The cumulative venous thromboembolism incidence and risk factors in intensive care patients receiving the guideline-recommended thromboprophylaxis

Zhang, Chuanlin; Zhang, Zeju; Mi, Jie; Wang, Xueqin; Zou, Yujun; Chen, Xiaoya; Zhi, Nie; Luo, Xiaohu; Gan, Ruiying

doi:10.1097/md.0000000000015833

Cited by 68 publications

(77 citation statements)

References 34 publications

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“…Acute inflammation, as measured by elevations in these markers, has previously been associated with increased thrombotic and bleeding risk in patients without COVID-19 19,20 ; indeed, we found significant correlations between D-dimer levels and each measured inflammatory marker (Figure 1). Given previously reported 14-day cumulative VTE rates of 7% to 8% in critically ill patients without COVID-19 receiving standard heparinbased thromboprophylaxis, 21 our observed rate of 7.6% in critically ill patients receiving similar prophylactic treatment over a median follow-up of 10 days was comparable. Likewise, to contextualize our major bleeding rate of 5.6% in the critically ill, a large prospective study of bleeding events in 3746 critically ill patients without COVID-19 identified major bleeding (defined similarly as in our study) in 208 patients (5.6%).…”

Section: Discussionsupporting

confidence: 76%

COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection

Al‐Samkari

Leaf

Dzik

et al. 2020

Blood

1,171

1,222

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Patients with coronavirus disease 2019 (COVID-19) have elevated D-dimer levels. Early reports describe high venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC) rates, but data are limited. This multicenter, retrospective study described the rate and severity of hemostatic and thrombotic complications of 400 hospital-admitted COVID-19 patients (144 critically ill) primarily receiving standard-dose prophylactic anticoagulation. Coagulation and inflammatory parameters were compared between patients with and without coagulation-associated complications. Multivariable logistic models examined the utility of these markers in predicting coagulation-associated complications, critical illness, and death. The radiographically-confirmed VTE rate was 4.8% (95% CI, 2.9-7.3%) and the overall thrombotic complication rate was 9.5% (6.8-12.8%). The overall and major bleeding rates were 4.8% (2.9-7.3%) and 2.3% (1.0-4.2%). In the critically ill, radiographically-confirmed VTE and major bleeding rates were 7.6% (3.9-13.3%) and 5.6% (2.4-10.7%). Elevated D-dimer at initial presentation was predictive of coagulation-associated complications during hospitalization [D-dimer >2,500 ng/mL, adjusted OR for thrombosis, 6.79 (2.39-19.30), adjusted OR for bleeding, 3.56 (1.01-12.66)], critical illness, and death. Additional markers at initial presentation predictive of thrombosis during hospitalization included platelet count >450×109/L [adjusted OR, 3.56 (1.27-9.97)], C-reactive protein (CRP) >100 mg/L [adjusted OR, 2.71 (1.26-5.86)], and erythrocyte sedimentation rate >40 mm/h [adjusted OR, 2.64 (1.07-6.51)]. ESR, CRP, fibrinogen, ferritin, and procalcitonin were higher in patients with thrombotic complications than those without. DIC, clinically-relevant thrombocytopenia, and reduced fibrinogen were rare and were associated with significant bleeding manifestations. Given the observed bleeding rates, randomized trials are needed to determine any potential benefit of intensified anticoagulant prophylaxis in COVID-19 patients.

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Section: Discussionsupporting

confidence: 76%

COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection

Al‐Samkari

Leaf

Dzik

et al. 2020

Blood

1,171

1,222

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“…This incidence of thromboembolic events is considerably lower than the 15% to 42% incidence reported in critically ill patients with COVID-19 in Europe [10][11][12][13][14] and is more consistent with the incidence reported in critically ill pa-tients without COVID-19. 15 Understanding the reason for these differences will be important as hypercoagulability in COVID-19 is pursued as a potential therapeutic target. 16 This study identified considerable interhospital variation in the administration of medications and supportive therapies intended to treat COVID-19 and associated organ injury.…”

Section: Other Clinical Outcomesmentioning

confidence: 99%

Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US

et al. 2020

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IMPORTANCE The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19. OBJECTIVES To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020. EXPOSURES Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds. MAIN OUTCOMES AND MEASURES The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes. RESULTS A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (Ն80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (Ն40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (PaO 2 :FIO 2 <100 vs Ն300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2 vs 0: OR, 2.61; 95% CI, 1.30-5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46-4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs Ն100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies. CONCLUSIONS AND RELEVANCE This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.

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“…Previous analyses have estimated a significant lower incidence of acute PE in the ICU population, which generally increase in mechanically ventilated patients [34,35]. The high incidence of acute PE in critically ill patients may reflect a more severe pro-coagulant state [36][37][38][39].…”

Section: Discussionmentioning

confidence: 99%

Incidence of acute pulmonary embolism in COVID-19 patients: Systematic review and meta-analysis.

Roncon

Zuin

Valerio

et al. 2020

European Journal of Internal Medicine

127

116

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Background: Acute pulmonary embolism (PE) has been described as a frequent and prognostically relevant complication of COVID-19 infection. Aim: We performed a systematic review and meta-analysis of the in-hospital incidence of acute PE among COVID-19 patients based on studies published within four months of COVID-19 outbreak. Material and Methods: Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. We searched Medline, Scopus and Web of Science to locate all articles published up to August 1, 2020 reporting the incidence of acute PE (or lung thrombosis) in COVID-19 patients. The pooled inhospital incidence of acute PE among COVID-19 patients was calculated using a random effects model and presenting the related 95% confidence interval (CI). Statistical heterogeneity was measured using the Higgins I 2 statistic. Results: We analysed data from 7178 COVID-19 patients [mean age 60.4 years] included in twenty-three studies. Among patients hospitalized in general wards and intensive care unit (ICU), the pooled in-hospital incidence of PE (or lung thrombosis) was 14.7% of cases (95% CI: 9.9-21.3%, I 2 =95.0%, p<0.0001) and 23.4% (95% CI:16.7-31.8%, I2=88.7%, p<0.0001), respectively. Segmental/sub-segmental pulmonary arteries were more frequently involved compared to main/lobar arteries (6.8% vs18.8%, p<0.001). Computer tomography pulmonary angiogram (CTPA) was used only in 35.3% of patients with COVID-19 infection across six studies. Conclusions: The in-hospital incidence of acute PE among COVID-19 patients is higher in ICU patients compared to those hospitalized in general wards. CTPA was rarely used suggesting a potential underestimation of PE cases.

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The cumulative venous thromboembolism incidence and risk factors in intensive care patients receiving the guideline-recommended thromboprophylaxis

Cited by 68 publications

References 34 publications

COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection

COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection

Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US

Incidence of acute pulmonary embolism in COVID-19 patients: Systematic review and meta-analysis.

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