Low Rate of Thrombosis in Mexican Patients with COVID-19 Infection. a Benefit of Higher Doses Anticoagulants or a Sub Diagnosis?

Background: Patients with COVID-19 have an increased risk of thromboembolic disease, this has been partly attributed to an excessive inflammatory response that is associated with hypercoagulability; patients develop thrombotic complications with rates of 6.4% in non-critically ill and 15 to 31 % in critically ill patients. With this data some clinicians have incorporated thromboprophylaxis with higher dose heparin into the management of this patients, to date there´s no information of the effect of this intervention. Methods: We conducted a prospective cohort, including consecutive critical and non-critical adults admitted to a referral center in Mexico City, between March 18 and May 19, all with a positive RT-PCR for SARS-CoV 2. Conventional coagulation test results were collected on admission and during hospitalization; use of anticoagulation, and patient outcomes were recorded, all patients had been discharged at the time of the final analysis. Thromboprophylaxis was administered according to institutional recommendations and individual medical criteria, we defined anticoagulant dose according to each medication. We compared the basal characteristics and outcomes in critical and non-critical patients. We evaluated the factors associated with thrombosis, bleeding, and mortality using the Cox Regression Model. Results: We evaluated 447 consecutive hospitalized patients with COVID-19, median age was 50 years (range,18-91), 62.6 % were male, 111 (24.8%) were critical. At admission 156 patients (34.9%) had D-dimer values above 3000 ng/mL, median fibrinogen was 651 mg/dL (range 130-1095), APTT was prolonged (> 3 seconds) in 179 patients (40%), and INR >1.2 in 26 patients (5.8%), median platelet value 215 X103/uL (range 33-666). Thromboprophylaxis' dosages were prophylactic in 267 (59.7%), intermediate in 75 (16.8%) and therapeutic in 91 (20.4%), 14 patients (3.1%) did not receive any medical thromboprophylaxis and 26 patients (5.8%) received aspirin during hospitalization. According to the International Society on Thrombosis and Hemostasis' criteria (ISTH criteria) 40 patients (8.9%) had overt-DIC, sepsis induced coagulopathy (SIC) was present in 28 patients (6.3%), and high risk for bleeding by IMPROVE score ≥7 points was found in 5 patients (1.1%). Overall thrombotic event (TE) was confirmed in five patients (1.1%), arterial thrombosis events in 0.4%, one stroke and one acute myocardial infarction; radiographically confirmed venous thrombosis in 0.67%, two with pulmonary embolism (PE) and one with deep venous thrombosis (DVT). The TE were more common in critical than in non-critical patients (3.6% vs 0.3%). The number of CT pulmonary angiogram or duplex ultrasounds performed when PE/DVT was suspected was eighteen (4%), eight (47%) non-critically ill and ten (53%) in the ICU; the rate of radiographically positive results was 22.2%. The overall major bleeding rate was 2.5%, of these 91% were in the ICU. Mortality was 23.5% in the cohort. Table 1. No factors were found to be associated with thrombosis. The factors associated with bleeding were an INR >1.2 (HR 9.0, 95% CI 1.2-67.3, p 0.03), IMPROVE score ≥7 (HR 81.3, 95% CI 11.9-555.6, p < 0.01), and mechanical ventilation (HR 33.1, 95% CI 4.1-262.2, p 0.01). Factors associated with mortality were: age >70 (HR 2.5, 95% CI 1.5-4.2, p <0.01), D-Dimer >3000 ng/mL (HR 2.0,95% CI 1.2-3.4, p <0.01), and mechanical ventilation (HR 1.7, 95% CI 1.01-2.8, p = 0.02). The presence of more than 450x109/L platelets was associated with reduced mortality (HR 0.31 95% CI 0.19-0.50). Figure 1 Discussion: The late outbreak of COVID-19 in Latin America had led to an empiric use of aggressive thromboprophylaxis. Our data shows a low TE rate as compared with other groups, nevertheless we cannot prove a direct impact of the aggressive thromboprophylaxis, firstly because of the low rate or events, and secondly, due to the limitations of an observational study. On the other hand, the incidence of PE/DVT is conditioned by the number of studies performed, yet radiological confirmation has proven difficult due to concerns about virus exposure. Regarding the security of the intervention, major bleeding rates were slightly higher to what has been otherwise reported, but with no bleeding related deaths. The benefit of higher anticoagulant doses most be shown in clinical trials before we can recommend their generalized use in COVID-19 patients. Disclosures No relevant conflicts of interest to declare.

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The Association between D-dimer Levels and Thromboembolism, Worsening Severity, and Mortality among Hospitalized Adults with COVID-19

Acta Medica Philippina ◽

10.47895/amp.vi0.4153 ◽

2021 ◽

Author(s):

Patricia Pauline M. Remalante-Rayco ◽

Evelyn O. Salido ◽

Joey A. Tabula ◽

Maria Teresa S. Tolosa

Keyword(s):

Mechanical Ventilation ◽

Critical Illness ◽

Open Access ◽

Clinical Outcomes ◽

Observational Studies ◽

Prognostic Indicator ◽

Cochrane Library ◽

Increased Risk ◽

D Dimer

Objective. To assess the association between D-dimer and clinical outcomes in adults with COVID-19. Methods. We reviewed published articles and preprints from MEDLINE, Cochrane Library, Cornell Open Access Publication (COAP), MedRxiv, and BioRxiv databases. We included cohort studies on the association between D-dimer and the outcomes of thromboembolism, mortality, and worsening severity among hospitalized adults with COVID-19. Results. We found 25 observational studies on the association between D-dimer and the outcomes of thromboembolism, mortality, or worsening severity. There was an increased risk of thromboembolism (OR 5.61 [95% CI 3.97, 7.94]) with higher D-dimer levels across different COVID-19 severities. D-dimer levels are associated with higher in-hospital mortality (OR 5.57 [95% CI 2.74, 11.31]) and worsening severity manifesting as critical illness (OR 1.91 [95% CI 1.05, 3.48] to 2.58 [95% CI 1.57, 4.24]), disease progression (HR 2.846 [95% CI 2.10, 3.85]), or need for mechanical ventilation (HR 3.28 [95% CI 1.07, 10.10]). However, some methodological flaws, such as incomplete laboratory or follow-up data and concern on varied D-dimer cut-offs and definitions of worsening disease, raise some uncertainty in the widespread use of D-dimer as a prognostic marker. Conclusion. A higher D-dimer value is associated with worse clinical outcomes among hospitalized adults with COVID-19 and may be a useful prognostic indicator.

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Prevalence and Risk Factors of Thromboembolism among Patients With Coronavirus Disease-19: A Systematic Review and Meta-Analysis

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029620967083 ◽

2020 ◽

Vol 26 ◽

pp. 107602962096708

Author(s):

Belayneh Kefale ◽

Gobezie T. Tegegne ◽

Amsalu Degu ◽

Melaku Tadege ◽

Desalegn Tesfa

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

English Language ◽

Meta Analysis ◽

Thrombotic Event ◽

Cochrane Library ◽

Pooled Prevalence ◽

D Dimer

Emerging evidence shows that the recent pandemic of coronavirus disease 19 (COVID-19) is characterized by coagulation activation and endothelial dysfunction. This increases the risk of morbidity, mortality and economic loss among COVID-19 patients. Therefore, there was an urgent need to investigate the extent and risk factors of thromboembolism among COVID-19 patients. English-language based databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Cochrane library) were exhaustively searched to identify studies related to prevalence of thromboembolism among hospitalized COVID-19 patients. A random-effects model was employed to estimate the pooled prevalence of thromboembolism. The pooled prevalence of thrombotic events was computed using STATA 16.0 software. Heterogeneity analysis was reported using I2. A total of 19 studies with 2,520 patients with COVID-19 were included. The pooled prevalence of thrombotic events of hospitalized patients with COVID-19 was 33% (95% CI: 25-41%, I2 = 97.30%, p < 0.001) with a high degree of heterogeneity across studies. Elevated D-dimer hospitalized in the intensive care unit and being under mechanical ventilation were the most frequently associated factors for the development of thrombotic events. The pooled prevalence of thrombotic events in COVID-19 patients was 33%. The prevalence of thrombotic event is variables on the basis of study design and study centers. Several risk factors such as, elevated D-dimer, hospitalized in the intensive care unit and being under mechanical ventilation, were the most frequently reported risk factors identified. Therefore, healthcare professionals should consider these risk factors to optimally manage thromboembolism in COVID-19 patients.

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High risk of thrombosis in patients homozygous for factor V Leiden (activated protein C resistance) [see comments]

Blood ◽

10.1182/blood.v85.6.1504.bloodjournal8561504 ◽

1995 ◽

Vol 85 (6) ◽

pp. 1504-1508 ◽

Cited By ~ 648

Author(s):

FR Rosendaal ◽

T Koster ◽

JP Vandenbroucke ◽

PH Reitsma

Keyword(s):

Venous Thrombosis ◽

Protein C ◽

Absolute Risk ◽

Thrombotic Event ◽

Activated Protein C ◽

Factor V Leiden ◽

Coagulation Factor ◽

Factor V ◽

Increased Risk ◽

The Absolute

Resistance to activated protein C (APC) is a common inherited risk factor for venous thrombosis, which is associated with a mutation in coagulation factor V (factor V Leiden). We investigated the risk of venous thrombosis in individuals homozygous for this abnormality. We determined the factor V Leiden genotype in 471 consecutive patients aged less than 70 years with a first objectively confirmed deep-vein thrombosis and in 474 healthy controls. We found 85 heterozygous and seven homozygous individuals among the cases with thrombosis and 14 heterozygous individuals among the control subjects. The expected number of homozygous individuals among the controls was calculated from Hardy-Weinberg equilibrium and estimated at 0.107 (allele frequency, 1.5%). Whereas the relative risk was increased sevenfold for heterozygous individuals, it was increased 80-fold for homozygous individuals. These patients experienced their thrombosis at a much younger age (31 v 44 years). The homozygous individuals were predominantly women, most likely due to the effect of oral contraceptives. Because of the increased risk of thrombosis with age, the absolute risk becomes most pronounced in older patients, both for heterozygous and homozygous individuals. For the homozygous individuals, the absolute risk may become several percentage points per year. This implies that most individuals homozygous for factor V Leiden will experience at least one thrombotic event in their lifetime.

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Outcome of Acute Hypoxaemic Respiratory Failure. Insights from the Lung Safe Study

European Respiratory Journal ◽

10.1183/13993003.03317-2020 ◽

2020 ◽

pp. 2003317

Author(s):

Tài Pham ◽

Antonio Pesenti ◽

Giacomo Bellani ◽

Gordon Rubenfeld ◽

Eddy Fan ◽

...

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Hospital Mortality ◽

Distress Syndrome ◽

Pulmonary Involvement ◽

Positive End Expiratory Pressure ◽

Factors Associated ◽

Risk Of Death ◽

Increased Risk ◽

Current Incidence

BackgroundThe current incidence and outcome of patients with acute hypoxaemic respiratory failure requiring mechanical ventilation in intensive care unit are unknown, especially for patients not meeting criteria for acute respiratory distress syndrome (ARDS).MethodsAn international, multicentre, prospective cohort study of patients presenting with hypoxemia early in the course of mechanical ventilation, conducted during four consecutive weeks in the winter of 2014 in 459 ICUs from 50 countries (LUNG SAFE). Patients were enrolled with PaO2/FiO2 ≤300 mmHg, new pulmonary infiltrates and need for mechanical ventilation with a positive end-expiratory pressure (PEEP) of at least 5 cm H2O. ICU prevalence, causes of hypoxemia, hospital survival, factors associated with hospital mortality were measured. Patients with unilateral versus bilateral opacities were compared.Findings12 906 critically ill patients received mechanical ventilation and 34.9% with hypoxaemia and new infiltrates were enrolled, separated into ARDS (69.0%), unilateral infiltrate (22.7%) and congestive heart failure (8.2%, CHF). The global hospital mortality was 38.6%. CHF patients had a mortality comparable to ARDS (44.1%versus 40.4%). Patients with unilateral-infiltrate had lower unadjusted mortality but similar adjusted mortality than ARDS. The number of quadrants on chest imaging was associated with an increased risk of death. There was no difference in mortality comparing patients with unilateral-infiltrate and ARDS with only 2 quadrants involved.InterpretationMore than one third of the patients receiving mechanical ventilation have hypoxaemia and new infiltrates with an hospital mortality of 38.6%. Survival is dependent on the degree of pulmonary involvement whether or not ARDS criteria are reached.

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An Inpatient COVID-19 Prophylaxis Protocol and Its Outcomes: Adherence and Efficacy

Blood ◽

10.1182/blood-2021-154453 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 4267-4267

Author(s):

Adrienne Kaufman ◽

Yael Kusne ◽

Molly Klanderman ◽

Heidi E. Kosiorek ◽

Thomas Oliver ◽

...

Keyword(s):

Native American ◽

Critically Ill ◽

Critically Ill Patients ◽

Conflicts Of Interest ◽

Demographic Data ◽

Thrombotic Event ◽

Thrombosis Risk ◽

Therapeutic Anticoagulation ◽

Increased Risk ◽

Venous Thromboembolic Events

Abstract Introduction: Patients with coronavirus disease 2019 (COVID-19) have an increased risk for venous thromboembolic events. Thrombotic events contribute to the morbidity and mortality associated with COVID-19 infection, and have prompted investigation into strategies for mitigating thrombosis risk in patients hospitalized with COVID-19 infection. Our team reviewed the charts of patients hospitalized with COVID-19 pneumonia at a tertiary hospital in metropolitan Phoenix Arizona between 2020-2021, to assess frequency and efficacy of utilizing a VTE prophylaxis algorithm designed to prevent thrombosis in patients infected with COVID-19. Methods: A total of 846 patients were retrospectively evaluated to determine if they were treated with guideline-appropriate anticoagulation while hospitalized with COVID-19, as well as if they developed venous or arterial thrombotic events, or major or minor bleeds. 317 patients were excluded for taking therapeutic anticoagulation prior to admission, or for having a COVID-19 diagnosis >7 days after admission. Appropriate anticoagulation was determined by an institutionally designed COVID-19 thromboprophylaxis algorithm, based on platelet count, d-dimer, bleeding risk, and level of medical care required. Regimen options included: no anticoagulation, prophylactic enoxaparin (40 mg SQ daily) or heparin in the setting of kidney dysfunction, weight-based dosing of enoxaparin (40 mg SQ BID if BMI>40), intermediate intensity enoxaparin without thrombus (30 mg BID if BMI<40, or 40 mg BID if BMI>40), and therapeutic anticoagulation (for example enoxaparin 1 mg/kg BID) with thrombus. Demographics: Demographic data and clinical characteristics were collected for 529 patients. Average age was 59 years old, and the majority were men (58.4%). Most patients were White (58.3%), followed by Hispanic (17.8%), or Native American (15.7%). Fewer patients had a normal BMI (21.3%; BMI 18.5 - 24.9) compared to those who were overweight (31.2%; BMI 25-29.9) or obese (43.1% BMI > 30). Other comorbidities included Type 1 or Type 2 diabetes mellitus (N= 172, 32.5%), hypertension (N = 271, 51.2%), and hyperlipidemia (N = 176, 33.3%). Results: A total of 42 patients (8%), were diagnosed with a venous thrombosis during hospitalization. Patients admitted to the ICU were significantly more likely to have a thrombotic event of any type compared to non-ICU patients (21.6% to 5.7%; p < 0.001). Specifically, critically ill patients had higher incidences of deep vein thrombosis (9.5% to 0.7%), pulmonary emboli (8.1% to 4.8%), and superficial thrombi (2.7% to 0.2%). Only 1.1% of patients (6/529) experienced any bleeding, of which 3 were classified as a major bleed. Discussion: Among patients hospitalized at our institution with COVID-19, the majority were anticoagulated appropriately according to the COVID-19 thromboprophylaxis algorithm. Overall incidence of thrombosis in the study population was 8%. A significantly higher percent of critically ill patients had thrombi, supporting reports of correlation between severity of illness and thrombosis risk. The two regimens of anticoagulation least adhered to were weight-based and intermediate-based dosing, likely reflecting a departure from the hospital's thromboprophylaxis regimens prior to COVID-19 pandemic. Further studies are needed to characterize whether identifiable risk factors correlate with the incidence of thrombosis, and whether treatment with lower than recommended doses of anticoagulation, based on the COVID-19 thromboprophylaxis algorithm, were associated with thrombosis. Disclosures No relevant conflicts of interest to declare.

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Effect of sedatives on in-hospital and long-term mortality of critically ill patients requiring extended mechanical ventilation for more than 48 hours

10.21203/rs.2.19879/v1 ◽

2020 ◽

Author(s):

Hannah Lee ◽

Seongmi Choi ◽

Eun Jin Jang ◽

Juhee Lee ◽

Dalho Kim ◽

...

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Significant Risk ◽

Population Based ◽

Case Volume ◽

Increased Risk ◽

Benzodiazepine Use ◽

Comorbidity Index ◽

One Year

Abstract Background The purpose of this study was to assess the correlation between sedatives and mortality in critically ill patients who required mechanical ventilation (MV) for ≥48 hours from 2007 to 2016.Methods We conducted a nationwide retrospective cohort study using population-based healthcare reimbursement claims database. : Data from adult patients (aged ≥18) who underwent MV for ≥48 hours between 2008 and 2016 were identified and extracted from the National Health Insurance Service database. The benzodiazepine group consisted of patients who were administered benzodiazepines for sedation during MV. All other patients were assigned to the non-benzodiazepine group.Results A total of 158,712 patients requiring MV for ≥48 hours were admitted in 55 centers in Korea from 2007 to 2016. The benzodiazepine group had significantly higher in-hospital and one-year mortality compared to the non-benzodiazepine group (37.0% vs. 34.3%, 55.0% vs. 54.4%, respectively). Benzodiazepine use decreased from 2008 to 2016, after adjusting for age, sex, and mean Elixhauser comorbidity index in the Poisson regression analysis (incidence rate ratio, 0.968; 95% CI 0.954–0.983; p < 0.001) whereas dexmedetomidine sales have continuously increased since the second half of 2010. Benzodiazepine use, older age, lower case volume (≤500 cases/year), chronic kidney disease, and higher Elixhauser comorbidity index were common significant risk factors for in-hospital and one-year mortality.Conclusion In critically ill patients undergoing MV for >48 hours, the use of benzodiazepines for sedation was associated with an increased risk of in-hospital mortality and one-year mortality.

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Markers Of Coagulation And Hemostatic Activation Identify COVID-19 Patients At High Risk For Thrombotic Events, ICU Admission and Intubation

10.1101/2020.10.04.20206540 ◽

2020 ◽

Author(s):

Darwish Alabyad ◽

Srikant Rangaraju ◽

Michael Liu ◽

Rajeel Imran ◽

Christine L. Kempton ◽

...

Keyword(s):

Thrombotic Event ◽

Anticoagulation Therapy ◽

Vascular Events ◽

Icu Admission ◽

Vein Thrombosis ◽

Coagulation Marker ◽

Increased Risk ◽

Patients At Risk ◽

Deep Vein ◽

D Dimer

ABSTRACTBackgroundCoronavirus disease 2019 (COVID-19) has been associated with a coagulopathy giving rise to venous and arterial thrombotic events. The objective of our study was to determine whether markers of coagulation and hemostatic activation (MOCHA) on admission could identify COVID-19 patients at risk for thrombotic events and other complications.MethodsCOVID-19 patients admitted to a tertiary academic healthcare system from April 3, 2020 to July 31, 2020 underwent standardized admission testing of MOCHA profile parameters (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) with abnormal MOCHA defined as ≥ 2 markers above the reference. Prespecified thrombotic endpoints included deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke, and access line thrombosis; other complications included ICU admission, intubation and mortality. We excluded patients on anticoagulation therapy prior to admission and those who were pregnant.ResultsOf 276 patients (mean age 59 ± 6.4 years, 47% female, 62% African American race) who met study criteria, 45 (16%) had a thrombotic event. Each coagulation marker on admission was independently associated with a vascular endpoint (p<0.05). Admission MOCHA with ≥ 2 abnormalities (n=203, 74%) was associated with in-hospital vascular endpoints (OR 3.3, 95% CI 1.2-8.8), as were admission D-dimer ≥ 2000 ng/mL (OR 3.1, 95% CI 1.5-6.6), and admission D-dimer ≥ 3000 ng/mL (OR 3.6, 95% CI 1.6-7.9). However, only admission MOCHA with ≥ 2 abnormalities was associated with ICU admission (OR 3.0, 95% CI 1.7-5.2) and intubation (OR 3.2, 95% CI 1.6-6.4), while admission D-dimer ≥2000 ng/mL and admission D-dimer ≥ 3000 ng/mL were not associated. MOCHA and D-dimer cutoffs were not associated with mortality. Admission MOCHA with <2 abnormalities (26% of the cohort) had a sensitivity of 88% and negative predictive value of 93% for a vascular endpoint.ConclusionsAdmission MOCHA with ≥ 2 abnormalities identified COVID-19 patients at increased risk of ICU admission and intubation during hospitalization more effectively than isolated admission D-dimer measurement. Admission MOCHA with <2 abnormalities identified a subgroup of patients at low risk for vascular events. Our results suggest that an admission MOCHA profile can be useful to risk-stratify COVID-19 patients.

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Neuromonitoring of delirium with quantitative pupillometry In sedated mechanically ventilated critically ill patients

10.21203/rs.2.19734/v2 ◽

2020 ◽

Author(s):

Eva Favre ◽

Adriano Bernini ◽

Paola Morelli ◽

Jerôme Pasquier ◽

John-Paul Miroz ◽

...

Keyword(s):

Mechanical Ventilation ◽

Brain Injury ◽

Critically Ill ◽

Critically Ill Patients ◽

Potential Utility ◽

Icu Patients ◽

Mechanically Ventilated ◽

Increased Risk ◽

Infrared Pupillometry ◽

Icu Delirium

Abstract Background. Intensive care unit (ICU) delirium is a frequent secondary neurological complication in critically ill patients undergoing prolonged mechanical ventilation. Quantitative pupillometry is an emerging modality for the neuromonitoring of primary acute brain injury, but its potential utility in patients at risk of ICU delirium is unknown. Methods. This was an observational cohort study of medical-surgical ICU patients, without acute or known primary brain injury, who underwent sedation and mechanical ventilation for at least 48 hours. Starting at day 3, automated infrared pupillometry – blinded to ICU caregivers – was used for repeated measurement of the pupillary function, including quantitative pupillary light reflex (q-PLR, expressed as % pupil constriction to a standardized light stimulus) and constriction velocity (CV, mm/sec). The relationship between delirium, using the CAM-ICU score, and quantitative pupillary variables was examined. Results. A total of 59/100 patients had ICU delirium, diagnosed at a median 8 (5-13) days from admission. Compared to non-delirious patients, subjects with ICU delirium had lower values of q-PLR (25 [19-31] vs. 20 [15-28] %) and CV (2.5 [1.7-2.8] vs. 1.7 [1.4-2.4] mm/sec) at day 3, and at all additional time-points tested ( p <0.05). After adjusting for the SOFA score and the cumulative dose of analgesia and sedation, lower q-PLR was associated with an increased risk of ICU delirium (OR 1.057 [1.007-1.113] at day 3; p =0.03). Conclusions. Sustained abnormalities of quantitative pupillary variables at the early ICU phase correlate with delirium and precede clinical diagnosis by a median 5 days. These findings suggest a potential utility of quantitative pupillometry in sedated mechanically ventilated ICU patients at high risk of delirium.

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The decrease of CD4 T cell is associated with mortality in critical inpatients with COVID-19

10.21203/rs.3.rs-30057/v1 ◽

2020 ◽

Author(s):

Jun Xiong ◽

Mei Yang ◽

Weize Yang ◽

Xiaomin Luo ◽

Ke Hu ◽

...

Keyword(s):

Risk Factors ◽

T Cell ◽

Cell Count ◽

Intravenous Immunoglobulin ◽

Critically Ill ◽

Cardiac Troponin ◽

Cd4 T Cell ◽

Critical Patients ◽

Clinical Records ◽

D Dimer

Abstract Background The 2019 novel coronavirus (SARS-CoV-2) has caused an outbreak in the world. The critically ill patients had a high mortality. However, the possible risk factors of critical patients with coronavirus disease 2019 (COVID-19) are not fully known. We aim to investigate the risk factors in critical patients with COVID-19 and to address their role in predicting disease progression.Methods In this single-centered, retrospective, observational study, we enrolled 91 critically ill adult patients with COVID-19 in Renmin Hospital of Wuhan University between Jan 20, 2020 and Feb 28, 2020. Data were collected using a standard method including clinical records and laboratory findings.Results 39 patients (42.9%) were dead and 52 patients (57.1%) were cured and discharged before Mar 22, 2020. CD4 T cell count, CD8 T cell count and glomerular filtration rate were significantly lower in non-survivors than in survivors. However, the non-survivors presented a higher proportion of D-dimer, Cardiac troponin and immunoglobulin G than in survivors. Intravenous immunoglobulin was more common in survivors than in non-survivors. On multivariate analysis, D-dimer (༞1 µg/mL, OR = 9.53, 95% CI, 2.53–35.88), CD4 + T count (༜200/µl, OR = 9.68, 95%CI, 2.76-40.00 ) and cardiac troponin (༞0.04 ng/mL, OR = 5.73, 95% CI, 1.86–17.66) were independent risk factors for mortality.Conclusion The decrease of CD4 T cell is associated with higher risk mortality in critical inpatients with COVID-19. Intravenous immunoglobulin was more common in survivors than in non-survivors.

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Heparin for Moderately Ill Patients with Covid-19

10.1101/2021.07.08.21259351 ◽

2021 ◽

Author(s):

Michelle Sholzberg ◽

Grace H. Tang ◽

Hassan Rahhal ◽

Musaad AlHamzah ◽

Lisa Baumann Kreuziger ◽

...

Keyword(s):

Mechanical Ventilation ◽

Major Bleeding ◽

Odds Ratio ◽

Primary Outcome ◽

Invasive Mechanical Ventilation ◽

Heparin Group ◽

Intention To Treat ◽

Non Invasive ◽

Primary Composite Outcome ◽

D Dimer

Background Heparin, in addition to its anticoagulant properties, has anti-inflammatory and potential anti-viral effects, and may improve endothelial function in patients with Covid-19. Early initiation of therapeutic heparin could decrease the thrombo-inflammatory process, and reduce the risk of critical illness or death. Methods We randomly assigned moderately ill hospitalized ward patients admitted for Covid-19 with elevated D-dimer level to therapeutic or prophylactic heparin. The primary outcome was a composite of death, invasive mechanical ventilation, non-invasive mechanical ventilation or ICU admission. Safety outcomes included major bleeding. Analysis was by intention-to-treat. Results At 28 days, the primary composite outcome occurred in 37 of 228 patients (16.2%) assigned to therapeutic heparin, and 52 of 237 patients (21.9%) assigned to prophylactic heparin (odds ratio, 0.69; 95% confidence interval [CI], 0.43 to 1.10; p=0.12). Four patients (1.8%) assigned to therapeutic heparin died compared with 18 patients (7.6%) assigned to prophylactic heparin (odds ratio, 0.22; 95%-CI, 0.07 to 0.65). The composite of all-cause mortality or any mechanical ventilation occurred in 23 (10.1%) in the therapeutic heparin group and 38 (16.0%) in the prophylactic heparin group (odds ratio, 0.59; 95%-CI, 0.34 to 1.02). Major bleeding occurred in 2 patients (0.9%) with therapeutic heparin and 4 patients (1.7%) with prophylactic heparin (odds ratio, 0.52; 95%-CI, 0.09 to 2.85). Conclusions In moderately ill ward patients with Covid-19 and elevated D-dimer level, therapeutic heparin did not significantly reduce the primary outcome but decreased the odds of death at 28 days.

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