Risk assessment of venous thromboembolism and bleeding in COVID-19 patients

Prevalence and Risk Factors of Deep Venous Thrombosis in Intensive Inpatient Neurorehabilitation Unit

Venous thromboembolism (VTE) (deep vein thrombosis and its complication, pulmonary embolism) is a major cause of morbidity and mortality in hospitalized patients and about 7% of these cases are due to immobility secondary to a neurological impairment. Acquired brain injury (ABI) has also been recognized as one of the main risk factors for VTE. Numerous epidemiological studies have been conducted to assess the risk factors for VTE in institutionalized polytrauma patients, although there is a lack of information about neurorehabilitation wards. Since VTE is often undiagnosed, this prospective study aimed to determine the prevalence and clinical characteristics of lower-limb deep venous thrombosis (DVT) in ABI patients at neurorehabilitation admission.

METHODS

ABI patients were screened for DVT on admission to the intensive rehabilitation unit (IRU) with compression ultrasonography and basal D-dimer assay and were daily clinically monitored until discharge. A total of 127 consecutive ABI patients (mean age: 60.1 ± 17.6 years; 63% male; time from event: 30.9 ± 22.1 days; rehabilitation time in IRU: 84.6 ± 58.4 days) were enrolled.

RESULTS

On admission to the IRU, the DVT prevalence was about 8.6%. The mean D-dimer level in patients with DVT was significantly higher than in patients without DVT (6 ± 0.9 vs. 1.97 ± 1.61, p-value = 0.0001). ABI patients with DVT did not show any significant clinical characteristics with respect to ABI without DVT, although a prevalence of hemorrhagic strokes and patients originating from the Intensive Care Unit and Neurosurgery ward was revealed. During the rehabilitation period, patients with DVT showed a significant difference in pharmacological DVT prophylaxis (high prevalence of nadroparin with 27.3% vs. 1.7%, p-value = 0.04) and a prevalence of transfers in critical awards (36% versus 9.5% of patients without DVT, p-value = 0.05). The mortality rate was similar in the two groups.

CONCLUSIONS

Our research offers a more comprehensive view of the clinical development of DVT patients and confirms the prevalence rate of DVT in ABI patients as determined upon IRU admission. According to our findings, screening these individuals regularly at the time of rehabilitation admission may help identify asymptomatic DVT quickly and initiate the proper treatment to avoid potentially fatal consequences. However, to avoid time-consuming general ultrasonography observation, a more precise selection of patients entering the rehabilitation ward is required.

Thrombosis and Bleeding Risk Scores Are Strongly Associated with Mortality in Hospitalized Patients with COVID-19: A Multicenter Cohort Study

Background: Internationally established guidelines mention pharmacological prophylaxis for all hospitalized COVID-19 patients. However, there are concerns regarding the efficacy and safety of anticoagulants. This study investigated the associations between thrombosis/bleeding risk scores and clinical outcomes. Methods: We conducted a retrospective review of adult patients admitted to two hospitals between 2021 and 2022. We analyzed clinical data, laboratory results, low molecular weight heparin (LMWH) use, thrombosis, bleeding, and 30-day survival. Results: Of the 160 patients, 69.4% were female, and the median age was 59 years. The rates of thrombotic complications and mortality were 12.5% and 36.3%, respectively. LMWH prophylaxis was administered to 73 of the patients (45.6%). The patients with high Padua prediction scores (PPS) and high IMPROVEVTE scores had a significantly higher risk of venous thromboembolism (VTE) compared to those with low scores (30.8% vs. 9.0%, p = 0.006 and 25.6% vs. 7.7%, p = 0.006). Similarly, elevated IMPROVEVTE and IMPROVEBRS scores were associated with increased mortality (hazard ratios of 7.49 and 6.27, respectively; p < 0.001). Interestingly, LMWH use was not associated with a decreased incidence of VTE when stratified by risk groups. Conclusions: this study suggests that COVID-19 patients with high thrombosis and bleeding risk scores have a higher mortality rate.

Which are the optimal thromboprophylaxis strategies for hospitalized patients with COVID-19? current controversies

Novel coronavirus 2019 (COVID-19) represents a significant risk factor for the development of venous thromboembolism (VTE) in hospitalized with both moderate and severe/critical COVID-19. Herein, we present a brief updated review on emerging robust data on diverse thromboprophylaxis strategies used to mitigate VTE complications, as well as a personal point of view of current controversies in regards the use of therapeutic and prophylactic anticoagulation strategies, particularly in the moderately-ill subgroup of patients with COVID-19.

Prediction of bleeding in patients being considered for venous thromboembolism prophylaxis

BACKGROUND

Venous thromboembolism (pulmonary embolism and deep vein thrombosis) is an important preventable cause of in-hospital death. Prophylaxis with low doses of anticoagulants reduces the incidence of venous thromboembolism but can also cause bleeding. It is, therefore, important to stratify the risk of bleeding for hospitalized patients when considering pharmacologic prophylaxis. The IMPROVE (international medical prevention registry on venous thromboembolism) and Consensus risk assessment models (RAMs) are the two tools available for such patients. Few studies have evaluated their ability to predict bleeding in a large, unselected cohort of patients. We assessed the ability of the IMPROVE and Consensus bleeding RAMs to predict bleeding within 90 days of hospitalization in a comprehensive analysis encompassing all hospitalized patients, regardless of surgical vs nonsurgical status.

METHODS

We analyzed consecutive first hospital admissions of 1,228,448 unique surgical and nonsurgical patients to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. IMPROVE and Consensus scores were generated using data from a repository of their common electronic medical records. We assessed the ability of the two RAMs to predict bleeding within 90 days of admission. We used area under the receiver operating characteristic curves to determine the prediction of bleeding by each RAM.

RESULTS

Of 1,228,448 hospitalized patients, 324,959 (26.5%) were surgical and 903,489 (73.5%) were nonsurgical. Of these patients, 68,372 (5.6%) had a bleeding event within 90 days of admission. The Consensus RAM scores ranged from -5.60 to -1.21 (median, -4.93; interquartile range, -5.60 to -4.93). The IMPROVE RAM scores ranged from 0 to 22 (median, 3.5; interquartile range, 2.5-5). Both showed good calibration, with higher scores associated with higher bleeding rates. The ability of both RAMs to predict 90-day bleeding was low (area under the receiver operating characteristic curve 0.61 for the IMPROVE RAM and 0.59 for the Consensus RAM). The predictive ability was also low at 30 and 60 days for surgical and nonsurgical patients, patients receiving prophylactic, therapeutic, or no anticoagulation, and patients hospitalized for ≥72 hours. Prediction was also low across different bleeding outcomes (ie, any bleeding, gastrointestinal bleeding, nongastrointestinal bleeding, and bleeding or death).

CONCLUSIONS

In this large, unselected, nationwide cohort of surgical and nonsurgical hospital admissions, increasing IMPROVE and Consensus bleeding RAM scores were associated with increasing bleeding rates. However, both RAMs had low ability to predict bleeding at 0 to 90 days after admission. Thus, the currently available RAMs require modification and rigorous reevaluation before they can be applied universally.

Incidence of Thromboembolism in COVID-19 Patients in Intensive Care Units: A Retrospective Cohort Analysis

INTRODUCTION

Coronavirus disease 2019 (COVID-19) infection was declared a pandemic, causing high mortality and morbidity worldwide. It predisposes patients to both arterial and venous thromboembolism, which causes high mortality, and is one of the most serious complications of the disease.

OBJECTIVE

The aim of this retrospective study was to determine the frequency of thromboembolic events in patients diagnosed with COVID-19 in the intensive care unit (ICU) and to identify the factors causing thromboembolism.

MATERIAL AND METHODS

The digital records of patients admitted to the adult ICU of Derince Training and Research Hospital, Kocaeli, Turkey, with a diagnosis of COVID-19 between March 13, 2020, and December 31, 2021, were retrospectively reviewed.

RESULTS

Data of 484 patients, 248 (51.2%) female and 236 (48.8%) male, aged between 18-98 years were analyzed. The overall, arterial and venous incidence of thromboembolism was 14.8%, 11.3%, and 3.5%, respectively. There was no significant association between COVID-19 variants and the development of thromboembolism. The effect of various patient variables on the development of thromboembolism was evaluated, including cardiovascular disease (p<0.001), age (p=0.003), use of acetylsalicylic acid (ASA) (p<0.001), antiplatelet therapy (p<0. 001), acute physiology and chronic health evaluation (APACHE) II score (p=0.003), D-dimer (p=0.015), fibrinogen (p=0.032), ferritin (p=0.015), prothrombin time (PT) (p=0.015), international normalized ratio (INR) (p=0.012), troponin (p=0.012) values at the ICU admission were found statistically significant. The cut-off values were 2.565 (μg/mL) for D-dimer, 435.51 (mg) for fibrinogen, 633.55 (ml/ng) for ferritin, 1.155 for INR, and 0.085 (ng/mL) for troponin.

CONCLUSION

 Although low-molecular-weight heparin (LMWH) is the first choice, it may be appropriate to add ASA and other antiplatelet agents to reduce the risk of thromboembolism in patients with high thromboembolic risk including advanced age, cardiovascular disease, and elevated levels of D-dimer, troponin, ferritin, and fibrinogen.

The risk of venous thromboembolism and blood hyperlactatemia is associated with increased mortality among critically ill patients with Covid-19

INTRODUCTION

Coronavirus disease 2019 (Covid-19) following venous thromboembolism (VTE) and blood hyperlactatemia are associated with higher mortality. However, reliable biomarkers for this association remain to be elucidated. This study investigated the associations of VTE risk and blood hyperlactatemia with mortality among critically ill Covid-19 patients admitted to the intensive care unit (ICU).

METHODS

In this single-centre retrospective study, we included 171 patients aged ≥18 years with confirmed Covid-19 admitted to the ICU at a tertiary healthcare clinic in the Eastern region of Saudi Arabia between 1 March 2020 and 31 January 2021. Patients were divided into two groups: survivor and non-survivor. The survivors have been identified as the patients discharged from the ICU alive. The VTE risk was defined using a Padua prediction score (PPS) >4. The blood lactate concentration (BLC) cut-off value >2 mmol/L was used to determine the blood hyperlactatemia.

RESULTS

Multi-factor Cox analysis showed that PPS >4 and BLC >2 mmol/L were more likely to be significantly associated with higher odds of ICU mortality in critically ill Covid-19 patients (hazard ratio [HR] = 2.80, 95% confidence interval [CI] = 1.00-8.08, p = 0.050; HR = 3.87, 95% CI = 1.12-13.45, p = 0.033, respectively). The Area under the Curve for VTE and blood hyperlactatemia were 0.62 and 0.85, respectively.

CONCLUSION

VTE risk and blood hyperlactatemia have been associated with a higher mortality risk in critically ill Covid-19 patients who are hospitalized in the ICU in Saudi Arabia. According to our findings, these people needed more effective VTE prevention strategies based on a personalized assessment of their risk of bleeding. Moreover, persons without diabetes and other groups with a high risk of dying from COVID-19 may be recognized by measuring glucose as having elevated glucose and lactate jointly.

The effect of anti-coagulation dosage on the outcome of hospitalized COVID-19 patients in Ethiopia: a multi-center retrospective cohort study

BACKGROUND

Studies have indicated that hospitalized COVID-19 patients benefit from anticoagulation therapy in terms of survival; however, there is an ongoing controversy over the optimum anticoagulant dosage. This study aimed to compare clinical outcomes between patients who received prophylactic anticoagulation and those who received therapeutic anticoagulation.

METHODS

A multi-center retrospective cohort study was conducted to determine the impact of anticoagulation dosage in hospitalized COVID-19 patients in Ethiopia. The primary outcome measure was in-hospital mortality, and it was assessed using multivariable binary logistic regression and covariate-adjusted Cox Proportional Hazard model. For critical and severe COVID-19 patients, subgroup analyses were performed using multivariable binary logistic regression model and multivariable Cox regression models.

RESULT

A total of 472 hospitalized COVID-19 patients were included in this study, of whom 235 (49.8%) received therapeutic anticoagulation and 237 (50.2%) received prophylactic dose. The demographic and baseline clinical characteristics were roughly similar between the groups. After adjustment for several confounders, in critical COVID-19 subgroup, therapeutic dose of anticoagulation was significantly associated with a higher inpatient mortality (AOR 2.27, 95% CI, 1.18-4.35, p = 0.013), whereas in severe COVID-19 subgroup, anticoagulation dosage was not associated with inpatient mortality (OR, 1.02, 95% CI, 0.45 - 2.33, p = 0.958). In severe COVID-19 patient group however, the incidence of thrombosis was slightly lower in the therapeutic group as compared with prophylactic group although the difference was not statistically significant (AOR 0.15, 95% CI, 0.02 - 1.20, p = 0.073). Although there were only six major bleeding events in this study, all these were recorded from patients in the therapeutic subgroup, making the difference statistically significant (p = 0.013).

CONCLUSION

Although this study is limited by its observational design, our results are not consistent with current recommendations on anti-coagulation dose for hospitalized patients with COVID-19, necessitating the need for RCT in resource limited settings.

Risks associated with prior oral anticoagulation use in hospitalized COVID-19 patients - A retrospective cohort study on 5392 patients from a tertiary centre

INTRODUCTION

There are conflicting data on prior oral-anticoagulant (OAC) use and outcomes of hospitalized COVID-19 patients. Due to uncertainties regarding associated risks with the prior OAC use, we have investigated this issue in a large cohort of hospitalized COVID-19 patients from our institution.

METHODS

We have retrospectively evaluated a total of 5392 consecutive COVID-19 patients hospitalized in our tertiary center institution in period 3/2020 to 6/2021. Majority of patients received low-molecular-weight-heparin thromboprophylaxis and corticosteroids during hospitalization. Patients' characteristics and clinical outcomes were documented as a part of a hospital registry project and were evaluated according to the prior non-OAC, warfarin and direct oral anticoagulants (DOAC) use.

RESULTS

Median age was 72 years, median Charlson comorbidity index (CCI) was 4 points. There were 56.2% male patients. Majority of patients had severe (70.5%) or critical (15.8%) COVID-19 on admission. A total of 84.8% patients did not receive prior OAC, 9% were previously anticoagulated with warfarin and 6.2% were previously anticoagulated with DOACs. In the multivariate regression analyses, prior warfarin use was associated increased in-hospital mortality (OR 1.24, P = 0.048) independently of older age (OR 2.12, P < 0.001), male sex (OR 1.27, P < 0.001), higher CCI (OR 1.26, P < 0.001) and severe or critical COVID-19 on admission (OR 22.66, P < 0.001). Prior DOAC use was associated with higher occurrence of major bleeding (OR 1.72, P = 0.045) independently of higher CCI (OR 1.08, P = 0.017).

CONCLUSION

Prior OAC use could be associated with worse clinical outcomes during COVID-19 hospitalization. These phenomena might be OAC type specific and persist after multivariate adjustments.

Enoxaparin Posology According to Prothrombotic Status and Bleeding Risk in Hospitalized Patients with SARS-CoV-2 Pneumonia

Some patients with COVID-19 have complex hypercoagulable abnormalities that are related to mortality. The optimal dosage of low molecular weight heparin in hospitalized patients with SARS-CoV-2 pneumonia is still not clear. Our objective is to evaluate the effects of adapting the dosage of low molecular weight heparin to thrombotic and bleeding risk scales in this setting. We performed a cohort, retrospective, observational, and analytical study at the Hospital Universitario of Jerez de la Frontera, with patients admitted with SARS-CoV-2 pneumonia from 1 October 2020 to 31 January 2021. They were classified according to whether they received prophylactic, intermediate, or therapeutic doses of enoxaparin. The primary endpoint was intrahospital mortality. Secondary endpoints were the need for invasive ventilation, thromboembolic events, bleeding, and the usefulness of thrombotic and bleeding scales. After binary logistic regression analysis, considering confounding variables, it was found that the use of enoxaparin at therapeutic doses was associated with lower mortality during admission compared to prophylactic and intermediate doses (RR 0.173; 95% CI, 0.038-0.8; p = 0.025). IMPROVE bleeding risk score correlated with a higher risk of minor bleeding (RR 1.263; 95% CI, 1.105-1.573; p = 0.037). In adult hospitalized patients with SARS-CoV-2 pneumonia presenting elevated D-dimer and severe proinflammatory state, therapeutic doses of enoxaparin can be considered, especially if bleeding risk is low according to the IMPROVE bleeding risk score.

Prevalence and Risk Factors of Venous Thromboembolism in Critically Ill Patients with Severe COVID-19 and the Association between the Dose of Anticoagulants and Outcomes

Introduction

COVID-19 is characterized by a procoagulant state that increases the risk of venous and arterial thrombosis. The dose of anticoagulants in patients with severe COVID-19 pneumonia without suspected or confirmed thrombosis has been debated.

Aim of the study

We evaluated the prevalence, predictors, and outcomes of venous thromboembolism (VTE) in critically ill COVID-19 patients and assessed the association between the dose of anticoagulants and outcomes.

Materials and methods

This retrospective cohort included patients with COVID-19 who were admitted to the ICU between March and July 2020. Patients with clinically suspected and confirmed VTE were compared to those not diagnosed to have VTE.

Results

The study enrolled 310 consecutive patients with severe COVID-19 pneumonia: age 60.0±15.1 years, 67.1% required mechanical ventilation and 44.7% vasopressors. Most (97.1%) patients received anticoagulants during ICU stay: prophylactic unfractionated heparin (N=106), standard-dose enoxaparin (N=104) and intermediate-dose enoxaparin (N=57). Limb Doppler ultrasound was performed for 49 (15.8%) patients and chest computed tomographic angiography for 62 (20%). VTE was diagnosed in 41 (13.2%) patients; 20 patients had deep vein thrombosis and 23 had acute pulmonary embolism. Patients with VTE had significantly higher D-dimer on ICU admission. On multivariable Cox regression analysis, intermediate-dose enoxaparin versus standard-dose unfractionated heparin or enoxaparin was associated with lower VTE risk (hazard ratio, 0.06; 95% confidence interval, 0.01-0.74) and lower risk of the composite outcome of VTE or hospital mortality (hazard ratio, 0.42; 95% confidence interval, 0.23-0.78; p=0.006). Major bleeding was not different between the intermediate- and prophylactic-dose heparin groups.

Conclusions

In our study, clinically suspected and confirmed VTE was diagnosed in 13.2% of critically ill patients with COVID-19. Intermediate-dose enoxaparin versus standard-dose unfractionated heparin or enoxaparin was associated with decreased risk of VTE or hospital mortality.

The Pattern of Heparin Dosing as Venous Thromboembolism Prophylaxis in Adult Underweight Patients Admitted to Critical Care Units at a Tertiary Hospital

BACKGROUND

 Venous thromboembolism (VTE) is one of the causes of hospital-related deaths in critically ill patients. Guidelines recommended VTE prophylaxis with standardized, fixed doses for most patients. The underweight population has limited data to guide the appropriate drug and dosing regimen.

OBJECTIVE

 The aim of this study was to describe the pattern of VTE prophylaxis dose regimens for underweighted critically ill adult patients and the prevalence of associated VTE and bleeding.

METHODS

 This study is a retrospective cohort study, conducted at the King Abdulaziz Medical City, Riyadh, Saudi Arabia. It included all critical patients admitted to the intensive care units (ICUs) and were above 14 years old with weight less than 50 kg or body mass index (BMI) of 18.5 kg/m² or less, and were on heparin as VTE prophylaxis for more than 72 h from January 2016 until January 2020.

RESULTS

 After screening 270 patients, only 40 patients were included in this study according to our inclusion and exclusion criteria. Only six patients (15%) received VTE prophylaxis as an adjusted dose of heparin 2500 U Q12, while the rest of the patients were taking standard dosing of heparin; 5000 U Q12 was given to 21 (52.50%) patients, and 5000 U Q8 was given to 13 (32.50%) patients. None of the adjusted doses developed any complications such as VTE or bleeding. There was no significant difference compared with the standard dose group.

CONCLUSIONS

 In this study, we described the pattern of heparin doses as VTE prophylaxis in underweight patients. We also compared the standard dosing and adjusted dosage of VTE prophylaxis on underweight patients and any complications. There was no significant difference in the complications outcome or benefits between the two groups.

Increased Susceptibility for Thromboembolic Events versus High Bleeding Risk Associated with COVID-19

The infection with the SARS-CoV-2 virus is associated with numerous systemic involvements. Besides the severe respiratory injuries and cardiovascular complications, it became obvious early on that this disease carries an increased risk of thromboembolic events, but a higher propensity for bleedings as well. We researched the medical literature over significant PubMed published articles debating on the prevalence, category of patients, the moment of occurrence, and evolution of venous thromboembolism (VTE), but also of venous and arterial “in situ” thrombosis (AT), and hemorrhagic events as well. Most researchers agree on an increased prevalence of thromboembolic events, ranging between 25 and 31% for VTE, depending on the analyzed population. For AT and hemorrhagic complications lower rates were reported, namely, about 2–3%, respectively, between 4.8 and 8%, occurring mostly in older patients, suffering from moderate/severe forms of COVID-19, with associated comorbidities. It is important to mention that patients suffering from hemorrhages frequently received thromboprophylaxis with anticoagulant drugs. As a consequence of thromboembolic and hemorrhagic complications which are both important negative prognostic factors, the evolution of patients infected with the SARS-CoV-2 virus is aggravated, determining an augmented morbidity and mortality of this population.

Upper gastrointestinal system bleedings in COVID-19 patients: Risk factors and management/a retrospective cohort study

BACKGROUND

Upper gastrointestinal system bleeding (UGIB) that occurs with the effect of coagulopathy due to COVID-19 disease itself and drugs such as LMWH and steroids used in the treatment negatively affects the outcomes. In this study, we aimed to examine the frequency of gastrointestinal system bleeding in COVID-19 patients, risk factors, effect on outcomes, and management.

METHODS

Institutional center (a third-level pandemic center) database was searched for patients hospitalized for COVID-19 between March 11, 2020, and December 17, 2020, retrospectively. Patients with UGIB symptoms/signs were included in the study. Age, gender, body mass index (kg/m2), hospital department where bleeding was diagnosed, previous bleeding history, comorbidities, and medication were steroid, anticoagulant, low weight molecule heparin, and proton-pomp inhibitor, endoscopic findings/treatment, transfusion, and mortality rates were evaluated. Patients were divided into two groups as survivors and non-survivors and parameters were compared.

RESULTS

Forty-five of a total 5484 patients under COVID-19 treatment had upper gastrointestinal bleeding (0.8%). The average age of the patients was 70.1 years and 73% bleeders were male. Nineteen patients (44%) underwent endoscopy. The most common etiologies of bleeding were gastric/duodenal ulcer (n=9), erosive gastritis (n=4), and hemorrhagic gastritis (n=3). Active bleeding re-quiring intervention was detected in only one patient; therapeutic band ligation was applied to only 1 (2%) of all patients. The most common etiologies of bleeding were gastric/duodenal ulcer (n=9), erosive gastritis (n=4), and hemorrhagic gastritis (n=3). In terms of statistical significance, it was observed that the rate of steroid treatment (77% vs. 39%) and the number of days of steroid treatment were higher in non-survivor group.

CONCLUSION

UGIB is less common in COVID-19 patients compared to other hospitalized patients. However, it significantly increases mortality. Mortality risk increases even more in patients using steroids. These risks should be considered in patients under COVID-19 treatment. The majority of the bleeding patients does not require endoscopic treatment and should be managed conser-vatively. It is worth considering reducing unnecessary endoscopies in the pandemic.

Life-threatening hematomas in COVID-19 patients

BACKGROUND

The COVID-19 pandemic has caused over 1.75 million deaths in the world to date. Although the leading cause of mortality is respiratory disorders and thromboembolic pathologies, other rare pathologies may also increase mortality and morbidity. In our study, we aimed to examine life-threatening hematomas, risk factors, and management during COVID-19.

METHODS

Institutional center (a third level pandemic center) database was searched for patients hospitalized for COVID-19 during 10 months period between March 11, 2020, and December 17, 2020, retrospectively. Patients with bleeding symptoms/signs were de-tected. Patients with gastrointestinal system bleeding were excluded from the study. Patients with hematomas were included in the study.

RESULTS

Eleven of a total 5484 patients had hematomas (0.2%). Median age was 76 (min-max: 56-90). Seven (63.6%) patients were male and 4 (36.4%) were female. All patients had at least one comorbidities, been under treatment dose of low-molecular-weight hep-arin (LMWH) and severe or critical COVID-19 disease. Seven retroperitoneal hematomas, two rectus sheath hematomas, one breast hematoma, and in one patient both retroperitoneal and breast hematomas were diagnosed. Angiographic arterial embolization was applied to 5 (45.5%) patients. Overall mortality rate in patients with bleeding complications was 54.5% (n=6), and the male-to-female ratio was 66.7% (n=4) versus 33.3% (n=2).

CONCLUSION

Hematomas are rare, but mortality increasing phenomena in COVID-19 patients. Age, male gender, severe or critical COVID-19 disease, comorbidities, and treatment dose of LMWH may be risk factors. New onset of abdominal/back pain and ecchymotic skin lesions may be signs of bleeding in this patient group. Mortality can be reduced by early diagnosis of hematoma and interventional methods.

Increased risk for thromboembolic events from combination of a gynecologic malignancy with severe acute respiratory syndrome coronavirus 2 infection: a case report

PURPOSE

During the severe acute respiratory syndrome coronavirus 2 pandemic, several patient groups are at particular risk. Mortality is higher among cancer patients and may be increased further by thromboembolic events, which are more common in coronavirus 2019 patients according to recent publications. We discuss the association of gynecologic malignancies, Severe acute respiratory syndrome coronavirus 2, and thromboembolism by reporting a case study and summarizing available literature.

CASE REPORT

A 71-year-old Caucasian patient with ovarian cancer receiving first-line chemotherapy was diagnosed with deep vein thrombosis and pulmonary embolism. Routine screening revealed infection with severe acute respiratory syndrome coronavirus 2 in absence of specific symptoms. After uneventful recovery, oncologic treatment could be continued a few weeks later.

METHODS

We performed a systematic review of the literature on PubMed following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The search included articles ahead of print, published between 1 December 2019 and 1 June 2020. Cross-searches were conducted on all relevant articles.

RESULTS

We identified five articles meeting the defined criteria, including two retrospective studies, a review, a position paper, as well as a letter to the editor.

CONCLUSION

Cancer patients infected with severe acute respiratory syndrome coronavirus 2 have a relatively poor outcome, which may partially be due to a higher rate of thromboembolic events. Thromboprophylaxis is recommended, and scoring systems are helpful in early detection. In cancer patients with severe acute respiratory syndrome coronavirus 2, individual risk for thromboembolic events should be taken into account when considering interruption versus continuation of antitumoral therapy. However, further data and studies are required.

Spontaneous Hematomas and Deep Vein Thrombosis during the Recovery from a SARS-CoV-2 Infection: Case Report and Literature Review

Background: The frequent occurrence of thromboembolic events in patients infected with the severe acute respiratory syndrome CoV2 (SARS-CoV-2) virus is a well-recognized fact in the medical literature, but less data is available about possible hemorrhagic incidents. Methods: We report the case of a 76-year-old patient who suffered from a mild COVID-19 infection in September 2021 and after four weeks, experienced a completely spontaneous popliteal hematoma followed by deep vein thrombosis (DVT). Therapy with low molecular weight heparins (LMWH) was started, but subsequently, the patient developed a massive sub-pectoral and calf hematoma leading to moderate post-hemorrhagic anemia and acute kidney injury. This patient was treated completely conservatively. Conclusions: Considering the continuous spread of the infection with various, continuously evolving strains of this virus and the extended use of LWMH in clinical practice, such cases were seldom described in the medical literature, but should be considered as a potential cause for hemorrhagic events.

Incidence of VTE and Bleeding Among Hospitalized Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis

BACKGROUND

Individual studies have reported widely variable rates for VTE and bleeding among hospitalized patients with coronavirus disease 2019 (COVID-19).

RESEARCH QUESTION

What is the incidence of VTE and bleeding among hospitalized patients with COVID-19?

METHODS

In this systematic review and meta-analysis, 15 standard sources and COVID-19-specific sources were searched between January 1, 2020, and July 31, 2020, with no restriction according to language. Incidence estimates were pooled by using random effects meta-analyses. Heterogeneity was evaluated by using the I² statistic, and publication bias was assessed by using the Begg and Egger tests.

RESULTS

The pooled incidence was 17.0% (95% CI, 13.4-20.9) for VTE, 12.1% (95% CI, 8.4-16.4) for DVT, 7.1% (95% CI, 5.3-9.1) for pulmonary embolism (PE), 7.8% (95% CI, 2.6-15.3) for bleeding, and 3.9% (95% CI, 1.2-7.9) for major bleeding. In subgroup meta-analyses, the incidence of VTE was higher when assessed according to screening (33.1% vs 9.8% by clinical diagnosis), among patients in the ICU (27.9% vs 7.1% in the ward), in prospective studies (25.5% vs 12.4% in retrospective studies), and with the inclusion of catheter-associated thrombosis/isolated distal DVTs and isolated subsegmental PEs. The highest pooled incidence estimate of bleeding was reported for patients receiving intermediate- or full-dose anticoagulation (21.4%) and the lowest in the only prospective study that assessed bleeding events (2.7%).

INTERPRETATION

Among hospitalized patients with COVID-19, the overall estimated pooled incidence of VTE was 17.0%, with higher rates with routine screening, inclusion of distal DVT, and subsegmental PE, in critically ill patients and in prospective studies. Bleeding events were observed in 7.8% of patients and were sensitive to use of escalated doses of anticoagulants and nature of data collection. Additional studies are required to ascertain the significance of various thrombotic events and to identify strategies to improve patient outcomes.

TRIAL REGISTRY

PROSPERO; No.: CRD42020198864; URL: https://www.crd.york.ac.uk/prospero/.

Utility of D-dimer as a Prognostic Factor in SARS CoV2 Infection: A Review

Coronavirus Disease-2019 (COVID-19) is currently a public health emergency and has been listed by the World Health Organization (WHO) as a pandemic. It has commonly been associated with pulmonary manifestations and there is a growing body of evidence of multisystem involvement of the virus. As evidenced by various case reports and cohort studies, COVID-19-associated coagulopathy has been a common manifestation amongst the critically ill and has been associated with increased mortality. The presence of venous thromboembolic events in patients who are critically ill due to COVID-19 has prompted the adoption of anticoagulation regimens aimed at preventing thromboembolic phenomena. Coagulation abnormalities have also been implicated in the progression and the severity of COVID-19 related acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC). There is strong evidence that D-dimer levels help predict which patients are at risk of thromboembolic events, progression to ARDS, DIC, immune dysregulation and mortality. We will review the utility of D-dimer as screening tool and in the risk stratification of COVID-19 patients prone to developing thromboembolic events, DIC, immune dysregulation and death. To date, the studies that have been published show the presence of elevated D-dimer levels in both the adult and pediatric populations and the measured level correlates with disease severity. Studies have also shown the relative increase of D-dimer levels in non-survivors compared to survivors. The elevation of D-dimer levels has shown to guide clinical decision making, namely the initiation of therapeutic anticoagulation and mortality benefit in patients with severe COVID-19 pneumonia compared to severe non COVID-19 pneumonia. Although the current body of literature suggested the use of D-dimer as a risk stratification tool and as a test to augment clinical judgement regarding the initiation of anticoagulation, randomized control trials are needed to fully understand the relationship between COVID-19 infection and the efficacy of D-dimer assays in clinical decision making.