Incidence of thrombotic complications in critically ill ICU patients with COVID-19

Background: Literature has well established COVID-19 associated coagulopathy with resulting thrombotic complications including microthrombi as an underlying mechanism leading to severe respiratory disease. Therapeutic anticoagulation (TAC) for COVID-19 patients has therefore been widely trialed to combat COVID-19’s coagulopathic effects. However, literature has yet to define which population of patients TAC benefits; the most current randomized controlled trials (RCTs) reveal TAC to be possibly beneficial to moderately-ill hospitalized COVID-19 patients, whereas benefits did not outweigh risks in critically-ill ICU patients. Importantly, these studies excluded patients who received prehospital TAC. We examined outcomes in critically ill COVID-19 ICU patients who received TAC vs prophylactic anticoagulation (PAC) and specifically whether prehospital TAC effected outcomes. Methods: Retrospective cohort study of 132 COVID-19 ICU patients admitted March-June, 2020. Initial clinical practice provided PAC, as literature demonstrating COVID-19 associated coagulopathy and increased thromboembolic complications emerged, a TAC protocol was initiated. Results: 130 patients were included in the study, 95 of whom received TAC and 35 PAC. There was 50.8% overall mortality, with lower mortality in the TAC vs PAC group (46.3% vs 62.9%, p=0.094). There were few thromboembolic and hemorrhagic complications, with no significant difference between TAC and PAC patients. Of 24 patients anticoagulated prior to and during hospitalization, only 1 (4.2%) died, whereas the mortality was 60.6% among patients therapeutically anticoagulated during hospitalization only (p<0.001). Multivariable analysis revealed patients who received prehospital and in hospital TAC had a 92% lower risk of death (p=0.008) compared to in hospital only TAC and PAC patients. Conclusions: Overall, therapeutic anticoagulation did not result in mortality benefit to COVID-19 ICU patients compared to prophylactic anticoagulation. However, a sub-population of patients who received TAC both prior to and during hospitalization had a 12-fold lower risk of death. This suggests a protective effect of TAC when it is continued before and during hospitalization. RCTs are needed to specifically examine this subset of COVID-19 patients.

Download Full-text

The impact of viremia on organ failure, biomarkers and mortality in a Swedish cohort of critically ill COVID-19 patients

Scientific Reports ◽

10.1038/s41598-021-86500-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Josef D. Järhult ◽

Michael Hultström ◽

Anders Bergqvist ◽

Robert Frithiof ◽

Miklos Lipcsey

Keyword(s):

Organ Failure ◽

Critically Ill ◽

Independent Predictor ◽

Corticosteroid Treatment ◽

Blood Stream ◽

Common Finding ◽

Icu Patients ◽

Extra Pulmonary ◽

The Impact ◽

Swedish Cohort

AbstractThe spread of virus via the blood stream has been suggested to contribute to extra-pulmonary organ failure in Coronavirus disease 2019 (COVID-19). We assessed SARS-CoV-2 RNAemia (RNAemia) and the association between RNAemia and inflammation, organ failure and mortality in critically ill COVID-19 patients. We included all patients with PCR verified COVID-19 and consent admitted to ICU. SARS-CoV-2 RNA copies above 1000/ml measured by PCR in plasma was defined as RNAemia and used as surrogate for viremia. In this cohort of 92 patients 59 (64%) were invasively ventilated. RNAemia was found in 31 patients (34%). Hypertension and corticosteroid treatment was more common in patients with RNAemia. Extra-pulmonary organ failure biomarkers and the extent of organ failure were similar in patients with and without RNAemia, but the former group had more renal replacement therapy and higher mortality (26 vs 16%; 35 vs 16%, respectively, p = 0.04). RNAemia was not an independent predictor of death at 30 days after adjustment for age. SARS-CoV2 RNA copies in plasma is a common finding in ICU patients with COVID-19. Although viremia was not associated with extra pulmonary organ failure it was more common in patients who did not survive to 30 days after ICU admission.Trial registration: ClinicalTrials NCT04316884.

Download Full-text

Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study (Preprint)

10.2196/preprints.16301 ◽

2019 ◽

Author(s):

Dong Chang ◽

Jennifer Parrish ◽

Nader Kamangar ◽

Janice Liebler ◽

May Lee ◽

...

Keyword(s):

Intensive Care Unit ◽

Critically Ill ◽

Critically Ill Patients ◽

Decision Makers ◽

Care Planning ◽

Improvement Strategy ◽

Icu Patients ◽

Family Meetings ◽

Planning Approach ◽

Icu Physicians

BACKGROUND Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients’ goals of care. OBJECTIVE The aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality. METHODS This study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization. RESULTS The study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020. CONCLUSIONS The successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/16301

Download Full-text

Low albumin levels are associated with poorer outcomes in a case series of COVID-19 patients in Spain: a retrospective cohort study

10.1101/2020.05.07.20094987 ◽

2020 ◽

Cited By ~ 2

Author(s):

Roberto de la Rica ◽

Marcio Borges ◽

María Aranda ◽

Alberto del Castillo ◽

Antonia Socias ◽

...

Keyword(s):

Disease Severity ◽

Critically Ill ◽

Critically Ill Patients ◽

Case Series ◽

Hospitalized Patients ◽

University Hospital ◽

Limited Information ◽

Icu Patients ◽

Epidemiological Features ◽

Initial Symptoms

ABSTRACTOBJECTIVETo describe the clinical characteristics and epidemiological features of severe (non-ICU) and critically patients (ICU) with COVID-19 at triage, prior hospitalization, in one of the main hospitals in The Balearic Islands health care system.DESIGNRetrospective observational studySETTINGSon Llatzer University Hospital in Palma de Mallorca (Spain)PARTICIPANTSAmong a cohort of 52 hospitalized patients as of 31 March 2020, 48 with complete demographic information and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive test, were analyzed. Data were collected between March 15th, 2020, and March 31th 2020, inclusive of these dates.MAIN OUTCOMESClinical, vital signs and routine laboratory outcomes at the time of hospitalization, including symptoms reported prior to hospitalization. Demographics and baseline comorbidities were also collected. Mortality was reported at the end of the study.RESULTS48 patients (27 non-ICU and 21 ICU) resident in Mallorca, Spain (mean age, 66 years, [range, 33-88 years]; 67% males) with positive SARS-CoV-2 infection were analyzed. There were no differences in age or sex among groups (p >.05). Initial symptoms included fever (100%), coughing (85%), dyspnea (76%), diarrhea (42%) and asthenia (21%). The majority of patients in this case series were hospitalized because of low SpO2 (SpO2 below 90%) and presentation of bilateral pneumonia (94%) at triage. ICU patients had a higher prevalence of dyspnea compared to non-ICU patients (95% vs 61%, p = .022). Acute respiratory syndrome (ARDS) was presented in 100% of the ICU-patients. All the patients included in the study required oxygen therapy. ICU-patients had lymphopenia as well as hypoalbuminemia. Inflammatory markers such as lactate dehydrogenase (LDH), C-reactive protein (CRP), and procalcitonin were significantly higher in ICU patients compared to non-ICU (p < .001).Lower albumin levels were associated with poor prognosis measured as longer hospital length (r= −0.472, p <.001) and mortality (r= −0.424, p=.003). Interestingly we also found, that MCV was lower among of those patients who died (p=.0002). As of April 28, 2020, 10 patients (8 ICU and 2 non-ICU) had died (21% mortality) and while 100% of the non-ICU patients had been discharged, 33% of ICU patients still remained hospitalized (5 in ICU and 2 had been transferred to ward).CONCLUSIONCritically ill patients with COVID-19 present lymphopenia, hypoalbuminemia as well high levels of inflammation. Lower levels of albumin were associated with poorer outcomes in COVID-19 patients. Albumin might be of importance because of its association with disease severity in patients infected with SARS-CoV-2.WHAT IS ALREADY KNOWN IN THIS TOPICSpain has been hit particularly hard by the pandemic. By the time that this manuscript was written more than 25.000 deaths related to COVID-19 have been confirmed. There is limited information available describing the clinical and epidemiological features of Spanish patients requiring hospitalization for COVID-19. Also, it is important to know the characteristics of the hospitalized patients who become critically illWHAT THIS STUDY ADDSThis small case series provides the first steps towards a comprehensive clinical characterization of severe and critical COVID-19 adult patients in Spain. The overall mortality in our patients was 21%. To our knowledge this is the first report with reporting these features in Spain. At triage the majority of patients had lower SpO2 (<90%) and bilateral pneumonia. The most common comorbidities were hypertension (70%), dyslipidemia (62%) and cardiovascular disease (30%). Critically ill patients present hypoalbuminemia and lymphopenia, as well as higher levels of inflammation. Albumin might be of importance because of its association with disease severity and mortality in patients infected with SARS-CoV-2.

Download Full-text

Cutoff values of functional status score for the ICU(FSS-ICU) to predict patient discharge in critically ill ICU patients

Journal of the Japanese Society of Intensive Care Medicine ◽

10.3918/jsicm.28_99 ◽

2021 ◽

Vol 28 (2) ◽

pp. 99-104

Author(s):

Shun Aikawa ◽

Shinya Matsushima ◽

Hitoshi Yokoyama ◽

Takeichi Rie ◽

Hironobu Katata ◽

...

Keyword(s):

Functional Status ◽

Critically Ill ◽

Patient Discharge ◽

Icu Patients ◽

Status Score ◽

Cutoff Values

Download Full-text

COVID-19 Thrombosis: Understanding the Negative Predictive Value in a Pandemic

Blood ◽

10.1182/blood-2020-142127 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 5-5

Author(s):

Talat Almukhtar ◽

Julio Hajdenberg ◽

Gurjot Garcha

Keyword(s):

Negative Predictive Value ◽

Predictive Value ◽

Conflicts Of Interest ◽

False Negative ◽

Hospitalized Patients ◽

Radiographic Examination ◽

Icu Patients ◽

Proinflammatory Mediators ◽

Cortical Edema ◽

Thrombotic Complications

A test's negative predictive value-the probability that a negative result is a true negative result-is dependent on the prevalence of the condition. The present pandemic circumstances present us with unique challenges. False negatives in current testing methodology are to be expected.[1] Thus, a rigorous and contextual interpretation of a negative test result is necessary. Blood hypercoagulability and the risk of thrombosis are well documented in cases of the novel SARS-CoV-2 coronavirus (COVID-19) pandemic.[2] The systemic inflammatory response is associated with endothelial upregulation of proinflammatory mediators that lead to in situ thrombi, as well as a generalized disseminated intravascular coagulation. As many as 31% of ICU patients with COVID-19 have been reported to have thrombotic complications. More specifically, cerebral thrombotic complications confined to the arterial bed have been well described.[3, 4]. The case described shows that milder forms of coronavirus infection may lead to other types of critical and unusual thrombotic complications. An otherwise healthy 47-year-old Caucasian woman developed fever and respiratory signs and symptoms consistent with a possible case of COVID-19 infection in late March of 2020. Interstitial opacities were seen on radiographic examination. Two COVID-19 PCR nasopharyngeal tests were negative, and she recovered at home over the following 2 weeks. Three weeks later, she developed headaches, expressive aphasia, and a generalized tonic-clonic seizure. The patient was treated for a possible ischemic stroke with alteplase thrombolysis at a local hospital. After subsequent transfer and evaluation, a diagnosis of a left transverse and sigmoid sinus thrombosis with adjacent cortical edema was made. On review of her history, the patient denied taking any form of hormonal contraception, and did not have personal, or family history indicative of thrombophilia. She recovered fully after anticoagulation with enoxaparin and subsequent dabigatran. Prior to discharge a COVID-19, IgG antibody test was reported as positive. Decontextualized and overly simplistic interpretation of COVID-19 negative tests amidst a pandemic is problematic. In addition to the obvious infection control issues associated with the resulting lack of isolation and contract tracing, it may deprive some patients of the opportunity to receive antithrombotic therapy. Prophylactic and therapeutic regimens for hospitalized patients are in evolution, and have been associated with improved clinical outcomes.[5] We are aware that the role of anticoagulation in outpatient cases is not well studied, but we believe it deserves proper investigation. References: West, C.P., V.M. Montori, and P. Sampathkumar,COVID-19 Testing: The Threat of False Negative Results.Mayo Clin Proc, 2020.Thachil, J., et al.,ISTH interim guidance on recognition and management of coagulopathy inCOVID-19.J Thromb Haemost, 2020.18(5): p. 1023-1026.Oxley, T.J., et al.,Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young.N Engl J Med, 2020.Klok, F.A., et al.,Confirmation of the high cumulative incidence of thrombotic complications incritically ill ICU patients with COVID-19: An updated analysis.Thromb Res, 2020.Paranjpe, I., et al.,Association of Treatment Dose Anticoagulation with In-Hospital SurvivalAmong Hospitalized Patients with COVID-19.J Am Coll Cardiol, 2020. Disclosures No relevant conflicts of interest to declare.

Download Full-text

Discomforts in Critically ill Patients: Our Experience in Intensive Care Unit of a Tertiary Care Hospital in India

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/46882.14586 ◽

2021 ◽

Author(s):

Reetu Verma ◽

Sasmita Panda ◽

Rajeev Kumar Nishad

Keyword(s):

Intensive Care ◽

Environmental Factors ◽

Critically Ill ◽

Nursing Care ◽

Critically Ill Patients ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Care Hospital ◽

Icu Patients ◽

Common Cause

Introduction: Patients admitted in the Intensive Care Units (ICUs) experiences various discomforts which may be recognised or unrecognised. These discomforts may arise from the environment, may be related to the ICU care and discomfort related to the health status of the patient and critical care interventions. Aim: To identify the various discomforts in ICU patients, to classify them with respective causes, identify the most common cause among them and whether ICU sedation helps in reducing discomforts. Materials and Methods: This observational study was conducted from 15th July to 15th October 2018 on 120 mixed ICU patients in a Tertiary Care Hospital in India. Patients who were admitted to ICU for more than 24 hours, aged 18 years and above, those who gave written informed consent were observed and enquired for any discomfort. Discomforts have been identified and recorded by a fulltime intensivist by direct observation, by interacting with the patients and asking the family members and others (indirect approach). Through this study discomforts of critically ill patients were broadly classified into four categories 1. Due to existing illness, 2. Due to ICU interventions, 3. Due to improper nursing care and 4. Due to environmental factors. Results: Out of 120 patients studied, 84 patients (70%) reported some kind of discomfort during their ICU stay. Existing illness was the most common cause of discomfort, 80 patients (66.6%) suffered due to it. ICU interventions was the second most common cause, 71 patients (59.1%) had discomfort due to interventions. Thirty five patients (29.1%) suffered due to improper nursing care and 25 patients (20.8%) suffered due to the environmental factors. In this study, it was observed that sedation reduces all kind of discomforts. conclusion: In this study 70% of patients, who were admitted to ICU due to various illness reported some kind of discomfort. The most common cause of ICU discomforts was existing illness followed by ICU interventions. In this study it was observed that sedation reduces all kind of discomforts. Sedated patients tolerate the endotracheal tube better and they had less environmental and procedure related discomforts. With the present study observation it can be suggested that ICU charts of nurses and doctors can carry a separate column for mentioning discomforts in different duty shifts. However, with the use of appropriate analgesia and sedation discomfort can be reduced.

Download Full-text