Pulmonary embolism after discharge for COVID-19: A report of two cases

Previous studies have found critically ill patients with COVID-19 to have an increased risk of thromboembolic complications. In this case report of two patients admitted with symptomatic COVID-19, both patients developed pulmonary embolism within a few days after hospital discharge. Both patients received thromboprophylaxis and had an increasing fibrin D-dimer during their hospital stay. Continued thromboprophylaxis after hospital discharge may be indicated for patients with COVID-19, especially for patients at high risk of thrombosis with elevated levels of fibrin D-dimer.

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Increased risk of death and readmission after hospital discharge of critically ill patients in a developing country: a retrospective multicenter cohort study

Intensive Care Medicine ◽

10.1007/s00134-018-5252-3 ◽

2018 ◽

Vol 44 (7) ◽

pp. 1090-1096 ◽

Cited By ~ 3

Author(s):

Vanessa Chaves Barreto Ferreira de Lima ◽

Ana Luiza Bierrenbach ◽

Gizelton Pereira Alencar ◽

Ana Lucia Andrade ◽

Luciano Cesar Pontes Azevedo

Keyword(s):

Cohort Study ◽

Developing Country ◽

Hospital Discharge ◽

Critically Ill ◽

Critically Ill Patients ◽

Multicenter Cohort Study ◽

Risk Of Death ◽

Multicenter Cohort ◽

Increased Risk

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Pulmonary Embolism in Patients with COVID-19

Clinical Cardiology and Cardiovascular Interventions ◽

10.31579/2641-0419/236 ◽

2022 ◽

Vol 5 (1) ◽

pp. 01-06

Author(s):

Scarduelli Cleante ◽

Scarduelli Sara ◽

Borghi Claudio

Keyword(s):

Pulmonary Embolism ◽

Usual Care ◽

Hospital Discharge ◽

Critically Ill ◽

Critically Ill Patients ◽

Therapeutic Dose ◽

High Rate ◽

Organ Support ◽

Probability Of Survival ◽

Prophylactic Anticoagulation

Infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) and the resulting syndrome, COVID-19, have been associated with inflammation and a prothrombotic state, with increases in fibrin, fibrinogen, fibrin degradation products and D-dimers. In some studies, elevations in these markers have been associated with worse clinical outcomes. Several studies have demonstrated a high prevalence of venous thromboembolism (VTE), and pulmonary embolism (PE), particularly in patients admitted to the intensive care unit (ICU), even in those receiving prophylactic anticoagulation. The high rate of thrombosis in COVID-19 is driven by at least two interrelated processes: a hypercoagulable state responsible for large-vessel thrombosis and thromboembolism and direct vascular and endothelial injury responsible for in situ microvascular thrombosis. The presence of PE and pulmonary thrombosis may explain why hypoxemia is out of proportion to impairment in lung compliance in some patients with COVID-19 pneumonia. Diagnosing PE in patients with COVID-19 pneumonia may be challenging, because the two pathologies share many signs and symptoms. It has been demonstrated that the administration of prophylactic anticoagulation within 24 h of admission in patients with COVID-19 was associated with decreased mortality when compared with no prophylactic anticoagulation. Given the antithrombotic, anti-inflammatory and possibly antiviral properties of heparins, it has been hypothesized that anticoagulation with heparin administered at doses higher than conventionally used for venous thromboprophylaxis may improve outcomes. In non-critically ill patients hospitalized with COVID-19, therapeutic-dose anticoagulants with heparin (most commonly, low-molecular-weight heparin) increased the probability of survival until hospital discharge with a reduced need for ICU-level organ support at 21 days as compared with usual-care thromboprophylaxis. In Critically ill patients with confirmed COVID-19, therapeutic-dose anticoagulation did not increase the probability of survival to hospital discharge or the number of days free of cardiovascular o respiratory organ support and had a 95% probability of being inferior to usual-care pharmacologic thromboprophylaxis. Currently, randomized trials evaluating the use of tissue plasminogen activator and Tenecteplase in patients with COVID-19 ARDS are underway.

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Thrombotic Complications in a Canadian Population of Critically Ill Patients with COVID-19

Blood ◽

10.1182/blood-2020-141996 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 41-42

Author(s):

Simard Camille ◽

Maral Koolian ◽

Diana Escobar ◽

Mark Blostein ◽

Jed Lipes ◽

...

Keyword(s):

Pulmonary Embolism ◽

Critically Ill ◽

Critically Ill Patients ◽

Tertiary Care ◽

The United States ◽

Hospital Death ◽

Thrombotic Complication ◽

Arterial Thromboembolism ◽

Increased Risk ◽

Thrombotic Complications

Introduction Coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), a virus strain that appeared in Wuhan China in December 2019, that has since spread to become pandemic. An increased risk of venous and arterial thromboembolism has been consistently reported in critically ill patients with COVID-19 in several countries. The mechanism is thought to be multifactorial, largely mediated by the interplay between inflammation and the coagulation system, or thromboinflammation. We aim to report the risk of thrombosis in a Canadian patient population admitted to the intensive care unit (ICU) with COVID-19. Method We conducted a retrospective cohort study of all consecutive patients with COVID-19 admitted to the ICU between March 1st, 2020 and May 10th, 2020 at the Jewish General Hospital (JGH) in Montreal, Canada. The JGH is a tertiary care centre in Montreal, the epicenter of the COVID-19 pandemic in Canada, and the JGH was the first designated hospitalization centre in Montreal for COVID-19 patients. Patients were followed from date of ICU admission to the earliest of the following: objectively confirmed venous or arterial thrombosis; discharge from hospital; death; or study end date (May 24th, 2020). We determined risk of venous (pulmonary embolism (PE) and deep vein thrombosis (DVT)) and arterial (myocardial infarction, cerebrovascular accident, arterial limb ischemia, and mesenteric ischemia) thrombotic events. Results During the study period, a total of 90 patients admitted to the ICU with COVID-19 were included. The median age was 66 years (standard deviation (SD) 13.8), and 41.1% of patients were female. The median body mass index was 30 kg/m2(SD 5.1), and 64% of patients were mechanically ventilated and 10.1% received continuous renal replacement therapy. The median duration of follow-up was 17.1 days (SD 13.4). In all, 98.9% of patients were prescribed anticoagulation, among whom 78.2% were on a prophylaxis dose, 15.0% intermediate dose, and 6.9% therapeutic dose. In all, 11 (12.2%) patients developed a thrombotic complication among whom 9 patients had objectively diagnosed pulmonary embolism (PE) and 2 patients had an arterial thromboembolism. Both arterial events were cerebrovascular accidents. All PE episodes involved segmental arteries. One PE was incidental, and 3 patients had a concomitant diagnosis of DVT. Overall, death was observed in 16.7% of cohort patients and 12.2% of patients were still admitted to hospital at study end date. Conclusion In this first Canadian study of critically ill patients with COVID-19, we found a 12.2% risk of thrombotic complications despite almost 100% use of anticoagulation primarily with standard prophylaxis dosing. This risk is considerably lower than most reported estimates to date from critical care COVID-19 cohorts in Europe, China and the United States. Our results fuel the ongoing discussion of optimal dose of anticoagulation in these patients. Disclosures No relevant conflicts of interest to declare.

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Prevalence of thrombocytosis in critically ill patients and its association with symptomatic acute pulmonary embolism

Thrombosis and Haemostasis ◽

10.1160/th12-09-0658 ◽

2013 ◽

Vol 109 (02) ◽

pp. 272-279 ◽

Cited By ~ 11

Author(s):

Shaila Chavan ◽

Kwok Ho

Keyword(s):

Pulmonary Embolism ◽

Intensive Care ◽

Platelet Count ◽

Critically Ill ◽

Critically Ill Patients ◽

Acute Pulmonary Embolism ◽

Increased Risk ◽

Wide Range ◽

The Relationship ◽

Acute Pe

SummaryIt is uncertain whether thrombocytosis without underlying myeloproliferative diseases is associated with an increased risk of acute pulmonary embolism (PE). We investigated the relationship between thrombocytosis and risk of symptomatic acute PE, and whether Pulmonary Embolism Severity Index (PESI) was reliable in predicting mortality of acute PE. This multicentre registry study involved a total of 609,367 critically ill patients admitted to 160 intensive care units (ICUs) in Australia or New Zealand between 2006 and 2011. Forward stepwise logistic regression was used to assess the relationship between risk of acute PE and platelet counts on intensive care unit (ICU) admission. Acute PE (n=3387) accounted for 0.9% of all emergency ICU admissions. Over 20% of all PE required mechanical ventilation, 4.2% had cardiac arrest, and the mortality was high (14.8%). Thrombocytosis, defined by a platelet count >500×109 per litre, occurred in 2.1% of the patients and was more common in patients with acute PE than other diagnoses (3.4 vs. 2.0%). The platelet counts explained about 4.5% of the variability and had a linear relationship with the risk of acute PE (odds ratio 1.19 per 100×109 per litre increment in platelet count, 95% confidence interval 1.06–1.34), after adjusting for other covariates. The PESI had a reasonable discriminative ability (area under receiver-operating-characteristic curve = 0.78) and calibration to predict mortality across a wide range of severity of acute PE. In summary, thrombocytosis was associated with an increased risk of symptomatic acute PE. PESI was useful in predicting mortality across a wide range of severity of acute PE.

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Association of Low Alanine Aminotransferase Values with Extubation Failure in Adult Critically Ill Patients: A Retrospective Cohort Study

Journal of Clinical Medicine ◽

10.3390/jcm10153282 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3282

Author(s):

Yoav Weber ◽

Danny Epstein ◽

Asaf Miller ◽

Gad Segal ◽

Gidon Berger

Keyword(s):

Cohort Study ◽

High Risk ◽

Critically Ill ◽

Critically Ill Patients ◽

Alanine Aminotransferase ◽

Cox Regression ◽

Independent Predictor ◽

Extubation Failure ◽

Increased Risk ◽

Ventilated Patients

Background: Liberation from mechanical ventilation is a cardinal landmark during hospitalization of ventilated patients. Decreased muscle mass and sarcopenia are associated with a high risk of extubation failure. A low level of alanine aminotransferase (ALT) is a known biomarker of sarcopenia. This study aimed to determine whether low levels of ALT are associated with increased risk of extubation failure among critically ill patients. Methods: This was a retrospective single-center cohort study of mechanically ventilated patients undergoing their first extubation. The study’s outcome was extubation failure within 48 h and 7 days. Multivariable logistic and Cox regression were performed to determine whether ALT was an independent predictor of these outcomes. Results: The study included 329 patients with a median age of 62.4 years (IQR 48.1–71.2); 210 (63.8%) patients were at high risk for extubation failure. 66 (20.1%) and 83 (25.2%) failed the extubation attempt after 48 h and 7 days, respectively. Low ALT values were more common among patients requiring reintubation (80.3–61.5% vs. 58.6–58.9%, p < 0.002). Multivariable logistic regression analysis identified ALT as an independent predictor of extubation failure at 48 h and 7 days. ALT ≤ 21 IU/L had an adjusted hazard ratio (HR) of 2.41 (95% CI 1.31–4.42, p < 0.001) for extubation failure at 48 h and ALT ≤ 16 IU/L had adjusted HR of 1.94 (95% CI 1.25–3.02, p < 0.001) for failure after 7 days. Conclusions: Low ALT, an established biomarker of sarcopenia and frailty, is an independent risk factor for extubation failure among hospitalized patients. This simple laboratory parameter can be used as an effective adjunct predictor, along with other weaning parameters, and thereby facilitate the identification of high-risk patients.

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Therapeutic Anticoagulation in Non-Critically Ill Patients with Covid-19

10.1101/2021.05.13.21256846 ◽

2021 ◽

Author(s):

Patrick R. Lawler ◽

Ewan C. Goligher ◽

Jeffrey S. Berger ◽

Matthew D. Neal ◽

Bryan J. McVerry ◽

...

Keyword(s):

Hospital Discharge ◽

Critically Ill ◽

Critically Ill Patients ◽

Therapeutic Dose ◽

Controlled Trial ◽

Credible Interval ◽

Organ Support ◽

Absolute Increase ◽

Therapeutic Anticoagulation ◽

D Dimer

Background Thrombo-inflammation may contribute to morbidity and mortality in Covid-19. We hypothesized that therapeutic-dose anticoagulation may improve outcomes in non-critically ill patients hospitalized for Covid-19. Methods In an open-label adaptive multiplatform randomized controlled trial, non-critically ill patients hospitalized for Covid-19, defined by the absence of critical care-level organ support at enrollment, were randomized to a pragmatic strategy of therapeutic-dose anticoagulation with heparin or usual care pharmacological thromboprophylaxis. The primary outcome combined survival to hospital discharge and days free of organ support through 21 days, which was evaluated with Bayesian statistical models according to baseline D-dimer. Results The trial was stopped when prespecified criteria for superiority were met for therapeutic-dose anticoagulation in groups defined by high (≥2-fold elevated) and low (<2-fold elevated) D-dimer. Among 2219 participants in the final analysis, the probability that therapeutic anticoagulation increased organ support-free days compared to thromboprophylaxis was 99.0% (adjusted odds ratio 1.29, 95% credible interval 1.04 to 1.61). The adjusted absolute increase in survival to hospital discharge without organ support with therapeutic-dose anticoagulation was 4.6% (95% credible interval 0.7 to 8.1). In the primary adaptive stopping groups, the final probabilities of superiority for therapeutic anticoagulation were 97.3% in the high D-dimer group and 92.9% in the low D-dimer group. Major bleeding occurred in 1.9% and 0.9% of participants randomized to therapeutic anticoagulation and thromboprophylaxis, respectively. Conclusions In non-critically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increases the probability of survival to hospital discharge with reduced use of organ support.

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Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient

Journal of Intensive Care Medicine ◽

10.1177/0885066618796486 ◽

2018 ◽

Vol 34 (11-12) ◽

pp. 877-888 ◽

Cited By ~ 2

Author(s):

Tyler C. Lewis ◽

Jennifer Cortes ◽

Diana Altshuler ◽

John Papadopoulos

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

High Risk ◽

Critically Ill ◽

Critically Ill Patients ◽

Observational Studies ◽

Health Concern ◽

Fixed Dose ◽

Critically Ill Patient ◽

Increased Risk

Venous thromboembolism (VTE) is a major health concern associated with significant morbidity and mortality. Critically ill patients are at an increased risk of VTE compared to general medical patients due to unique risk factors: prolonged immobilization, invasive lines and devices, certain medications, and acquired thrombophilia. Furthermore, VTE in the critically ill is associated with increased duration of mechanical ventilation, increased length of intensive care unit and hospital stay, and a trend toward increased mortality. Clinical practice guidelines therefore recommend VTE prophylaxis with either subcutaneous heparin or low-molecular-weight heparin for all critically ill patients without contraindication. Yet, many patients will develop VTE despite appropriate pharmacologic prophylaxis, which has led to interest in risk-stratifying critically ill patients for more aggressive prophylaxis strategies. Recent research identified patients at highest risk of failure of thromboprophylaxis and provided insight into the pathophysiologic mechanisms. Obesity and the receipt of vasopressors are 2 risk factors consistently identified in observational studies; further clinical data support decreased absorption of anticoagulant administered via the subcutaneous route as the likely mechanism behind thromboprophylaxis failure in these patient populations. Several studies have investigated novel thromboprophylaxis strategies to circumvent pharmacokinetic limitations in patients who are obese or on vasopressors: increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion of a prophylactic dose of anticoagulant has shown promise in limited studies; however, the results have yet to demonstrate superiority compared to current standard-of-care. This review discusses observational studies identifying patients at risk of thromboprophylaxis failure and critiques clinical studies evaluating novel thromboprophylaxis strategies in high-risk, critically ill patients with a focus on their limitations. Future studies are currently being conducted that will provide further guidance into the appropriate use of individualized thromboprophylaxis.

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Diagnosis of Deep Vein Thrombosis (DVT) In Critically Ill Patients

Blood ◽

10.1182/blood.v116.21.5123.5123 ◽

2010 ◽

Vol 116 (21) ◽

pp. 5123-5123

Author(s):

Arino Yaguchi ◽

Ryuichi Moroi ◽

Tomoyuki Harada ◽

Munekazu Takeda ◽

Masaru Abe ◽

...

Keyword(s):

Pulmonary Embolism ◽

Critically Ill ◽

Critically Ill Patients ◽

Conflicts Of Interest ◽

Lower Limbs ◽

Duplex Scanning ◽

Icu Patients ◽

Vital Status ◽

Significant Difference ◽

D Dimer

Abstract Abstract 5123 Introduction: The assessment of existences of DVT is important to prevent pulmonary embolism for hospitalized patients. Especially, there is a high incidence of DVT in critically ill patients in the intensive care unit (ICU). Because almost all the patients in the ICU have limitations of their activities of daily living due to unstable vital status, controlled under the analgesia, or multiple injuries. The aim of the present study is to evaluate D-dimer levels as a diagnostic marker of DVT in critically ill patients. Methods: One-hundred ten adult patients (66 men, 44 women; age range 20–94 [median 64.5]) who admitted in our medico-surgical ICU in a university hospital were enrolled in this study. Serum D-dimer test and ultrasonic duplex scanning (ALOKA, Co., Ltd, Tokyo) were performed within one week after admission to the ICU. Serum D-dimer levels (μ g/mL) were measured by latex agglutination test (Sekisui Medical®, Tokyo) (normal <1.0μ g/mL). PT-INR (Quick one method) and APTT ratio (Langdell method) were also measured (Sysmex®, Kobe, Japan). DVT was diagnosed by ultrasonic duplex scanning. Value was expressed by median. Data were analyzed by Fisher's exact probability test and Mann-Whitney U test. A p < .05 was considered as statistically significant. Results: There were 32 patients (29.0 %) with DVT and 78 without DVT (71%) in the ICU. Primary diagnoses on admission were 31 cerebrovascular disease, 30 trauma patients, 16 sepsis, 9 acute respiratory failure, 8 hemorrhagic shock, 8 cardiogenic failure and 8 others. Between patients with DVT and without DVT, there were no significant differences in age (67.5 vs. 64.0, p=0.71), sex (19 men and 13 women vs. 47 men and 31 women, p=0.93), primary diagnosis (p=0.13), PT-INR (1.06 vs. 1.07, p=0.97) or APTT ratio (1.02 vs. 1.04, p=0.81), respectively. D-dimer level was also no statistically significant difference (10.4 vs. 7.3μ g/mL, p=0.21) between patients with DVT and without DVT. D-dimer level was higher in all DVT patients with DVT and in 95 per cent of non-DVT patients than normal range. Moreover, thromobosis tended to exist in soleal vein and femoral vein (Table) Conclusion: The present study suggests that D-dimer level could not be a useful marker for assessment of existence of DVT in critically ill patients. And DVT almost existed in soleal and femoral veins. D-dimer level elevates because of the primary disease and/or complications of patients in the ICU. The ultrasonic duplex scanning is an easy and non-invasive examination at the bed side, while there is a limitation to perform it for ICU patients due to their unstable vital status, difficulty of appropriate posture, such as prone positioning, or injured lower limbs. But at least the examination by duplex scan of soleal and femoral veins, which have more possibility to develop to pulmonary embolism, could be significance in the ICU patients. Disclosures: No relevant conflicts of interest to declare.

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