VTE Incidence and Risk Factors in Patients With Severe Sepsis and Septic Shock

The prevalence, risk factors, and outcomes of acute pulmonary embolism complicating sepsis and septic shock: a national inpatient sample analysis

The study aimed to evaluate the prevalence, risk factors, and clinical outcomes of pulmonary embolism in patients diagnosed with sepsis with and without shock. The National Inpatient Sample was used to identify adults with sepsis with and without shock between 2017 and 2019. The prevalence of acute pulmonary embolism and the association of acute pulmonary embolism with in-hospital mortality, hospital length of stay for survivors, and overall costs of hospitalization were evaluated. Multivariable logistic and linear regression analyses, adjusted for various parameters, were used to explore these associations. Of the estimated 5,019,369 sepsis hospitalizations, 1.2% of patients with sepsis without shock and 2.3% of patients with septic shock developed pulmonary embolism. The odds ratio for in-hospital mortality was 1.94 (95% confidence interval (CI) 1.85-2.03, p < 0.001). The coefficient for hospital length of stay was 3.24 (95% CI 3.03-3.45, p < 0.001). The coefficient for total costs was 46,513 (95% CI 43,079-49,947, p < 0.001). The prevalence of pulmonary embolism in patients diagnosed with sepsis with and without shock was 1.2 and 2.3%, respectively. Acute pulmonary embolism was associated with higher in-hospital mortality, longer hospital length of stay for survivors, and higher overall costs of hospitalization.

Review of the Predictive Value of Biomarkers in Sepsis Mortality

Sepsis is a leading cause of mortality among severely ill individuals, primarily due to its potential to induce fatal organ dysfunction. For clinicians, it is vital to have appropriate indicators, including the physiological status and personal experiences of patients with sepsis, to monitor the condition and assess prognosis. This approach aids in preventing the worsening of the illness and reduces mortality. Recent guidelines for sepsis focus on improving patient outcomes through early detection and timely treatment. Nonetheless, identifying severe cases and predicting their prognoses remain challenging. In recent years, there has been considerable interest in utilising the C-reactive protein (CRP)/albumin ratio (CAR) to evaluate the condition and forecast the prognosis of patients with sepsis. This research concentrates on the significance of CAR in the pathological process of sepsis, its association with prognosis, and the latest developments in employing procalcitonin, lactic acid, CRP, and other potential biomarkers. The CAR, with its predictive value for sepsis prognosis and mortality, is increasingly used as a clinical biochemical marker in diagnosing and monitoring patients with sepsis.

Incidence of Thrombosis in COVID-19 Patients Compared to Non-COVID-19 Sepsis Patients in the Intensive Care Unit

Background/Objectives: The hypercoagulable state associated with COVID-19 infection is associated with adverse outcomes and mortality. Studies have also demonstrated high rates of venous thromboembolism (VTE) events among patients with sepsis. We aimed to evaluate how the increase in thrombotic events in critically ill patients with COVID-19 infection compares to that of critically ill patients with non-COVID-19 sepsis. Methods: A chart review was performed of patients 18 years or older admitted to the intensive care unit (ICU) at Tampa General Hospital between 1 January 2020 and 31 December 2020 diagnosed with COVID-19 or sepsis secondary to other pathogens. Non-COVID-19 sepsis patients and COVID-19 patients were propensity-matched 3:1 on the Charlson Comorbidity Index. Multivariate analyses adjusting for confounding were conducted to report odds ratio (OR) and 95% confidence intervals (95% CIs) of predictors for thrombotic events and overall mortality. Results: After propensity score matching, 492 sepsis patients and 164 COVID-19 patients were included in the analysis. COVID-19 patients were significantly older (p = 0.021) and showed higher BMI (p < 0.001) than sepsis patients. COVID-19 patients did not show significantly higher odds of thrombosis after adjustment for confounders (OR 0.85, 95% CI 0.42-1.72), but had significantly lower odds of mortality than sepsis patients (OR 0.33, 95% CI 0.16-0.66). Conclusions: Our results suggest that further study is required to lower the rate of VTE in COVID-19 and non-COVID-19 sepsis patients admitted to the ICU; it is also reasonable to consider similar thromboembolism practices between these two patient groups.

Risk Assessment of Venous Thromboembolism among Septic Shock Patients: Single versus Concurrent Insertion of Central Venous Catheters

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.

The incidence and risk factors of proximal lower extremity deep vein thrombosis without pharmacologic prophylaxis in critically ill surgical Taiwanese patients: A prospective study

Background

Venous thromboembolism (VTE) in critically ill patients has been well-studied in Western countries. Many studies have developed risk assessments and established pharmacological protocols to prevent deep venous thrombosis (DVT). However, the DVT rate and need for pharmacologic VTE prophylaxis in critically ill Taiwanese patients are limited. This study aimed to prospectively determine the DVT incidence, risk factors, and outcomes in critically ill Taiwanese patients who do not receive pharmacologic VTE prophylaxis.

Methods

We conducted a prospective study in a surgical intensive care unit (SICU) of a tertiary academic medical center in Taiwan. Adult patients admitted to SICU from March 2021 to June 2022 received proximal lower extremities DVT surveillance with venous duplex ultrasound. No patient received pharmacologic VTE prophylaxis. The outcomes were the incidence and risk factors of DVT.

Results

Among 501 enrolled SICU patients, 21 patients (4.2%) were diagnosed with proximal lower extremities DVT. In a multivariate regression analysis, hypoalbuminemia (odd ratio (OR) = 6.061, 95% confidence interval (CI): 1.067-34.421), femoral central venous catheter (OR = 4.515, 95% CI: 1.547-13.174), ICU stays more than 10 days (OR = 4.017, 95% CI: 1.270-12.707), and swollen leg (OR = 3.427, 95% CI: 1.075-10.930) were independent risk factors for DVT. In addition, patients with proximal lower extremities DVT have more extended ventilator days (p = 0.045) and ICU stays (p = 0.044).

Conclusion

Our findings indicate critically ill Taiwanese patients have a higher incidence of DVT than results from prior retrospective studies in the Asian population. Physicians who care for this population should consider the specific risk factors for DVT and prescribe pharmacologic prophylaxis in high-risk groups.

Transperineal drainage of prostate abscesses: A minimally invasive, low-risk management strategy that yields satisfactory results

Objectives

In this narrative review, we aim to present two cases of transperineal drainage of prostate abscesses with a good clinical outcome. Furthermore, we reviewed the literature on this treatment approach and aim to propose a minimally invasive protocol for managing this rare condition.

Patients and Methods

Our patients are 33- and 61-year-old males who both underwent uncomplicated transperineal drainage of prostate abscess with the use of a Precision Point device with rapid clinical improvement and complete resolution of the abscess within the follow-up period. We used PubMed to conduct a literature search and included and evaluated 16 relevant case reports and case series in which the authors utilized transperineal drainage techniques for prostatic abscesses.

Results

Our first patient was young and very unwell with sepsis and a pulmonary embolism. He had a complex abscess extending through the prostate to the left pelvic side wall. Trans-gluteal drainage of the pelvic side-wall collection was required in addition to transperineal drainage of the prostate abscess. After drainage and a prolonged course of antibiotics, he achieved resolution of the abscess by 7 weeks with ejaculatory function intact. Our second patient who was very keen on the preservation of ejaculatory function had multiple small abscesses and underwent transperineal drainage. He had significant interval improvement of his abscess burden at the 4-week follow-up and complete resolution at the 6-month follow-up. The total number of cases in the literature on our review is 22, with considerable variability in how the authors managed the prostate abscesses that underwent transperineal drainage, including variability in their follow-up time frame, choice of imaging modality, duration of antibiotic treatment, drain placement, and use of irrigation solutions (including antibiotics) into the abscess cavity. Furthermore, the sizes of the prostate abscesses were not consistently reported. Given the small sample size and variability in management from different authors, it was not possible to draw any statistical analysis.

Conclusion

Transperineal prostate abscess drainage combined with prolonged antibiotic therapy provides a less invasive alternative to treating prostate abscesses for those who which to preserve ejaculatory function and avoid the other adverse events of transurethral de-roofing. In itself, it can achieve complete resolution of abscess. It provides the benefit of drainage under real-time imaging; for percutaneous drain placement; prevents urethral injury; retrograde ejaculation; and can be done under local anaesthetic which is preferable for the unstable patient. The utility of the procedure may be limited by the complexity of the abscess or whether it has extended beyond the prostate. The patient should always be informed that further drainage via percutaneous methods or transurethral methods may be necessary if their clinical condition does not improve. We recommend this procedure be offered as an alternative to transurethral methods in younger patients and those who would like to preserve ejaculatory function. Furthermore, we highly encourage a prolonged course of antibiotic therapy and interval follow-up with clinical review of symptoms and imaging to confirm resolution.

High and intermediate risk pulmonary embolism in the ICU

Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.

Factors influencing DVT formation in sepsis

INTRODUCTION

Sepsis is a global public health burden. Deep vein thrombosis (DVT) is the third most common cause of death from cardiovascular disease after heart attacks and strokes. We designed this experiment to investigate the factors influencing DVT formation in patients with sepsis.

METHODS

In this survey, 918 septic patients admitted to Peking Union Medical College Hospital, who underwent DVT screening were enrolled. The data were collected from June 8, 2013 to October 12, 2022. The differences between septic patients with and without DVT were studied from following aspects: basic information, comorbidities, inflammatory cytokines, albumin, source of infection, sequential organ failure assessment (SOFA) score, coagulation and prognosis.

MAIN RESULTS

In this study, the prevalence of DVT in patients with sepsis was 0.23. Elderly patients with sepsis were prone to DVT (p value < 0.001). In terms of comorbidities, septic patients with hypertension and atrial fibrillation were prone to DVT (p value 0.045 and 0.048). Inflammatory cytokines, such as procalcitonin (PCT), C-reactive protein (CRP), interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF)-α, had no significant correlation with DVT in patients with sepsis (p value 0.364, 0.882, 0.912, 0.789, 0.245, and 0.780). Levels of serum albumin correlated with DVT in patients with sepsis (p value 0.003). The SOFA total score had no relationship with DVT formation (p value 0.254). Coagulation and respiration function were negatively correlated with DVT (p value 0.018). Liver function was positively correlated with DVT (p value 0.020). Patients in the DVT group had longer duration of mechanical ventilation and longer intensive care unit (ICU) stays (p value < 0.001 and 0.006). There was no significant difference in survival in septic patients with and without DVT (p value 0.868).

CONCLUSIONS

The SOFA total score had no relationship with DVT formation. The function of each organ had different effects on DVT formation. Better coagulation and respiration function, easier DVT formation. Poorer liver function, easier DVT formation. DVT was associated with longer duration of mechanical ventilation and longer ICU stays.

MACHINE LEARNING FOR PREDICTING HEMODYNAMIC DETERIORATION OF PATIENTS WITH INTERMEDIATE-RISK PULMONARY EMBOLISM IN INTENSIVE CARE UNIT

ABSTRACT

Background: Intermediate-risk pulmonary embolism (PE) patients in the intensive care unit (ICU) are at a higher risk of hemodynamic deterioration than those in the general ward. This study aimed to construct a machine learning (ML) model to accurately identify the tendency for hemodynamic deterioration in the ICU patients with intermediate-risk PE. Method: A total of 704 intermediate-risk PE patients from the MIMIC-IV database were retrospectively collected. The primary outcome was defined as hemodynamic deterioration occurring within 30 days after admission to ICU. Four ML algorithms were used to construct models on the basis of all variables from MIMIC IV database with missing values less than 20%. The extreme gradient boosting (XGBoost) model was further simplified for clinical application. The performance of the ML models was evaluated by using the receiver operating characteristic curve, calibration plots, and decision curve analysis. Predictive performance of simplified XGBoost was compared with the simplified Pulmonary Embolism Severity Index score. SHapley Additive explanation (SHAP) was performed on a simplified XGBoost model to calculate the contribution and impact of each feature on the predicted outcome and presents it visually. Results: Among the 704 intermediate-risk PE patients included in this study, 120 patients experienced hemodynamic deterioration within 30 days after admission to the ICU. Simplified XGBoost model demonstrated the best predictive performance with an area under the curve of 0.866 (95% confidence interval, 0.800-0.925), and after recalibrated by isotonic regression, the area under the curve improved to 0.885 (95% confidence interval, 0.822-0.935). Based on the simplified XGBoost model, a web app was developed to identify the tendency for hemodynamic deterioration in ICU patients with intermediate-risk PE. Conclusion: A simplified XGBoost model can accurately predict the occurrence of hemodynamic deterioration for intermediate-risk PE patients in the ICU, assisting clinical workers in providing more personalized management for PE patients in the ICU.

Factors associated with venous thromboembolic disease due to failed thromboprophylaxis

INTRODUCTION

Available evidence to identify factors independently associated with failed thromboprophylaxis (FT) in medical patients is insufficient. The present study seeks to evaluate in hospitalized patients, which clinical factors are associated with the development of FT.

MATERIALS AND METHODS

A case-control study nested to a historical cohort, comparing patients who developed failed thromboprophylaxis (cases) with those who did not (controls). Univariate and multivariate regression analysis was performed to define the factors associated with FT.

RESULTS

We selected 204 cases and 408 controls (52.4% men, median age 63 years). Medical patients were 78.4%. The most frequent thromboprophylaxis scheme was enoxaparin. In the failed thromboprophylaxis group, most of the embolic events corresponded to pulmonary embolism (53.4%). Among cases, BMI was higher (26.3 vs. 25 kg/m2, p < 0.001), as was the proportion of patients with leukocytosis > 13,000 (27% vs. 18.9%, p:0.22), and patients who required intensive care management (48% vs. 24.8%, p < 0.001). Factors independently associated with FT were BMI (OR1.04;95%CI 1.00-1.09, p:0.39), active cancer (OR:1.63;95%IC 1.03-2.57, p:0.04), leukocytosis (OR:1.64;95%CI 1.05-2.57, p:0.03) and ICU requirement (OR:3.67;95%CI 2.31-5.83, p < 0.001).

CONCLUSION

Our study suggests that the failed thromboprophylaxis is associated with high BMI, active cancer, leukocytosis, and ICU requirement. Future studies should evaluate whether there is benefit in adjusting the thromboprophylaxis scheme in patients with one or more of these factors.

Crosstalk between septic shock and venous thromboembolism: a bioinformatics and immunoassay analysis

Background

Herein, we applied bioinformatics methods to analyze the crosstalk between septic shock (SS) and venous thromboembolism (VTE), focusing on the correlation with immune infiltrating cells.

Methods

Expression data were obtained from the Gene Expression Omnibus (GEO) database, including blood samples from SS patients (datasets GSE64457, GSE95233, and GSE57065) and VTE patients (GSE19151). We used the R package "limma" for differential expression analysis (p value<0.05,∣logFC∣≥1). Venn plots were generated to identify intersected differential genes between SS and VTE and conducted Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) Enrichment analysis. The protein-protein interaction (PPI) network of intersected genes was constructed by Cytoscape software. The xCell analysis identified immune cells with significant changes in VTE and SS and correlated them with significant molecular pathways of crosstalk. Finally, we validated the mRNA expression of crosstalk genes by qPCR, while Matrix Metalloprotein-9 (MMP-9) protein levels were assessed through Western blotting (WB) and Immunohistochemistry (IHC) in human umbilical vein endothelial cells (HUVECs) and mice.

Results

In the present study, we conducted a comparison between 88 patients with septic shock and 55 control subjects. Additionally, we compared 70 patients with venous thromboembolism to 63 control subjects. Twelve intersected genes and their corresponding three important molecular pathways were obtained: Metabolic, Estrogen, and FOXO signaling pathways. The resulting PPI network has 194 nodes and 388 edges. The immune microenvironment analysis of the two diseases showed that the infiltration levels of M2 macrophages and Class-switched memory B cells were correlated with the enrichment scores of metabolic, estrogen, and FOXO signaling pathways. Finally, qPCR confirmed that the expression of MMP9, S100A12, ARG1, SLPI, and ANXA3 mRNA in the SS with VTE group was significantly elevated. WB and IHC experiments revealed that MMP9 protein was significantly elevated in the experimental group.

Conclusion

Metabolic, estrogen, and FOXO pathways play important roles in both SS and VTE and are related to the immune cell microenvironment of M2 macrophages and Class-switched memory B cells. MMP9 shows promise as a biomarker for diagnosing sepsis with venous thrombosis and a potential molecular target for treating this patient population.

Anti-factor Xa level monitoring of low-molecular-weight heparin for prevention of venous thromboembolism in critically ill patients (AXaLPE): protocol of a randomised, open-label controlled clinical trial

INTRODUCTION

Whether and when to monitor the amount of anti-factor Xa (aFXa) activity in critically ill patients with complex diseases to prevent venous thromboembolism (VTE) remain unclear. This study is a randomised controlled trial to investigate the effect of aFXa level monitoring on reducing VTE and to establish a new method for accurately preventing VTE in critically ill patients with low-molecular-weight heparin (LMWH).

METHODS AND ANALYSIS

A randomised controlled trial is planned in two centres with a planned sample size of 858 participants. Participants will be randomly assigned to three groups receiving LMWH prophylaxis at a 1:1:1 ratio: in group A, peak aFXa levels will serve as the guide for the LMWH dose; in group B, the trough aFXa levels will serve as the guide for the LMWH dose; and in group C, participants serving as the control group will receive a fixed dose of LMWH. The peak and trough aFXa levels will be monitored after LMWH (enoxaparin, 40 mg, once daily) reaches a steady state for at least 3 days. The monitoring range for group A's aFXa peak value will be 0.3-0.5 IU/mL, between 0.1 and 0.2 IU/mL is the target range for group B's aFXa trough value. In order to reach the peak or trough aFXa levels, groups A and B will be modified in accordance with the monitoring peak and trough aFXa level. The incidence of VTE will serve as the study's primary outcome indicator. An analysis using the intention-to-treat and per-protocol criterion will serve as the main outcome measurement.

ETHICS AND DISSEMINATION

The Xuanwu Hospital Ethics Committee of Capital Medical University and Peking University First Hospital Ethics Committee have approved this investigation. It will be released in all available worldwide, open-access, peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05382481.

Risk Factors for Coated Midline Catheter-Related Thrombosis: A Secondary Analysis of Existing Trial Data

Midline catheter-related thrombosis (MCRT) is a high-stakes complication. The authors aimed to explore risk factors for the development of symptomatic MCRT, including patient, procedure, catheter, and vein characteristics. This study performed an analysis of existing trial data that compared MCRT in 2 MCs with differing antithrombotic properties. Cox regression was used for univariable and multivariable analyses to evaluate the primary outcome of MCRT. Among 191 patients in this analysis, the average age was 60.2 years (standard deviation = 16.7 years), and 59.7% were female (114/191). Clinical indications for MC placement included antibiotics (60.7%), difficult venous access (32.5%), or both (6.8%). Body temperature ≥38°C (adjusted hazard ratio [aHR] = 6.26; 95% CI, 1.24-20.29; P = .03), catheter-to-vein ratio >0.40 (aHR = 2.65; 95% CI, 0.99-6.74; P = .05), and MC distance from antecubital fossa >7.0 cm (aHR = 2.82; 95% CI, 1.10-7.90; P = .03), were each significantly associated with the higher risk of the occurrence of symptomatic MCRT. This study found that catheter-to-vein ratio >0.40, distance from the antecubital fossa >7 cm, and body temperature ≥38°C were each associated with higher risk of MCRT. Current practices should be modified to include a minimum vein size to avoid MC insertions that occupy >40% of a given vein. Further research is needed to explain the impact of the catheter tip position and fever in relation to MCRT.

Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis

Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).

The Management of COVID-19-Related Coagulopathy: A Focus on the Challenges of Metabolic and Vascular Diseases

The course of COVID-19 is highly dependent on the associated cardiometabolic comorbidities of the patient, which worsen the prognosis of coronavirus infection, mainly due to systemic inflammation, endothelium dysfunction, and thrombosis. A search on the recent medical literature was performed in five languages, using the PubMed, Embase, Cochrane, and Google Scholar databases, for the review of data regarding the management of patients with a high risk for severe COVID-19, focusing on the associated coagulopathy. Special features of COVID-19 management are presented, based on the underlying conditions (obesity, diabetes mellitus, and cardiovascular diseases), emphasizing the necessity of a modern, holistic approach to thromboembolic states. The latest findings regarding the most efficient therapeutic approaches are included in the article, offering guidance for medical professionals in severe, complicated cases of SARS-CoV-2 infection. We can conclude that severe COVID-19 is closely related to vascular inflammation and intense cytokine release leading to hemostasis disorders. Overweight, hyperglycemia, cardiovascular diseases, and old age are important risk factors for severe outcomes of coronavirus infection, involving a hypercoagulable state. Early diagnosis and proper therapy in complicated SARS-CoV-2-infected cases could reduce mortality and the need for intensive care during hospitalization in patients with cardiometabolic comorbidities.

CT Approach to Lung Injury

Diffuse alveolar damage (DAD), which represents the pathologic changes seen after acute lung injury, is caused by damage to all three layers of the alveolar wall and can ultimately result in alveolar collapse with loss of the normal pulmonary architecture. DAD has an acute phase that predominantly manifests as airspace disease at CT owing to filling of the alveoli with cells, plasma fluids, and hyaline membranes. DAD then evolves into a heterogeneous organizing phase, with mixed airspace and interstitial disease characterized by volume loss, architectural distortion, fibrosis, and parenchymal loss. Patients with DAD have a severe clinical course and typically require prolonged mechanical ventilation, which may result in ventilator-induced lung injury. In those patients who survive DAD, the lungs will remodel over time, but most will have residual findings at chest CT. Organizing pneumonia (OP) is a descriptive term for a histologic pattern characterized by intra-alveolar fibroblast plugs. The significance and pathogenesis of OP are controversial. Some authors regard it as part of a spectrum of acute lung injury, while others consider it a marker of acute or subacute lung injury. At CT, OP manifests with various forms of airspace disease that are most commonly bilateral and relatively homogeneous in appearance at individual time points. Patients with OP most often have a mild clinical course, although some may have residual findings at CT. In patients with DAD and OP, imaging findings can be combined with clinical information to suggest the diagnosis in many cases, with biopsy reserved for difficult cases with atypical findings or clinical manifestations. To best participate in the multidisciplinary approach to patients with lung injury, radiologists must not only recognize these entities but also describe them with consistent and meaningful terminology, examples of which are emphasized in the article. © RSNA, 2023 See the invited commentary by Kligerman et al in this issue. Quiz questions for this article are available in the supplemental material.

The Association of Vasopressor Administration through a Midline Catheter with Catheter-related Complications

Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.

An Evolving Understanding of the Basis and Management of Vascular Complications of COVID-19: Where Do We Go From Here?

The COVID-19 pandemic led to millions of deaths worldwide after its emergence in 2020. The SARS-CoV-2 virus primarily affects respiratory function, but immune dysregulation leading to systemic inflammation, endothelial dysfunction, and coagulopathy can predispose to systemic complications including hematologic and vascular complications. Treatment strategies for patients with COVID-19 have rapidly evolved and the effectiveness and safety of antithrombotic agents have been evaluated in multiple clinical trials. The findings have spurred interest in the prevention and treatment of the hematologic and vascular complications of non-COVID-19 respiratory infections. This review is focused on hematological and vascular complications of COVID-19, including their pathophysiology, clinical manifestations, and management. Because of the perpetually changing nature of the disease, the review places previous data in temporal contexts and outlines potential next steps for future research in COVID-19 and other severe respiratory infections.

Risk of venous thromboembolism in patients with COVID-19 during 2020; a retrospective cross-sectional study in a Swedish health care system

To establish the impact of COVID-19 on the pre-test probability for VTE in patients with suspected VTE. This was a retrospective, observational, cross-sectional study of patients 18 years and older undergoing diagnostic tests for VTE in an integrated healthcare system covering a population of 465,000 during the calendar year of 2020. We adjusted for risk factors such as age, sex, previous VTE, ongoing anticoagulant treatment, malignancy, Charlson score, ward care, ICU care and wave of COVID-19. In total, 303 of 5041 patients had a positive diagnosis of COVID-19 around the time of investigation. The prevalence of VTE in COVID-positive patients was 10.2% (36/354), 14.7% (473/3219) in COVID-19 negative patients, and 15.6% (399/2589) in patients without a COVID-19 test. A COVID-positive status was not associated with an increased risk for VTE (crude odds ratio 0.64, 95% CI 0.45-0.91, adjusted odds ratio 0.46, 95%CI 0.19-1.16). We found no increased VTE risk in COVID-positive patients. This indicates that COVID-19 status should not influence VTE workup.The study was pre-registered on May 26, 2020 at ClinicalTrials.gov with identifier NCT04400877.

Early Administration of Vancomycin Inhibits Pulmonary Embolism by Remodeling Gut Microbiota

Pulmonary embolism (PE) is a common and potentially fatal condition in the emergency department, and early identification of modifiable risk factors for prevention and management is highly desirable. Although gut dysbiosis is associated with a high incidence of venous thromboembolism, the role and mechanisms of the gut microbiome in the pathogenesis of venous thromboembolism, especially PE, remain unexplored. Here, we attempted to elucidate the benefits of the gut microbiome in the pathogenesis of PE using multiple antibiotics and fecal microbiota transplantation (FMT) for early intervention in a classical mouse model of PE. The results showed that early administration of various antibiotics (except ampicillin) could inhibit pulmonary thrombosis to a certain extent and reduced mortality in young and old mice with PE. Among them, vancomycin has the best inhibitory effect on PE. With the help of gut microbiota sequencing analysis, we found that antibiotic treatment can reshape the gut microbiota; especially vancomycin can significantly improve the gut microbiota structure in PE mice. Furthermore, FMT could transfer vancomycin-modified gut microbes into mice and inhibit the pathogenesis of PE, possibly due to increased intestinal colonization by Parasutterella. These data elucidate the underlying molecular mechanism by which early administration of vancomycin can remodel the gut microbiota to suppress PE, providing new clues for clinical optimization and development of PE prevention strategies.

The mechanistic and structural role of von Willebrand factor in endotoxemia-enhanced deep vein thrombosis in mice

BACKGROUND

Although the concept of immunothrombosis has established a link between inflammation and thrombosis, the role of inflammation in the pathogenesis of deep vein thrombosis remains to be fully elucidated. Further, although various constituents of venous thrombi have been identified, their localizations and cellular and molecular interactions are yet to be combined in a single, multiplexed analysis.

OBJECTIVES

The objective of this study was to investigate the role of the von Willebrand factor (VWF) in inflammation-associated venous thrombosis. We also performed a proof-of-concept study of imaging mass cytometry to quantitatively and simultaneously analyze the localizations and interactions of 10 venous thrombus constituents.

METHODS

We combined the murine inferior vena cava stenosis model of deep vein thrombosis with the lipopolysaccharide model of endotoxemia. We also performed a proof-of-concept study of imaging mass cytometry to assess the feasibility of this approach in analyzing the structural composition of thrombi.

RESULTS

We found that lipopolysaccharide-treated mice had significantly higher incidences of venous thrombosis, an effect that was mitigated when VWF was inhibited using inhibitory αVWF antibodies. Our detailed structural analysis also showed that most thrombus components are localized in the white thrombus regardless of endotoxemia. Moreover, although endotoxemia modulated the relative representation and interactions of VWF with other thrombus constituents, the scaffolding network, comprised VWF, fibrin, and neutrophil extracellular traps, remained largely unaffected.

CONCLUSIONS

We observe a key role for VWF in the pathogenesis of inflammation-associated venous thrombosis while providing a more comprehensive insight into the molecular interactions that constitute the architecture of venous thrombi.

Thrombotic Events Develop in 1 Out of 5 Patients Receiving ECMO Support: An 11-Year Referral Centre Experience

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) for critically ill patients is growing rapidly given recent developments in technology. However, adverse events are frequently reported that have potentially devastating impacts on patient outcomes. The information on predictors and risk factors for thrombotic events, especially that focusing on the comparison of veno-arterial and veno-venous ECMO configurations, are still inconsistent and sparse; therefore, we aimed to close this gap.

METHODS

We performed a retrospective analysis of all patients on extracorporeal life support admitted to the intensive care units of a tertiary university center in Europe.

RESULTS

From 645 patients, 417 who received extracorporeal life support due to cardiogenic shock (290, 70%), respiratory failure (116, 28%) or hypothermia (11, 3%) were included. In total, 22% (92) of the patients experienced thrombotic events with a similar incidence in both ECMO configurations. Anticoagulation consisted of unfractionated heparin (296, 71%) and argatroban (70, 17%). Univariate Cox analyses identified hemoconcentration and increased maximal clot firmness (thromboelastometry) as risk factors for thrombosis. Moreover, the patients experiencing thrombosis had longer ECMO duration and intensive care stays.

CONCLUSIONS

ECMO is a specialized life-support modality with a high risk of complications. A longer ECMO duration is associated with thrombosis occurrence in patients receiving ECMO support. Following hemorrhage, thromboembolic complications are common adverse events. However, in contrast to major bleeding, no impact on mortality was observed. The question arises if a protocol with less anticoagulation may have a role to play in the future.

Risk factors associated with venous thromboembolism in laparoscopic surgery in non-obese patients with benign disease

INTRODUCTION

Few studies have focused on intraoperative positioning as a risk factor for venous thromboembolism (VTE). Positioning that places the legs in a dependent position may be a risk factor. We theorized that the reverse-Trendelenburg position specifically would increase the risk of postoperative VTE.

METHODS AND PROCEDURES

374,017 subjects undergoing laparoscopic surgery in the 2015-2018 NSQIP database were included. Diagnosis of cancer and BMI ≥ 30 were excluded. Subjects were grouped based on positioning: reverse-Trendelenburg (RT), supine (S), and Trendelenburg (T).

RESULTS

The RT, S, and T groups consisted of 117,887, 66,511, and 189,619 subjects, respectively. Overall median BMI was 25.7, and 82.8% of subjects were non-smokers. VTE within 30 days postoperative was seen in 0.25% RT, 0.23% S, and 0.4% T (p < 0.0001); 30-day mortality was 0.34% RT, 0.25% S, and 0.19% T (p < 0.0001). After adjusting for potential confounders and other risk factors, RT position was associated with a lower risk of VTE compared to S (OR 1.49 with 95% CI 1.16, 1.93) and T (OR 1.34 with 95% CI 1.15, 1.56) positions. VTE risk was significantly different across the three groups (p = 0.0001). Inpatient procedures had a higher VTE risk vs outpatient (OR 2.49 with 95% CI 2.10, 2.95). Increasing operative time was associated with higher VTE risk [4th (> 106 min) vs 1st (≤ 40 min) quartiles (OR 3.54 with 95% CI 2.79, 4.48)].

CONCLUSIONS

Among other risk factors, inpatient procedures and longer operative times are associated with higher VTE risk in laparoscopic surgery performed for benign disease in non-obese patients. The risk was significantly different across the three positioning groups with lowest risk in the RT group and highest risk in the S group.

Assessing the performance of genetic risk score for stratifying risk of post-sepsis cardiovascular complications

Background

Patients with sepsis are at increased risk for cardiovascular complications, including myocardial infarction (MI), ischemic stroke (IS), and venous thromboembolism (VTE). Our objective is to assess whether genetic risk score (GRS) can differentiate risk for these complications.

Methods

A population-based prospective cohort of 483,177 subjects, derived from the UK Biobank, was followed for diagnosis of sepsis and its complications (MI, IS, and VTE) after the study recruitment. GRS for each complication was calculated based on established risk-associated single nucleotide polymorphisms (SNPs). Time to incident MI, IS, and VTE was compared between subjects with or without sepsis and GRS risk groups using Kaplan-Meier log-rank test and Cox-regression analysis.

Results

During an average of 12.6 years of follow-up, 10,757 (2.23%) developed sepsis. Patients with sepsis had an overall higher risk than non-sepsis subjects for each complication, but the risk differed by time after a sepsis diagnosis; exceedingly high in short-term (0-30 days), considerably high in mid-term (31 days to 2 years), and reduced in long-term (>2 years). Furthermore, in White subjects, GRS was a significant predictor of complications, independent of sepsis and other risk factors. For example, GRS_MI further differentiated their risk in patients with sepsis; 3.49, 4.73, and 9.03% in those with low- (<0.5), intermediate- (0.5-1.99), high- GRS_MI (≥2.0), P_trend  < 0.001.

Conclusion

Risk for post-sepsis cardiovascular complications differed considerably by time after a sepsis diagnosis and GRS. These findings, if confirmed in other ancestry-specific populations, may guide personalized management for preventing post-sepsis cardiovascular complications.

Septic Shock: Management and Outcomes

The incidence rates of sepsis and septic shock as a complication have become more common over the past several decades. With this increase, sepsis remains the most common cause of intensive care unit (ICU) admissions and one of the most mortality factors, with a huge burden on healthcare facilities. Septic shock has devastating consequences on patients' lives, including organ failures and other long-term complications. Due to its dynamic clinical presentations, guidelines and tools have been established to improve the diagnosis and management effectively. However, there is still a need for evidence-based standardized procedures for the diagnosis, treatment, and follow-up of sepsis and septic shock patients due to the inconsistency of current guidelines and studies contrasting with each other. The standardization would help physicians better manage sepsis, minimize complications and reduce mortality. Septic shock is usually challenging to manage due to its variety of clinical characteristics and physiologic dynamics, affecting the outcomes. Therefore, this review presented the available data in the literature on septic shock diagnosis, management, and prognosis to have an overview of the updated best practice approach to septic shock.

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.

Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry

Previous studies that assessed risk factors for venous thromboembolism (VTE) in COVID-19 patients have shown inconsistent results. Our aim was to investigate VTE predictors by both logistic regression (LR) and machine learning (ML) approaches, due to their potential complementarity. This cohort study of a large Brazilian COVID-19 Registry included 4120 COVID-19 adult patients from 16 hospitals. Symptomatic VTE was confirmed by objective imaging. LR analysis, tree-based boosting, and bagging were used to investigate the association of variables upon hospital presentation with VTE. Among 4,120 patients (55.5% men, 39.3% critical patients), VTE was confirmed in 6.7%. In multivariate LR analysis, obesity (OR 1.50, 95% CI 1.11-2.02); being an ex-smoker (OR 1.44, 95% CI 1.03-2.01); surgery ≤ 90 days (OR 2.20, 95% CI 1.14-4.23); axillary temperature (OR 1.41, 95% CI 1.22-1.63); D-dimer ≥ 4 times above the upper limit of reference value (OR 2.16, 95% CI 1.26-3.67), lactate (OR 1.10, 95% CI 1.02-1.19), C-reactive protein levels (CRP, OR 1.09, 95% CI 1.01-1.18); and neutrophil count (OR 1.04, 95% CI 1.005-1.075) were independent predictors of VTE. Atrial fibrillation, peripheral oxygen saturation/inspired oxygen fraction (SF) ratio and prophylactic use of anticoagulants were protective. Temperature at admission, SF ratio, neutrophil count, D-dimer, CRP and lactate levels were also identified as predictors by ML methods. By using ML and LR analyses, we showed that D-dimer, axillary temperature, neutrophil count, CRP and lactate levels are risk factors for VTE in COVID-19 patients.

Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit

Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a "we suggest" vs a "we recommend" is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options.

How to cite this article

Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, et al. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022;26(S2):S51-S65.

The ICU-venous thromboembolism score and tumor grade can predict inhospital venous thromboembolism occurrence in critical patients with tumors

Background

Venous thromboembolism (VTE) is a threat to the prognosis of tumor patients, especially for critically ill patients. No uniform standard model of VTE risk for critically ill patients with tumors was formatted by now. We thus analyzed risk factors of VTE from the perspectives of patient, tumor, and treatment and assessed the predictive value of the ICU-VTE score, which consisted of six independent risk factors (central venous catheterization, 5 points; immobilization ≥ 4 days, 4 points; prior VTE, 4 points; mechanical ventilation, 2 points; lowest hemoglobin during hospitalization ≥ 90 g/L, 2 points; and baseline platelet count > 250,000/μL, 1 points).

Methods

We evaluated the data of tumor patients admitted to the intensive care unit of the Peking University Cancer Hospital between November 2011 and January 2022; 560 cases who received VTE-related screening during hospitalization were chosen for this retrospective study.

Results

The inhospital VTE occurrence rate in our cohort was 55.7% (312/560), with a median interval from ICU admission to VTE diagnosis of 8.0 days. After the multivariate logistic regression analysis, several factors were proved to be significantly associated with inhospital VTE: age ≥ 65 years, high tumor grade (G3–4), medical diseases, fresh frozen plasma transfusion, and anticoagulant prophylaxis. The medium-high risk group according to the ICU-VTE score was positively correlated with VTE when compared with the low-risk group (9–18 points vs. 0–8 points; OR, 3.13; 95% CI, 2.01–4.85, P < 0.001). The AUC of the ICU-VTE scores according to the ROC curve was 0.714 (95% CI, 0.67–0.75, P < 0.001).

Conclusions

The ICU-VTE score, as well as tumor grade, might assist in the assessment of inhospital VTE risk for critically ill patients with tumors. The predictive accuracy might be improved when combining two of them; further follow-up researches are needed to confirm it.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02705-z.

Examining D-dimer and Empiric Anti-coagulation in COVID-19-Related Thrombosis

Objective

Thrombosis is thought to occur frequently in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to elucidate the relationship between macro/microvascular thrombosis, D-dimer levels, and empiric anticoagulation in coronavirus disease 2019 (COVID-19).

Methods

This was an exploratory prospective, single-site, observational study. Adult emergency department patients with COVID-19 requiring hospitalization received a point-of-care lower extremity venous duplex ultrasound. The primary endpoint was thromboembolism and associated D-dimer level. Secondary endpoints included rates of micro and macro thrombotic complications as well as empiric anticoagulant use.

Results

Between January 13^th and April 12^th 2021, 52 patients were enrolled. Median D-dimer at presentation was 650 ng/mL (range 250-10,000 ng/mL) among patients with negative duplex studies. During hospitalization, 18 patients underwent 20 additional studies assessing for venous thromboembolism (VTE). These studies yielded one deep vein thrombosis (DVT) diagnosis. Among patients with negative studies median D-dimer was 1,246 ng/mL (range 329-10,000 ng/mL). Two patients experienced microvascular complications. Seven patients were started on empiric full dose anticoagulation.

Conclusion

While VTE remains a major concern amongst patients with COVID-19, the normal D-dimer cut off of >500 ng/mL likely should not be used to initiate further VTE workup. Additionally, moderately elevated D-dimer did not correlate strongly with microvascular complications and may not be relevant in the decision to initiate empiric anticoagulation.

3D-PAST: Risk Assessment Model for Predicting Venous Thromboembolism in COVID-19

Hypercoagulability is a recognized feature in SARS-CoV-2 infection. There exists a need for a dedicated risk assessment model (RAM) that can risk-stratify hospitalized COVID-19 patients for venous thromboembolism (VTE) and guide anticoagulation. We aimed to build a simple clinical model to predict VTE in COVID-19 patients. This large-cohort, retrospective study included adult patients admitted to four hospitals with PCR-confirmed SARS-CoV-2 infection. Model training was performed on 3531 patients hospitalized between March and December 2020 and validated on 2508 patients hospitalized between January and September 2021. Diagnosis of VTE was defined as acute deep vein thrombosis (DVT) or pulmonary embolism (PE). The novel RAM was based on commonly available parameters at hospital admission. LASSO regression and logistic regression were performed, risk scores were assigned to the significant variables, and cutoffs were derived. Seven variables with assigned scores were delineated as: DVT History = 2; High D-Dimer (>500−2000 ng/mL) = 2; Very High D-Dimer (>2000 ng/mL) = 5; PE History = 2; Low Albumin (<3.5 g/dL) = 1; Systolic Blood Pressure <120 mmHg = 1, Tachycardia (heart rate >100 bpm) = 1. The model had a sensitivity of 83% and specificity of 53%. This simple, robust clinical tool can help individualize thromboprophylaxis for COVID-19 patients based on their VTE risk category.

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

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.

Comparison of deep vein thrombosis risks in acute respiratory distress syndrome caused by COVID-19 and bacterial pneumonia: a retrospective cohort study

BACKGROUND

High incidence of deep vein thrombosis (DVT) has been observed in patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 and those by bacterial pneumonia. However, the differences of incidence and risk factors of DVT in these two groups of ARDS had not been reported before.

STUDY DESIGN AND METHODS

We performed a retrospective cohort study to investigate the difference of DVT in incidence and risk factors between the two independent cohorts of ARDS and eventually enrolled 240 patients, 105 of whom with ARDS caused by COVID-19 and 135 caused by bacterial pneumonia. Lower extremity venous compression ultrasound scanning was performed whenever possible regardless of clinical symptoms in the lower limbs. Clinical characteristics, including demographic information, clinical history, vital signs, laboratory findings, treatments, complications, and outcomes, were analyzed for patients with and without DVT in these two cohorts.

RESULTS

The 28-days incidence of DVT was higher in patients with COVID-19 than in those with bacterial pneumonia (57.1% vs 41.5%, P = 0.016). Taking death as a competitive risk, the Fine-Gray test showed no significant difference in the 28-day cumulative incidence of DVT between these two groups (P = 0.220). Fine-Gray competing risk analysis also showed an association between increased CK (creatine kinase isoenzyme)-MB levels (P = 0.003), decreased PaO2 (partial pressure of arterial oxygen)/FiO2 (fraction of inspired oxygen) ratios (P = 0.081), increased D-dimer levels (P = 0.064) and increased incidence of DVT in COVID-19 cohort, and an association between invasive mechanical ventilation (IMV; P = 0.001) and higher incidence of DVT and an association between VTE prophylaxis (P = 0.007) and lower incidence of DVT in bacterial pneumonia cohort. The sensitivity and specificity of the corresponding receiver operating characteristic curve originating from the combination of CK-MB levels, PaO2/FiO2 ratios, and D-dimer levels ≥0.5 μg/mL were higher than that of the DVT Wells score (P = 0.020) and were not inferior to that of the Padua prediction score (P = 0.363) for assessing the risk of DVT in COVID-19 cohort.

CONCLUSIONS

The incidence of DVT in patients with ARDS caused by COVID-19 is higher than those caused by bacterial pneumonia. Furthermore, the risk factors for DVT are completely different between these two ARDS cohorts. It is suggested that COVID-19 is probably an additional risk factor for DVT in ARDS patients.

Influence of Steric Shield on Biocompatibility and Antithrombotic Activity of Dendritic Polyphosphate Inhibitor

The polyanion, inorganic polyphosphate (polyP), is a procoagulant molecule which has become a promising therapeutic target in the development of antithrombotics. Neutralizing polyP's prothrombotic activity using polycationic inhibitors is one of the viable strategies to design new polyP inhibitors. However, in this approach, a fine balance between the electrostatic interaction of polyP and the inhibitor is needed. Any unprotected polycations are known to interact with negatively charged blood components, potentially resulting in platelet activation, cellular toxicity, and bleeding. Thus, designing potent polycationic polyP inhibitors with good biocompatibility is a major challenge. Building on our previous research on universal heparin reversal agent (UHRA), we report polyP inhibitors with a modified steric shield design. The molecular weight, number of cationic binding groups, and the length of the polyethylene glycol (PEG) chains were varied to arrive at the desired inhibitor. We studied two different PEG lengths (mPEG-750 versus mPEG-350) on the polyglycerol scaffold and investigated their influence on biocompatibility and polyP neutralization activity. The polyP inhibitor with mPEG-750 brush layer, mPEG₇₅₀ UHRA-10, showed superior biocompatibility compared to its mPEG-350 analogs by a number of measured parameters without losing its neutralization activity. An increase in cationic binding groups (25 groups in mPEG₇₅₀ UHRA-8 and 32 in mPEG₇₅₀ UHRA-10 [HC]) did not alter the neutralization activity, which suggested that the mPEG-750 shield layer provides significant protection of cationic binding groups and thus helps to minimize unwanted nonspecific interactions. Furthermore, these modified polyP inhibitors are highly biocompatible compared to conventional polycations that have been previously used as polyP inhibitors (e.g., PAMAM dendrimers and polyethylenimine). Through this study, we demonstrated the importance of the design of steric shield toward highly biocompatible polyP inhibitors. This approach can be exploited in the design of highly biocompatible macromolecular inhibitors.

Clinical features of thrombosis and bleeding in COVID-19

Infection with the SARS-CoV-2 virus, resulting in COVID-19 disease has presented a unique scenario associated with high thrombotic rates. The risk of venous thrombosis is some 3-6 fold higher than for patients admitted to hospital for other indications and for patients who have thrombosis, mortality appears increased. Thrombosis may be a presenting feature of COVID-19. Pulmonary thrombi are the most frequent events, some related to deep vein thrombosis, but also in situ micro- and macrovascular thrombosis. Other venous thromboses include catheter and circuit-associated in patients requiring haemofiltration and ECMO. Arterial thrombosis is less commonly documented, with 3% of ICU patients having major arterial strokes and up to 9% myocardial infarction, which is likely multifactorial. Risk factors for thrombosis above those already documented in hospital settings include duration of COVID-19 symptoms before admission to hospital. Laboratory parameters associated with higher thrombotic risk include higher D-dimer, low fibrinogen and low lymphocyte count, with higher FVIII and von Willebrand factor levels indicative of more severe COVID-19 infection. All patients should receive thromboprophylaxis when admitted with COVID-19 infection, but the dose and length of treatment still remain debated. Treatment for thrombosis remains as per standard VTE guidelines, but adjustments may be required depending on other factors relevant to the patient admission.

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

BACKGROUND

The coronavirus disease 2019 (COVID-19) is a newly recognized illness that has spread rapidly all over the world. More and more reports highlight the risk of venous thromboembolism (VTE) in COVID-19. Our study aims to identify in-hospital VTE risk and bleeding risk in COVID-19 patients.

METHODS

We retrospectively studied 138 consecutively enrolled patients with COVID-19 and identified in-hospital VTE and bleeding risk by Padua Prediction Score and Improve bleed risk assessment model. The clinical data and features were analyzed in VTE patients.

RESULTS

Our findings identified that 23 (16.7%) patients with COVID-19 were at high risk for VTE according to Padua prediction score and 9 (6.5%) patients were at high risk of bleeding for VTE prophylaxis according to Improve prediction score. Fifteen critically ill patients faced double high risk from thrombosis (Padua score more than 4 points in all 15 [100%] patients) and hemorrhage (Improve score more than 7 points in 9 [60.0%] patients). Thrombotic events were identified in four patients (2.9%) of all COVID-19 patients. All of them were diagnosed with deep vein thrombosis by ultrasound 3 to 18 days after admission. Three (75.0%) were critically ill patients, which means that the incidence of VTE among critically ill patients was 20%. One major hemorrhage happened in critically ill patients during VTE treatment.

CONCLUSION

Critically ill patients with COVID-19 suffered both a high risk of thrombosis and bleeding risks. More effective VTE prevention strategies based on an individual assessment of bleeding risks were necessary for critically ill patients with COVID-19.

Overactivation of IL6 cis‑signaling in leukocytes is an inflammatory hallmark of deep vein thrombosis

Inflammation is a protective response of the body to various injuries, which is strictly regulated by a variety of factors, including immune cells and soluble mediators. However, dysfunction of this defensive mechanism often results in inflammation‑driven diseases, such as deep vein thrombosis (DVT). The complex relationship between inflammatory cell activity and DVT has not been fully elucidated. The present study aimed to investigate the role of interleukin‑6 (IL6) signaling transduction in DVT. To this aim, the expression levels of transmembrane isoforms of the IL6 receptor (IL6R) and the glycoprotein 130 responsible for the IL6 cis‑signaling were evaluated in the peripheral blood mononuclear cells of patients with DVT and of healthy controls. The results indicated that leukocytes from patients with DVT exhibited overexpression of both IL6R and gp130 membrane isoforms and that these were strongly associated with the occurrence of DVT. Overall, the present findings indicated that IL6 cis‑signaling may have a direct involvement in the leukocyte activation in DVT and may serve as a predictive biomarker of DVT development.

Incidence of proximal deep vein thrombosis in medical critical care patients

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.

Risk Factors for Pulmonary Embolism in ICU Patients: A Retrospective Cohort Study from the MIMIC-III Database

Pulmonary embolism (PE) is a common and potentially lethal form of venous thromboembolic disease in ICU patients. A limited number of risk factors have been associated with PE in ICU patients. In this study, we aimed to screen the independent risk factors of PE in ICU patients that can be used to evaluate the patient's condition and provide targeted treatment. We performed a retrospective cohort study using a freely accessible critical care database Medical Information Mart for Intensive Care (MIMIC)-III. The ICU patients were divided into two groups based on the incidence of PE. Finally, 9871 ICU patients were included, among which 204 patients (2.1%) had pulmonary embolism. During the multivariate logistic regression analysis, sepsis, hospital_LOS (the length of stay in hospital), type of admission, tumor, APTT (activated partial thromboplastin time) and platelet were independent risk factors for patients for PE in ICU, with OR values of 1.471 (95%CI 1.001-2.162), 1.001 (95%CI 1.001-1.001), 3.745 (95%CI 2.187-6.414), 1.709 (95%CI 1.247-2.341), 1.014 (95%CI 1.010-1.017) and 1.002 (95%CI 1.001-1.003) (P_s < 0.05). ROC curve analysis showed that the composite indicator had a higher predictive value for ICU patients with PE, with a ROC area under the curve (AUC) of 0.743 (95%CI 0.710 -0.776, p < 0.001). Finally, sepsis, tumor, platelet count, length of stay in the hospital, emergency admission and APTT were independent predictors of PE in ICU patients.

Medication Changes and Diagnosis of New Chronic Illnesses in COVID-19 Intensive Care Unit Survivors

Background

Currently, there is limited literature on the impact of the COVID-19 infection on medications and medical conditions in COVID-19 intensive care unit (ICU) survivors. Our study is, to our knowledge, the first multicenter study to describe the prevalence of new medical conditions and medication changes at hospital discharge in COVID-19 ICU survivors.

Objective

To determine the number of medical conditions and medications at hospital admission compared to at hospital discharge in COVID-19 ICU survivors.

Methods

Retrospective multicenter observational study (7 ICUs) evaluated new medical conditions and medication changes at hospital discharge in patients with COVID-19 infection admitted to an ICU between March 1, 2020, to March 1, 2021. Patient and hospital characteristics, baseline and hospital discharge medication and medical conditions, ICU and hospital length of stay, and Charlson comorbidity index were collected. Descriptive statistics were used to describe patient characteristics and number and type of medical conditions and medications. Paired t-test was used to compare number of medical conditions and medications from hospital discharge to admission.

Results

Of the 973 COVID-19 ICU survivors, 67.4% had at least one new medical condition and 88.2% had at least one medication change. Median number of medical conditions (increased from 3 to 4, P < .0001) and medications (increased from 5 to 8, P < .0001) increased from admission to discharge. Most common new medical conditions at discharge were pulmonary disorders, venous thromboembolism, psychiatric disorders, infection, and diabetes. Most common therapeutic categories associated with medication change were cardiology, gastroenterology, pain, hematology, and endocrinology.

Conclusion and Relevance

Our study found that the number of medical conditions and medications increased from hospital admission to discharge. Our results provide additional data to help guide providers on using targeted approaches to manage medications and diseases in COVID-19 ICU survivors after hospital discharge.

Pulmonary Embolism in Post-CoviD-19 Patients, a Literature Review: Red Flag for Increased Awareness?

Although COVID-19 was primarily considered a respiratory illness, rapidly accumulating data suggest that COVID-19 is associated with a high incidence of venous thromboembolic complications. The primary objective of this review article was to reveal whether we need to increase awareness of pulmonary embolism in the period following the COVID-19 infection given that the epidemiologic facts are still poor. A literature search and a critical review of the collected studies were conducted. An electronic search of PubMed, Science Direct Scopus, Google Scholar, and Excerpta Medica Database (EMBASE) from June 2020 until June 2022. The long-term health consequences of COVID-19 remain largely unclear. This review highlights the importance of awareness of the potentially increased incidence of venous thromboembolism in post-COVID-19 patients, even those with mild or asymptomatic disease. Further research is required to establish appropriate clinical management guidelines for the prevention of thromboembolic complications in the post-COVID-19 period.

Mechanistic Studies of DNase I Activity: Impact of Heparin Variants and PAD4

Background

Excessive production of neutrophil extracellular traps (NETs) in sepsis contributes to vascular occlusion by acting as a scaffold and stimulus for thrombus formation. Removal of extracellular DNA, the major structural component of NETs, by DNase I may reduce host injury.

Objectives

(1) To determine how heparin variants (unfractionated heparin, enoxaparin, Vasoflux, and fondaparinux) affect DNase I activity, (2) to measure temporal changes in circulating DNA and DNase I in septic patients.

Methods

DNA–histone complexes were treated with DNase I ± heparin variants and visualized via agarose gels. We compared the ability of DNase I ± heparin variants to digest NETs released by phorbol 12-myristate 13-acetate-stimulated neutrophils versus DNA–histone complexes released by necrotic HEK293 cells. Plasma DNA and DNase I levels were measured longitudinally in 76 septic patients.

Results

Heparin enhances DNase I-mediated digestion of DNA–histone complexes in a size-dependent manner that does not require the antithrombin-binding region. In contrast, DNase I alone was able to degrade the DNA–histone component of NETs presumably due to peptidylarginine deiminase 4 (PAD4)-mediated histone citrullination that weakens DNA–histone interactions. In purified systems, PAD4 treatment of DNA–histone complexes enhanced the ability of DNase I to degrade histone-bound DNA. In septic patients, endogenous DNase I levels remained persistently low over 28 days, and there were no significant correlations between DNA and DNase I levels.

Conclusion

Heparin enhances DNA-mediated digestion of DNA–histone complexes in a size-dependent manner that is independent of its anticoagulant properties. Citrullination of histones by PAD4 renders DNA–histone complexes susceptible to DNase I digestion. Endogenous DNase I levels are persistently decreased in septic patients, which supports the potential utility of DNase I as a therapy for sepsis.

Human platelets display dysregulated sepsis-associated autophagy, induced by altered LC3 protein-protein interaction of the Vici-protein EPG5

Platelets mediate central aspects of host responses during sepsis, an acute profoundly systemic inflammatory response due to infection. Macroautophagy/autophagy, which mediates critical aspects of cellular responses during inflammatory conditions, is known to be a functional cellular process in anucleate platelets, and is essential for normal platelet functions. Nevertheless, how sepsis may alter autophagy in platelets has never been established. Using platelets isolated from septic patients and matched healthy controls, we show that during clinical sepsis, the number of autophagosomes is increased in platelets, most likely due to an accumulation of autophagosomes, some containing mitochondria and indicative of mitophagy. Therefore, autophagy induction or early-stage autophagosome formation (as compared to decreased later-stage autophagosome maturation or autophagosome-late endosome/lysosome fusion) is normal or increased. This was consistent with decreased fusion of autophagosomes with lysosomes in platelets. EPG5 (ectopic P-granules autophagy protein 5 homolog), a protein essential for normal autophagy, expression did increase, while protein-protein interactions between EPG5 and MAP1LC3/LC3 (which orchestrate the fusion of autophagosomes and lysosomes) were significantly reduced in platelets during sepsis. Furthermore, data from a megakaryocyte model demonstrate the importance of TLR4 (toll like receptor 4), LPS-dependent signaling for regulating this mechanism. Similar phenotypes were also observed in platelets isolated from a patient with Vici syndrome: an inherited condition caused by a naturally occurring, loss-of-function mutation in EPG5. Together, we provide evidence that autophagic functions are aberrant in platelets during sepsis, due in part to reduced EPG5-LC3 interactions, regulated by TLR4 engagement, and the resultant accumulation of autophagosomes.Abbreviations: ACTB: beta actin; CLP: cecal ligation and puncture; Co-IP: co-immunoprecipitation; DAP: death associated protein; DMSO: dimethyl sulfoxide; EPG5: ectopic P-granules autophagy protein 5 homolog; ECL: enhanced chemiluminescence; HBSS: Hanks' balanced salt solution; HRP: horseradish peroxidase; ICU: intensive care unit; LPS: lipopolysaccharide; LAMP1: lysosomal associated membrane protein 1; MAP1LC3/LC3: microtubule associated protein 1 light chain 3; MTOR: mechanistic target of rapamycin kinase; MKs: megakaryocytes; PFA: paraformaldehyde; PBS: phosphate-buffered saline; PLA: proximity ligation assay; pRT-PCR: quantitative real-time polymerase chain reaction; RT: room temperature; SQSTM1/p62: sequestosome 1; SDS-PAGE: sodium dodecyl sulfate-polyacrylamide gel electrophoresis; TLR4: toll like receptor 4; TEM: transmission electron microscopy; WGA: wheat germ agglutinin.