scholarly journals Clinical Outcomes in Critically-Ill Patients with COVID-19 Treated with Therapeutic Dose of Anticoagulants for Suspected Thromboembolism

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2138-2138
Author(s):  
Phyu Thin Naing ◽  
Hadya Elshakh ◽  
Lauren Elreda ◽  
Joon Ha Woo ◽  
Michael Karass ◽  
...  
Keyword(s):  
New York ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Data Encryption ◽  
Evidence Based ◽  
Icu Patients ◽  
Therapeutic Drugs ◽  
Therapeutic Anticoagulation ◽  
D Dimer

Abstract Introduction Since March 2020, the New York City hospitals have experienced a tremendous surge of COVID-19 cases. Our hospital admitted 877 patients in a 2-week period, from March 15 to Apr 1, 2020. The exact mechanism of how COVID-19 causes vascular injury is unclear but some experts attribute it to widespread vascular inflammation[2,3]. The limited understanding of the hypercoagulable mechanism has limited our treatment techniques. To date, whether therapeutic anticoagulation is the right choice in regard to optimal management of patients with COVID-19 in suspected but not confirmed DVT (deep vein thrombosis) or PE (pulmonary embolism) is still a question[4]. Method We performed a retrospective observational cohort analysis of 145 adult ICU patients at an acute care teaching hospital located in Queens County, New York between March 15, 2020 to April 1, 2020. The study was approved by IRB. All patients >18 years of age with confirmed SARS-CoV-2 infection and determined to require admission to intensive care units between March 15, 2020 and April 1, 2020, inclusive of those dates, were included in the investigation, with the exclusion of pregnant patients. All data was collected from the electronic health record (Allscripts) and was compiled in REDCap software for data encryption. During that study period, therapeutic anticoagulants were used in hospitalized patients with COVID-19 with high clinical risk or suspicion for venous thromboembolism (VTE). As per hospital protocol, heparin continuous infusion with a target activated partial thromboplastin time of 50 to 70 seconds or enoxaparin 1mg/kilogram(kg) twice a day for creatinine clearance (CrCl) above 30 ml/min or once a day for CrCl below 30 ml/min were used to achieve therapeutic anticoagulation. The primary outcome of the study was 28-day in-hospital mortality for critically ill patients affected by COVID-19 with or without the use of therapeutic anticoagulation. Covariates included in analysis were hypertension, diabetes, hyperlipidemia, cardiac history, and use of antiplatelet and anticoagulant medications prior to admission. Statistical analysis was done using R version 4.0.2. Results Out of 145 ICU patients, 61 received therapeutic anticoagulation. Kaplan-Meier survival curves show the survival probability with respect to days after admission for the two groups (those who used anticoagulant therapeutic drugs and those who didn't) using 28-day in-hospital mortality.(Fig 1) Median age for patients was 61 years for patients who didn't receive therapeutic anticoagulants compared to 60 years for patients who received therapeutic doses. The mean D-dimer among patients who received therapeutic anticoagulation was 20462 ng/ml (D-dimer units) compared to 7872 ng/ml for those who did not. The median number of days of survival for those who did not take anticoagulant therapeutic drugs is 10 days, while the median for those who did take anticoagulant therapeutic drugs is 25 days. After adjusting for hypertension, diabetes, hyperlipidemia, cardiac history, home antiplatelet medication use and continuous response for peak d-dimer levels, the results also show that there is a causal effect of 22.2 % decreased risk of 28-day in-hospital mortality if one received the therapeutic anticoagulant in the hospital. Conclusion Our findings suggest that there is a significantly higher median survival time in critically ill patients who received therapeutic anticoagulants in the hospital compared to those who didn't. However, our study is limited by observational nature, possible unobserved confounding, lack of metrics to classify illness severity as well as lack of evidence based decision guideline in initiation of therapeutic anticoagulation. There is an urgent need for further evidence-based studies like clinical trials which are necessary to provide specific guidelines for use of therapeutic anticoagulants in patients with COVID-19 infection. References 1. Becker RC. COVID-19 update: Covid-19-associated coagulopathy. J Thromb Thrombolysis. 2020;50(1):54-67. 2. Tay, M.Z., Poh, C.M., Rénia, L. et al. The trinity of COVID-19: immunity, inflammation and intervention. Nat Rev Immunol 20, 363-374 (2020). 3. Lisa K. Moores, Tobias Tritschler, et al. Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019: CHEST Guideline and Expert Panel Report, Chest, Volume 158, Issue 3, 2020, Pages 1143-1163, ISSN 0012-3692. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals Post-anticoagulant D-dimer is a highly prognostic biomarker of COVID-19 mortality

2021 ◽  
pp. 00018-2021
Author(s):  
Xiaoyu Song ◽  
Jiayi Ji ◽  
Boris Reva ◽  
Himanshu Joshi ◽  
Anna Pamela Calinawan ◽  
...  
Keyword(s):  
New York ◽  
Hospital Mortality ◽  
Research Question ◽  
Vital Signs ◽  
Adult Patients ◽  
Logistic Regression Models ◽  
Clinical Biomarkers ◽  
Therapeutic Anticoagulation ◽  
Emerging Treatments ◽  
D Dimer

Research QuestionClinical biomarkers that accurately predict mortality are needed for the effective management of patients with severe COVID-19 illness. In this study, we determine whether changes in D-dimer levels after anticoagulation are independently predictive of in-hospital mortality.Study DesignAdult patients hospitalised for severe COVID-19 who received therapeutic anticoagulation for thromboprophylaxis were identified from a large COVID-19 database of the Mount Sinai Health System in New York City. We studied the ability of post-anticoagulant D-dimer levels to predict in-hospital mortality, while taking into consideration 65 other clinically important covariates including patient demographics, comorbidities, vital signs and several laboratory tests.Results1835 adult patients with PCR-confirmed COVID-19 who received therapeutic anticoagulation during hospitalisation were included. Overall, 26% of patients died in the hospital. Significantly different in-hospital mortality rates were observed in patient groups based on mean D-dimer levels and trend following anticoagulation: 49% for the high mean-increase trend (HI) group; 27% for the high-decrease (HD) group; 21% for the low-increase (LI) group; and 9% for the low-decrease (LD) group (p<0.001). Using penalised logistic regression models to simultaneously analyze 67 clinical variables, the HI (adjusted odds ratios [ORadj]: 6.58, 95% CI 3.81–11.16), LI (ORadj: 4.06, 95% CI 2.23–7.38) and HD (ORadj: 2.37; 95% CI 1.37–4.09) D-dimer groups (reference: LD group) had the highest odds for in-hospital mortality among all clinical features.ConclusionChanges in D-dimer levels and trend following anticoagulation are highly predictive of in-hospital mortality and may help guide resource allocation and future studies of emerging treatments for severe COVID-19.

scholarly journals Clinical Value of Presepsin in Comparison to hsCRP as a Monitoring and Early Prognostic Marker for Sepsis in Critically Ill Patients

Medicina ◽  
2019 ◽  
Vol 55 (2) ◽  
pp. 36 ◽  
Author(s):  
Elham Hassan ◽  
Abeer Abdel Rehim ◽  
Asmaa Ahmed ◽  
Hanan Abdullahtif ◽  
Alaa Attia
Keyword(s):  
Hospital Mortality ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Characteristic Curve ◽  
High Sensitivity ◽  
Clinical Value ◽  
Icu Patients ◽  
Prognostic Accuracy ◽  
Early Predictors ◽  
Kaplan Meier

Sepsis carries a poor prognosis for critically ill patients, even withintensive management. We aimed to determined early predictors of sepsis-related in-hospital mortality and to monitor levels of presepsin and high sensitivity C reactive protein (hsCRP) during admission relative to the applied treatment and the development of complications.An observational study was conducted on 68 intensive care unit (ICU) patients with sepsis. Blood samples from each patient were collected at admission (day 0) for measuring presepsin, hsCRP, biochemical examination, complete blood picture and microbiological culture and at the third day (day 3) for measuring presepsin and hsCRP. Predictors of sepsis-related in-hospital mortality were assessed using regression analysis. Predictive abilities of presepsin and hsCRP were compared using the area under a receiver operating characteristic curve. The Kaplan–Meier method was used to estimate the overall survival rate.Results showed that the sepsis-related in-hospital mortality was 64.6%. The day 0 presepsin and SOFA scores were associated with this mortality. Presepsin levels were significantly higher at days 0 and 3 in non-survivors vs. survivors (p = 0.03 and p < 0.001 respectively) and it decreased over the three days in survivors. Presepsin had a higher prognostic accuracy than hsCRP at all the evaluated times. Overall, in comparison with hsCRP, presepsin was an early predictor of sepsis-related in-hospital mortality in ICU patients. Changes in presepsin concentrations over time may be useful for sepsis monitoring, which in turn could be useful for stratifying high-risk patients on ICU admission that benefit from intensive treatment.

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

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.

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

Blood ◽  
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 &lt;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 &lt; .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.

scholarly journals Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study

Critical Care ◽  
2010 ◽  
Vol 14 (1) ◽  
pp. R25 ◽  
Author(s):  
Alistair D Nichol ◽  
Moritoki Egi ◽  
Ville Pettila ◽  
Rinaldo Bellomo ◽  
Craig French ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Multi Centre Study ◽  
Centre Study

Epidemiology and outcomes of obese critically ill patients in Australia and New Zealand

2020 ◽  
Vol 22 (1) ◽  
pp. 35-44
Author(s):  
Paul Secombe ◽  
◽  
Richard Woodman ◽  
Sean Chan ◽  
David Pilcher ◽  
...  
Keyword(s):  
New Zealand ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Adult Population ◽  
Diagnostic Category ◽  
Class Ii ◽  
Adverse Outcomes ◽  
Class I ◽  
Class I Obesity

OBJECTIVE: The apparent survival benefit of being overweight or obese in critically ill patients (the obesity paradox) remains controversial. Our aim is to report on the epidemiology and outcomes of obesity within a large heterogenous critically ill adult population. DESIGN: Retrospective observational cohort study. SETTING: Intensive care units (ICUs) in Australia and New Zealand. PARTICIPANTS: Critically ill patients who had both height and weight recorded between 2010 and 2018. OUTCOME MEASURES: Hospital mortality in each of five body mass index (BMI) strata. Subgroups analysed included diagnostic category, gender, age, ventilation status and length of stay. RESULTS: Data were available for 381 855 patients, 68% of whom were overweight or obese. Increasing level of obesity was associated with lower unadjusted hospital mortality: underweight (11.9%), normal weight (7.7%), overweight (6.4%), class I obesity (5.4%), and class II obesity (5.3%). After adjustment, mortality was lowest for patients with class I obesity (adjusted odds ratio, 0.78; 95% CI, 0.74– 0.82). Adverse outcomes with class II obesity were only seen in patients with cardiovascular and cardiac surgery ICU admission diagnoses, where mortality risk rose with progressively higher BMIs. CONCLUSION: We describe the epidemiology of obesity within a critically ill Australian and New Zealand population and confirm that some level of obesity is associated with lower mortality, both overall and across a range of diagnostic categories and important subgroups. Further research should focus on potential confounders such as nutritional status and the appropriateness of BMI in isolation as an anthropometric measure in critically ill patients.

Abstract 15293: Noninvasive Echocardiographic Cardiac Power Output Predicts Mortality in Cardiac Intensive Care Unit Patients

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Barry Burstein ◽  
Vidhu Anand ◽  
Bradley Ternus ◽  
Meir Tabi ◽  
Nandan S Anavekar ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Power Output ◽  
Critically Ill Patients ◽  
Cardiac Intensive Care Unit ◽  
Cardiac Power ◽  
The Mean ◽  
Cardiac Intensive Care

Introduction: A low cardiac power output (CPO), measured invasively, identifies critically ill patients at increased risk of mortality. CPO can also be measured non-invasively with transthoracic echocardiography (TTE), although prognostic data in critically ill patients is not available. Hypothesis: Reduced CPO measured by TTE is associated with increased hospital mortality in cardiac intensive care unit (CICU) patients. Methods: Using a database of CICU patients admitted between 2007 and 2018, we identified patients with TTE within one day (before or after) of CICU admission who had data necessary for calculation of CPO. Multivariable logistic regression determined the relationship between CPO and adjusted hospital mortality. Results: We included 5,585 patients with a mean age of 68.3±14.8 years, including 36.7% females. Admission diagnoses included acute coronary syndrome (ACS) in 57%, heart failure (HF) in 50%, cardiac arrest (CA) in 12%, and cardiogenic shock (CS) in 13%. The mean left ventricular ejection fraction (LVEF) was 47±16%, and the mean CPO was 1.0±0.4 W. CPO was inversely associated with the risk of hospital mortality (Figure A), including among patients with ACS, HF, and CS (Figure B). On multivariable analysis, lower CPO was associated with higher hospital mortality (OR 0.96 per 0.1 W, 95% CI 0.0.93-0.99, p=0.03). Hospital mortality was highest in patients with low CPO coupled with reduced LVEF, increased vasopressor requirements, or higher admission lactate. Hospital mortality was higher among patients with a CPO <0.6 W (adjusted OR 1.57, 95% CI 1.13-2.19, p = 0.007), particularly in the presence of admission lactate level >4 mmol/L (50.9%). Conclusions: Echocardiographic CPO was inversely associated with hospital mortality in CICU patients, particularly among patients with increased lactate and vasopressor requirements. Routine measurement of CPO provides important information beyond LVEF and should be considered in CICU patients.

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