scholarly journals Pulmonary Embolism in Patients with COVID-19

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.

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.

scholarly journals The management of venous thromboembolism in hospitalized patients with COVID-19

2020 ◽  
Vol 4 (16) ◽  
pp. 4028-4028 ◽  
Author(s):  
Alex C. Spyropoulos
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
High Rate ◽  
Coagulation System ◽  
High Incidence ◽  
Recent Statement ◽  
Clinical Questions

Abstract The high incidence of thromboembolic disease, and in particular venous thromboembolism (VTE), has emerged as an important consideration in hospitalized and critically ill patients with coronavirus disease 2019 (COVID-19). The coagulopathy of COVID-19 is postulated to result from interactions of the inflammatory and immune systems with the coagulation system, manifesting as a cytokine storm associated with hyperinflammation and coagulation and platelet activation. Unique characteristics of VTE in hospitalized and critically ill patients with COVID-19 include the high incidence of VTE (and especially pulmonary embolism) when compared with historical controls; the finding of in situ pulmonary embolism associated with microthrombi, which suggests a thrombotic microangiopathic process in addition to classic macrovessel disease; and, most important from a clinical perspective, the unusually high rate of VTE that has been reported despite standard thromboprophylaxis. This raises the possibility that intermediate or weight-based heparin dosing may be more effective than fixed dosing for thromboprophylaxis in high-risk subsets of patients hospitalized with COVID-19. There have been several guidance statements focusing on the management of VTE in hospitalized and critically ill patients with COVID-19, including the most recent statement by the Scientific and Standardization Committee of the International Society of Thrombosis and Haemostasis, which includes comprehensive guidance on the diagnosis, prevention, and treatment of VTE in this patient population. Ongoing randomized trials that address key clinical questions, especially more intense thromboprophylactic strategies and novel antithrombotic approaches, have the potential to reduce the morbidity and mortality from VTE in hospitalized and critically ill patients with COVID-19.

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

2021 ◽  
Vol 10 ◽  
pp. 204800402110349
Author(s):  
Mikkel Rodin Deutch ◽  
Mathias J Holmberg ◽  
Tina Gissel ◽  
Malene Hollingdal
Keyword(s):  
Pulmonary Embolism ◽  
Case Report ◽  
High Risk ◽  
Hospital Stay ◽  
Hospital Discharge ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Thromboembolic Complications ◽  
Increased Risk ◽  
D Dimer

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.

scholarly journals Impact of high dose prophylactic anticoagulation in critically ill patients with COVID-19 pneumonia

CHEST Journal ◽  
2021 ◽  
Author(s):  
Charles Tacquard ◽  
Alexandre Mansour ◽  
Alexandre Godon ◽  
Julien Godet ◽  
Julien Poissy ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
High Dose ◽  
Prophylactic Anticoagulation

scholarly journals Protein intake and outcome of critically ill patients: analysis of a large international database using piece-wise exponential additive mixed models

Critical Care ◽  
2022 ◽  
Vol 26 (1) ◽  
Author(s):  
Wolfgang H. Hartl ◽  
Philipp Kopper ◽  
Andreas Bender ◽  
Fabian Scheipl ◽  
Andrew G. Day ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Critically Ill ◽  
Acute Phase ◽  
Critically Ill Patients ◽  
Protein Intake ◽  
High Protein ◽  
Protein Diet ◽  
High Protein Intake ◽  
Low Protein ◽  
Standard Protein

Abstract Background Proteins are an essential part of medical nutrition therapy in critically ill patients. Guidelines almost universally recommend a high protein intake without robust evidence supporting its use. Methods Using a large international database, we modelled associations between the hazard rate of in-hospital death and live hospital discharge (competing risks) and three categories of protein intake (low: < 0.8 g/kg per day, standard: 0.8–1.2 g/kg per day, high: > 1.2 g/kg per day) during the first 11 days after ICU admission (acute phase). Time-varying cause-specific hazard ratios (HR) were calculated from piece-wise exponential additive mixed models. We used the estimated model to compare five different hypothetical protein diets (an exclusively low protein diet, a standard protein diet administered early (day 1 to 4) or late (day 5 to 11) after ICU admission, and an early or late high protein diet). Results Of 21,100 critically ill patients in the database, 16,489 fulfilled inclusion criteria for the analysis. By day 60, 11,360 (68.9%) patients had been discharged from hospital, 4,192 patients (25.4%) had died in hospital, and 937 patients (5.7%) were still hospitalized. Median daily low protein intake was 0.49 g/kg [IQR 0.27–0.66], standard intake 0.99 g/kg [IQR 0.89– 1.09], and high intake 1.41 g/kg [IQR 1.29–1.60]. In comparison with an exclusively low protein diet, a late standard protein diet was associated with a lower hazard of in-hospital death: minimum 0.75 (95% CI 0.64, 0.87), and a higher hazard of live hospital discharge: maximum HR 1.98 (95% CI 1.72, 2.28). Results on hospital discharge, however, were qualitatively changed by a sensitivity analysis. There was no evidence that an early standard or a high protein intake during the acute phase was associated with a further improvement of outcome. Conclusions Provision of a standard protein intake during the late acute phase may improve outcome compared to an exclusively low protein diet. In unselected critically ill patients, clinical outcome may not be improved by a high protein intake during the acute phase. Study registration ID number ISRCTN17829198

Application of Network Meta-Analysis to Assess the Comparative Effectiveness of Oral Care Interventions in Preventing Ventilator Associated Pneumonia in Critically Ill Patients.

2020 ◽  
Author(s):  
Satheeshkumar PS ◽  
Stephen Sonis
Keyword(s):  
Usual Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Povidone Iodine ◽  
Meta Analysis ◽  
Oral Care ◽  
Forest Plot ◽  
Care Groups ◽  
Ranking Order ◽  
Hierarchical Assessment

Abstract Background In this research, we assessed the efficacy of a novel analytic, network metanalysis (NMA), in creating a hierarchy to define the most effective oral care intervention (OCI) for the prevention and management of ventilation-associated pneumonia (VAP). Methods We applied NMA to a previously published robust pairwise meta-analysis (PMA). Statistical analyses were based on comparing rates of total VAP events between intervention groups and placebo-usual care groups. We synthesized a netgraph, reported ranking order of the treatment and summarized our output by a forest plot with a reference treatment placebo/usual care. Results With our inclusion and exclusion critiera for the NMA we extracted 25 studies (4473 subjects). The NMA included 16 treatments, 29 pairwise comparisons and 15 designs. Based on the results of multiple comparisons with frequentist ranking probability P scores, tooth brushing (P score fixed of 0.9353, P score random of 0.8892), toothbrushing with povidone iodine (P score fixed of 0.9091, P score random 0.8801), and furacillin (P score fixed of 0.8798, P score random 0.8358) were the best three interventions for preventing VAP. Conclusion NMA appeared to be an effective platform from which multiple interventions reported in disparate clinical trials could be compared to derive a hierarchical assessment of efficacy in the intervention of VAP. According to the NMA outcome, toothbrushing alone or toothbrushing along with a potent antiseptic mouthwash povidone iodine was related to the highest response rate in preventing VAP in critically ill patients followed by furacillin and chlorhexidine 0.2%, respectively.

Prognostic models based on administrative data alone inadequately predict the survival outcomes for critically ill patients at 180 days post–hospital discharge

2012 ◽  
Vol 27 (4) ◽  
pp. 422.e11-422.e21 ◽  
Author(s):  
Megan A. Bohensky ◽  
Damien Jolley ◽  
David V. Pilcher ◽  
Vijaya Sundararajan ◽  
Sue Evans ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Critically Ill ◽  
Administrative Data ◽  
Critically Ill Patients ◽  
Prognostic Models ◽  
Survival Outcomes
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