Zhang D, Jiang C, Mei H, Wang J, Zhang C, Li H, Xia X, Kong S, Liao J, Jia H, Pang X, Song Y, Tian Y, Wang B, Wu C, Yuan H, Zhang Y, Li Y, Sun W, Zhang Y, Zhu S, Wang S, Xie Y, Ge S, Zhang L, Hu Y, Xie M. Deep Vein Thrombosis in Hospitalized Patients With COVID-19 in Wuhan, China: Prevalence, Risk Factors, and Outcome. Circulation 2020; 142:114-128. [PMID: 32421381 DOI: 10.1161/circulationaha.120.046702] [Citation(s) in RCA: 297] [Impact Index Per Article: 74.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND To investigate deep vein thrombosis (DVT) in hospitalized patients with coronavirus disease 2019 (COVID-19), we performed a single institutional study to evaluate its prevalence, risk factors, prognosis, and potential thromboprophylaxis strategies in a large referral and treatment center. METHODS We studied a total of 143 patients with COVID-19 from January 29, 2020 to February 29, 2020. Demographic and clinical data, laboratory data, including ultrasound scans of the lower extremities, and outcome variables were obtained, and comparisons were made between groups with and without DVT. RESULTS Of the 143 patients hospitalized with COVID-19 (age 63±14 years, 74 [51.7%] men), 66 patients developed lower extremity DVT (46.1%: 23 [34.8%] with proximal DVT and 43 [65.2%] with distal DVT). Compared with patients who did not have DVT, patients with DVT were older and had a lower oxygenation index, a higher rate of cardiac injury, and worse prognosis, including an increased proportion of deaths (23 [34.8%] versus 9 [11.7%]; P=0.001) and a decreased proportion of patients discharged (32 [48.5%] versus 60 [77.9%]; P<0.001). Multivariant analysis showed an association only between CURB-65 (confusion status, urea, respiratory rate, and blood pressure) score 3 to 5 (odds ratio, 6.122; P=0.031), Padua prediction score ≥4 (odds ratio, 4.016; P=0.04), D-dimer >1.0 μg/mL (odds ratio, 5.818; P<0.014), and DVT in this cohort, respectively. The combination of a CURB-65 score 3 to 5, a Padua prediction score ≥4, and D-dimer >1.0 μg/mL has a sensitivity of 88.52% and a specificity of 61.43% for screening for DVT. In the subgroup of patients with a Padua prediction score ≥4 and whose ultrasound scans were performed >72 hours after admission, DVT was present in 18 (34.0%) patients in the subgroup receiving venous thromboembolism prophylaxis versus 35 (66.0%) patients in the nonprophylaxis group (P=0.010). CONCLUSIONS The prevalence of DVT is high and is associated with adverse outcomes in hospitalized patients with COVID-19. Prophylaxis for venous thromboembolism may be protective in patients with a Padua protection score ≥4 after admission. Our data seem to suggest that COVID-19 is probably an additional risk factor for DVT in hospitalized patients.
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Affiliation(s)
- Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Xiaokai Feng
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, China (X.F., C.J., Liming Zhang)
| | - Danqing Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Chunguo Jiang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, China (X.F., C.J., Liming Zhang)
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (H.M., Y.H.)
| | - Jing Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Cuihong Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Hong Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Xiaoling Xia
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Shuangshuang Kong
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Jia Liao
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Huijun Jia
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Xueqin Pang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Yue Song
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Ying Tian
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Bin Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Hongliang Yuan
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Yongxing Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Wei Sun
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Yanting Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Shuyuan Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Yuji Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
| | - Shuping Ge
- Department of Pediatrics, St Christopher's Hospital for Children, Tower Health and Drexel University, Philadelphia, PA (S.G.)
| | - Liming Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, China (X.F., C.J., Liming Zhang)
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (H.M., Y.H.)
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X.).,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China (Li Zhang, D.Z., J.W., C.Z., H.L., X.X., S.K., J.L., H.J., X.P., Y.S., Y.T., B.W., C.W., H.Y., Yongxing Zhang, Y.L., W.S., Yanting Zhang, S.Z., S.W., Y.X., M.X)
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Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res 2020; 191:9-14. [PMID: 32353746 PMCID: PMC7177070 DOI: 10.1016/j.thromres.2020.04.024] [Citation(s) in RCA: 1490] [Impact Index Per Article: 372.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/18/2020] [Accepted: 04/20/2020] [Indexed: 02/08/2023]
Abstract
Background Few data are available on the rate and characteristics of thromboembolic complications in hospitalized patients with COVID-19. Methods We studied consecutive symptomatic patients with laboratory-proven COVID-19 admitted to a university hospital in Milan, Italy (13.02.2020–10.04.2020). The primary outcome was any thromboembolic complication, including venous thromboembolism (VTE), ischemic stroke, and acute coronary syndrome (ACS)/myocardial infarction (MI). Secondary outcome was overt disseminated intravascular coagulation (DIC). Results We included 388 patients (median age 66 years, 68% men, 16% requiring intensive care [ICU]). Thromboprophylaxis was used in 100% of ICU patients and 75% of those on the general ward. Thromboembolic events occurred in 28 (7.7% of closed cases; 95%CI 5.4%–11.0%), corresponding to a cumulative rate of 21% (27.6% ICU, 6.6% general ward). Half of the thromboembolic events were diagnosed within 24 h of hospital admission. Forty-four patients underwent VTE imaging tests and VTE was confirmed in 16 (36%). Computed tomography pulmonary angiography (CTPA) was performed in 30 patients, corresponding to 7.7% of total, and pulmonary embolism was confirmed in 10 (33% of CTPA). The rate of ischemic stroke and ACS/MI was 2.5% and 1.1%, respectively. Overt DIC was present in 8 (2.2%) patients. Conclusions The high number of arterial and, in particular, venous thromboembolic events diagnosed within 24 h of admission and the high rate of positive VTE imaging tests among the few COVID-19 patients tested suggest that there is an urgent need to improve specific VTE diagnostic strategies and investigate the efficacy and safety of thromboprophylaxis in ambulatory COVID-19 patients. COVID-19 is characterized by coagulation activation and endothelial dysfunction. Few data are available on thromboembolic complications. We studied symptomatic patients with laboratory-proven COVID-19 admitted to a university hospital in Milan, Italy (13.02-10.04.2020). Venous and arterial thromboembolic events occurred in 8% of hospitalized patients (cumulative rate 21.0%) and 50% of events were diagnosed within 24 h of hospital admission. Forty-four (11% of total) patients underwent VTE imaging tests; 16 were positive (36% of tests), suggesting underestimation of thromboembolic complications. There is an urgent need to investigate VTE diagnostic strategies and the impact of thromboprophylaxis in ambulatory COVID-19 patients.
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Abstract
Coronavirus disease of 2019 (COVID-19) can be associated with high morbidity and mortality; patients with severe clinical manifestations may develop significant coagulopathy as well as unexpected thromboembolic complications. In response, centers are increasingly treating selected patients with intermediate-dose prophylactic or even therapeutic dose anticoagulation in order to prevent potentially catastrophic thrombotic complications. With this changing practice, the authors suspect that inpatient gastrointestinal consult teams across the country will be frequently managing COVID-19 patients with gastrointestinal bleeding (GIB). In order to reduce potentially avoidable hospital readmissions for GIB while improving patient outcomes, it is imperative to appropriately risk-stratify patients prior to initiation of anticoagulation. In this review, we discuss how to appropriately identify high-risk patients for GIB and how to mitigate GIB risk with proton-pump inhibitor co-therapy, medication reconciliation, and Helicobacter pylori testing and treating in this complex and morbid population.
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