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Ganesan V, Pandya R, Rodriguez AN, Horn AR, Abdelgawad AA, Razi AE. Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1911-1915. [PMID: 38459969 DOI: 10.1007/s00590-024-03862-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/16/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates. METHODS A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission. RESULTS The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss. CONCLUSION This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.
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Affiliation(s)
- Vanathi Ganesan
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
- College of Medicine, State University of New York (SUNY) Downstate, Brooklyn, NY, USA
| | - Radha Pandya
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
- College of Medicine, State University of New York (SUNY) Downstate, Brooklyn, NY, USA
| | - Ariel N Rodriguez
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA.
| | - Andrew R Horn
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
| | - Amr A Abdelgawad
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
| | - Afshin E Razi
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
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Okazaki E, Barion BG, da Rocha TRF, Di Giacomo G, Ho YL, Rothschild C, Fatobene G, de Carvalho Moraes BDG, Stefanello B, Villaça PR, Rocha VG, Orsi FA. Persistent hypofibrinolysis in severe COVID-19 associated with elevated fibrinolysis inhibitors activity. J Thromb Thrombolysis 2024; 57:721-729. [PMID: 38523179 DOI: 10.1007/s11239-024-02961-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/26/2024]
Abstract
Hypercoagulability and reduced fibrinolysis are well-established complications associated with COVID-19. However, the timelines for the onset and resolution of these complications remain unclear. The aim of this study was to evaluate, in a cohort of COVID-19 patients, changes in coagulation and fibrinolytic activity through ROTEM assay at different time points during the initial 30 days following the onset of symptoms in both mild and severe cases. Blood samples were collected at five intervals after symptoms onset: 6-10 days, 11-15 days, 16-20 days, 21-25 days, and 26-30 days. In addition, fibrinogen, plasminogen, PAI-1, and alpha 2-antiplasmin activities were determined. Out of 85 participants, 71% had mild COVID-19. Twenty uninfected individuals were evaluated as controls. ROTEM parameters showed a hypercoagulable state among mild COVID-19 patients beginning in the second week of symptoms onset, with a trend towards reversal after the third week of symptoms. In severe COVID-19 cases, hypercoagulability was observed since the first few days of symptoms, with a tendency towards reversal after the fourth week of symptoms onset. A hypofibrinolytic state was identified in severe COVID-19 patients from early stages and persisted even after 30 days of symptoms. Elevated activity of PAI-1 and alpha 2-antiplasmin was also detected in severe COVID-19 patients. In conclusion, both mild and severe cases of COVID-19 exhibited transient hypercoagulability, reverted by the end of the first month. However, severe COVID-19 cases sustain hypofibrinolysis throughout the course of the disease, which is associated with elevated activity of fibrinolysis inhibitors. Persistent hypofibrinolysis could contribute to long COVID-19 manifestations.
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Affiliation(s)
- Erica Okazaki
- University of Sao Paulo Medical School, Sao Paulo, Brazil
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Bárbara Gomes Barion
- University of Sao Paulo Medical School, Sao Paulo, Brazil
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Tania Rubia Flores da Rocha
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Giovanna Di Giacomo
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Yeh-Li Ho
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Cynthia Rothschild
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | | | | | - Bianca Stefanello
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Paula Ribeiro Villaça
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Vanderson Geraldo Rocha
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Fernanda Andrade Orsi
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil.
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Kasugai D, Tanaka T, Suzuki T, Ito Y, Nishida K, Ozaki M, Kutsuna T, Yokoyama T, Kaneko H, Ogata R, Matsui R, Goshima T, Hamada H, Ishii A, Kodama Y, Jingushi N, Ishikura K, Kamidani R, Tada M, Okada H, Yamamoto T, Goto Y. Association between loss of hypercoagulable phenotype, clinical features and complement pathway consumption in COVID-19. Front Immunol 2024; 15:1337070. [PMID: 38529277 PMCID: PMC10961343 DOI: 10.3389/fimmu.2024.1337070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/27/2024] [Indexed: 03/27/2024] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) features a hypercoagulable state, but therapeutic anticoagulation effectiveness varies with disease severity. We aimed to evaluate the dynamics of the coagulation profile and its association with COVID-19 severity, outcomes, and biomarker trajectories. Methods This multicenter, prospective, observational study included patients with COVID-19 requiring respiratory support. Rotational thromboelastometry findings were evaluated for coagulation and fibrinolysis status. Hypercoagulable status was defined as supranormal range of maximum clot elasticity in an external pathway. Longitudinal laboratory parameters were collected to characterize the coagulation phenotype. Results Of 166 patients, 90 (54%) were severely ill at inclusion (invasive mechanical ventilation, 84; extracorporeal membrane oxygenation, 6). Higher maximum elasticity (P=0.02) and lower maximum lysis in the external pathway (P=0.03) were observed in severely ill patients compared with the corresponding values in patients on non-invasive oxygen supplementation. Hypercoagulability components correlated with platelet and fibrinogen levels. Hypercoagulable phenotype was associated with favorable outcomes in severely ill patients, while normocoagulable phenotype was not (median time to recovery, 15 days vs. 27 days, P=0.002), but no significant association was observed in moderately ill patients. In patients with severe COVID-19, lower initial C3, minimum C3, CH50, and greater changes in CH50 were associated with the normocoagulable phenotype. Changes in complement components correlated with dynamics of coagulation markers, hematocrit, and alveolar injury markers. Conclusions While hypercoagulable states become more evident with increasing severity of respiratory disease in patients with COVID-19, normocoagulable phenotype is associated with triggered by alternative pathway activation and poor outcomes.
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Affiliation(s)
- Daisuke Kasugai
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taku Tanaka
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takako Suzuki
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Ito
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Nishida
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Ozaki
- Department of Critical Care Medicine, Komaki City Hospital, Komaki, Japan
| | - Takeo Kutsuna
- Department of Respiratory Medicine, Daido Hospital, Nagoya, Japan
| | - Toshiki Yokoyama
- Department of Emergency and Critical Care Medicine, Tosei General Hospital, Seto, Japan
| | - Hitoshi Kaneko
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
| | - Ryo Ogata
- Department of Respiratory Medicine, Meitetsu Hospital, Nagoya, Japan
| | - Ryohei Matsui
- Department of Emergency and Critical Care Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Takahiro Goshima
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Hiroshi Hamada
- Department of Internal Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Azusa Ishii
- Department of Respiratory Medicine, Chukyo Hospital, Nagoya, Japan
| | - Yusuke Kodama
- Department of Internal Medicine, Kyoritsu General Hospital, Nagoya, Japan
| | - Naruhiro Jingushi
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ken Ishikura
- Department of Emergency and Disaster Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ryo Kamidani
- Department of Emergency and Critical Care Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masashi Tada
- Department of Internal Medicine, SaiShukan Hospital, Kitanagoya, Japan
| | - Hideshi Okada
- Department of Emergency and Critical Care Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takanori Yamamoto
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukari Goto
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Emergency Medicine, Nagoya EkiSaikai Hospital, Nagoya, Japan
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Hulshof AM, Nab L, van Rosmalen F, de Kok J, Mulder MMG, Hellenbrand D, Sels JWEM, Ten Cate H, Cannegieter SC, Henskens YMC, van Bussel BCT. Rotational thromboelastometry as a biomarker for mortality - The Maastricht Intensive Care COVID cohort. Thromb Res 2024; 234:51-58. [PMID: 38159324 DOI: 10.1016/j.thromres.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with severe coronavirus disease 2019 (COVID-19) present with persisting hypercoagulability, hypofibrinolysis and prolonged clot initiation as measured with viscoelastic assays. The objective of this study was to investigate the trajectories of traditional assays of hemostasis, routine and tissue plasminogen activator (tPA) rotational thromboelastometry (ROTEM) in COVID-19 patients and to study their association with mortality. METHODS Patients enrolled within the Maastricht Intensive Care COVID (MaastrICCht) cohort were included. Traditional assays of hemostasis (prothrombin time; PT, fibrinogen and D-dimer) were measured daily and ROTEM EXTEM, FIBTEM and tPA assays were performed weekly. Trajectories of these biomarkers were analyzed over time for survivors and non-survivors using linear mixed-effects models. Additional Fine and Gray competing risk survival analysis was performed for the first available measurement after intubation. RESULTS Of the 138 included patients, 57 (41 %) died in the intensive care unit (ICU). Over 450, 400 and 1900 individual measurements were available for analysis of routine, tPA ROTEM and traditional assays of hemostasis, respectively, with a median [IQR] follow-up of 15 [8-24] days. Non-survivors on average had prolonged CT (clotting time) and increased fibrinogen compared to survivors. MCF (maximum clot firmness), LOT (lysis onset time), LT (lysis time) and PT measurements increased more over time in non-survivors compared to survivors. Associations persisted after adjustment for demographics and disease severity. EXTEM and FIBTEM CT at intubation were associated with increased 45-day ICU mortality. CONCLUSIONS ROTEM measurements demonstrate a further increase of hypercoagulability and (hypo)fibrinolysis parameters in non-survivors throughout ICU admission. Furthermore, prolonged CT at intubation was associated with higher 45-day ICU mortality.
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Affiliation(s)
- Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Linda Nab
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frank van Rosmalen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Jip de Kok
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Mark M G Mulder
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Anesthesiology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Dave Hellenbrand
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Jan Willem E M Sels
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands; Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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Tsui KHM, Chau WW, Liu WH, Tam CY, Yee DKH, Tso CY, Zhang N, Cheung WH, Tang N, Wong RMY. COVID-19 hip fracture outcomes: The role of Ct values and D-dimer levels? J Orthop Translat 2023; 43:14-20. [PMID: 37920546 PMCID: PMC10618614 DOI: 10.1016/j.jot.2023.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 08/11/2023] [Accepted: 09/24/2023] [Indexed: 11/04/2023] Open
Abstract
Introduction The COVID-19 pandemic has caused high mortality rates in hip fracture patients, but data for Asian patients are lacking. Whilst Cycle threshold (Ct) values and D-dimer have been reported as predictors of mortality in COVID-19 patients, their prognostic roles in those with concomitant hip fracture remain unknown. The objectives of this study were to i) assess the clinical outcomes of COVID-19 hip fractures patients in the Chinese population, ii) identify risk factors of mortality and complications, and iii) determine the prognostic roles of Ct values and D-dimer levels. Methodology This cohort study was conducted during the 5th wave of the COVID-19 pandemic. Inclusion criteria were 1) hip fracture 2) ≥ 60 years old 3) low-energy trauma. Outcomes were 90-day all-cause mortality, complications, length of stay, discharge destination and mobility status. Logistic regression analysis was performed to identify risk factors for mortality and complications. Subgroup analysis was performed for patients with Ct < 30 and Ct > 30, comparing their outcomes of operations performed within 48 h vs beyond 48 h. Results 159 hip fracture patients were included, 42 patients were COVID-19 positive. COVID-19 group had significantly higher 90-day mortality rates (21.4% vs 9.4%), complication rates (45.2% vs 28.2%) and longer length of stay (17.06 vs 10.84 nights). COVID-19 was an independent risk factor for mortality and complications. Amongst the COVID-19 group, risk factors for poor outcomes were advanced age, steroids use, conservative treatment and American Society of Anaesthesiologists (ASA) score ≥ 3. Conservative treatment was associated with higher mortality (OR = 16.00; p = 0.025) in COVID-19 hip fracture patients. There was no significant difference between Ct values < 30 and >30 regarding mortality and complication rate. D-dimer and timing to operation did not affect outcomes. Conclusions Patients with concomitant COVID-19 and hip fracture are at high risk of mortality and complications. Ct values and D-dimer levels have no prognostic roles for hip fracture outcomes. Early operative treatment is recommended as soon as patients are medically fit.
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Affiliation(s)
- Kwan Hung Moya Tsui
- Department of Orthopaedics & Traumatology, Prince of Wales Hospital, Hospital Authority, Hong Kong SAR, China
| | - Wai Wang Chau
- Department of Orthopaedics & Traumatology, Alice Ho Miu Ling Nethersole Hospital, Hospital Authority, Hong Kong SAR, China
| | - Wing Hong Liu
- Department of Orthopaedics & Traumatology, Prince of Wales Hospital, Hospital Authority, Hong Kong SAR, China
| | - Cheuk Yin Tam
- Department of Orthopaedics & Traumatology, Alice Ho Miu Ling Nethersole Hospital, Hospital Authority, Hong Kong SAR, China
| | - Dennis King Hang Yee
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chi Yin Tso
- Department of Orthopaedics & Traumatology, Prince of Wales Hospital, Hospital Authority, Hong Kong SAR, China
| | - Ning Zhang
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wing-Hoi Cheung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ning Tang
- Department of Orthopaedics & Traumatology, Prince of Wales Hospital, Hospital Authority, Hong Kong SAR, China
| | - Ronald Man Yeung Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
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Forgács R, Bokrétás GP, Monori Z, Molnár Z, Ruszkai Z. Thromboelastometry-Guided Individualized Fibrinolytic Treatment for COVID-19-Associated Severe Coagulopathy Complicated by Portal Vein Thrombosis: A Case Report. Biomedicines 2023; 11:2463. [PMID: 37760902 PMCID: PMC10525483 DOI: 10.3390/biomedicines11092463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
COVID-19-associated coagulopathy (CAC), mainly characterized by hypercoagulability leading to micro- and macrovascular thrombotic events due to the fibrinolysis shutdown phenomenon, is a life-threatening complication of severe SARS-CoV-2 infection. However, optimal criteria to assess patients with the highest risk for progression of severe CAC are still unclear. Bedside point-of-care viscoelastic testing (VET) appears to be a promising tool to recognize CAC, to support the appropriate therapeutic decisions, and to monitor the efficacy of the treatment. The ClotPro VET has the potential to reveal fibrinolysis resistance indicated by a clot lysis time (LT) > 300 s on the TPA-test. We present a case of severe SARS-CoV-2 infection complicated by CAC-resulting portal vein thrombosis (PVT) and subsequent liver failure despite therapeutic anticoagulation. Since fibrinolysis shutdown (LT > 755 s) caused PVT, we performed a targeted systemic fibrinolytic therapy. We monitored the efficacy of the treatment with repeated TPA assays every three hours, while the dose of recombinant plasminogen activator (rtPA) was adjusted until fibrinolysis shutdown completely resolved and portal vein patency was confirmed by an ultrasound examination. Our case report highlights the importance of VET-guided personalized therapeutic approach during the care of severely ill COVID-19 patients, in order to appropriately treat CAC.
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Affiliation(s)
- Robin Forgács
- Department of Anesthesiology and Intensive Therapy, Flór Ferenc Hospital Kistarcsa, 2143 Kistarcsa, Hungary; (R.F.); (G.P.B.); (Z.M.); (Z.R.)
| | - Gergely Péter Bokrétás
- Department of Anesthesiology and Intensive Therapy, Flór Ferenc Hospital Kistarcsa, 2143 Kistarcsa, Hungary; (R.F.); (G.P.B.); (Z.M.); (Z.R.)
| | - Zoltán Monori
- Department of Anesthesiology and Intensive Therapy, Flór Ferenc Hospital Kistarcsa, 2143 Kistarcsa, Hungary; (R.F.); (G.P.B.); (Z.M.); (Z.R.)
| | - Zsolt Molnár
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, 1082 Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Poznan University of Medical Sciences, 60-005 Poznan, Poland
| | - Zoltán Ruszkai
- Department of Anesthesiology and Intensive Therapy, Flór Ferenc Hospital Kistarcsa, 2143 Kistarcsa, Hungary; (R.F.); (G.P.B.); (Z.M.); (Z.R.)
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Budapest, Hungary
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Chehrassan M, Shakeri M, Akbarzadeh Arab A, Mozaffary M, Niazi E, Ghandhari H. Comparison of coagulation profile and thromboembolic events among patients undergoing spinal surgery before and after COVID-19 pandemic. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2288-2292. [PMID: 37014435 PMCID: PMC10071248 DOI: 10.1007/s00586-023-07688-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 11/07/2022] [Accepted: 03/24/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Impairment of coagulation parameters and increased rate of thromboembolism are known complications of COVID-19 infection. In this study the coagulation profile and rate of thromboembolic events between two groups of patients who underwent spinal surgery before and after the COVID-19 pandemic was compared. PATIENTS AND METHOD Clinically and laboratory negative for COVID-19 elective patients before (n: 211) and during COVID- 19 pandemic (n: 294) with spinal surgeries were included in this retrospective study. Surgical characteristics, Physiologic parameters, coagulation parameters and thromboembolic events were compared between the two study groups. RESULTS Preoperative coagulation parameters, including PT, PTT, and INR were significantly increased during the COVID-19 pandemic (P < 0.001. P = 0.001, and P < 0.001, respectively), while the platelet count was significantly reduced (P = 0.04). The same differences were observed between the two study groups after the spinal surgery. In addition, respiratory rate and postoperative bleeding of the first postoperative 24 h was significantly more in patients who were operated on during COVID-19 outbreak (P = 0.03 and P = 0.002, respectively). The rate of thromboembolic events was 3.1% during the COVID-19 pandemic (seven PE, one DVT, and one MI) and 0% before that. This difference was statistically significant (P = 0.043). CONCLUSION The rate of thromboembolic events seems to be increased during the COVID-19 pandemic. These findings urge more stringent monitoring of the patients' coagulation parameters during the COVID-19 outbreak.
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Affiliation(s)
- Mohammadreza Chehrassan
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Shakeri
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Akbarzadeh Arab
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahboobe Mozaffary
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Elmira Niazi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Ghandhari
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
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Milić D, Lazarević M, Vuković N, Kamenov A, Perić V, Golubović M, Stošić M, Spasić D, Stojiljković V, Stokanović D. Monitoring the Coagulation Profile of COVID-19 Patients Using Standard and ClotPro ® Hemostasis Tests. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1202. [PMID: 37512014 PMCID: PMC10386453 DOI: 10.3390/medicina59071202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: Coagulation disorders during COVID-19 infection are associated with a poorer prognosis and higher disease severity because thrombosis and inflammation are two processes that interfere with each other. A very important issue for clinicians is timely and adequate hemostasis and inflammation monitoring to prevent and treat potentially lethal consequences. The aim of this study was to identify specific hemostatic parameters that are associated with a higher risk of intrahospital mortality. Materials and Methods: This study was approved by the Ethics Committee of the Clinical Center Nis in Serbia. One hundred and forty-two patients presented with COVID-19 ARDS and were admitted to the ICU in the Clinic for Anesthesiology at the Clinical Center Nis from 14 April 2020 to 25 May 2020. Upon admission, blood was collected for biochemical and coagulation testing. The data obtained were analyzed using the Statistical Package for Social Sciences (SPSS v. 25, Chicago, IL, USA). Results: Among all the parameters assessed, older age; increased levels of fibrinogen, INR, D-dimer, and presepsin; and higher results in the platelet aggregation tests (aggregation induced by adenosine diphosphate based on the ADP test (AU/min), aggregation induced by arachidonic acid based on the ASPI test (AU/min), and aggregation induced by thrombin based on the TRAP test (AU/min)) and some assays of the viscoelastic test (clot amplitude after 5 min in the extrinsic coagulation pathway based on the A5 EX-test (mm), clot amplitude after 10 min in the extrinsic coagulation pathway based on the A10 EX-test (mm), clot amplitude after 5 min regarding functional fibrinogen based on the A5 FIB-test (mm), clot amplitude after 10 min regarding functional fibrinogen based on the A10 FIB-test (mm), and maximum clot firmness based on the MCF FIB-test (mm)); and lower values of viscoelastic clotting time in the extrinsic coagulation pathway based on the CT EX-test (s) were significantly correlated with mortality. In the multivariate analysis, D-dimer levels above 860 ng/mL, higher TRAP test value bins, and values above the normal reference range of the A10 FIB test were found to be independent predictors of mortality. Conclusions: Sophisticated hemostasis parameters can contribute to early risk assessment, which has initially been performed only on the basis of patients' clinical status. Hypercoagulability is the main coagulation disorder in COVID-19 infection.
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Affiliation(s)
- Dragan Milić
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Milan Lazarević
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Natalija Vuković
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, 18000 Nis, Serbia
| | - Aleksandar Kamenov
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Velimir Perić
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Mlađan Golubović
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Marija Stošić
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Dimitrije Spasić
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Vladimir Stojiljković
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
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9
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Kammerer T, Walzl A, Müller T, Groene P, Roveri G, Turner R, Roche J, Gatterer H, Siebenmann C, Schäfer ST. Effects of Hypobaric Hypoxia on Coagulation in Healthy Subjects Exposed to 3,500 m Altitude. High Alt Med Biol 2023; 24:94-103. [PMID: 37339401 DOI: 10.1089/ham.2022.0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Kammerer, Tobias, Anna Walzl, Thomas Müller, Philipp Groene, Giulia Roveri, Rachel Turner, Johanna Roche, Hannes Gatterer, Christoph Siebenmann, and Simon T. Schäfer. Effects of hypobaric hypoxia on coagulation in healthy subjects exposed to 3,500 m altitude. High Alt Med Biol. 24:94-103, 2023. Background: Hypoxia is discussed as a trigger for prothrombotic changes both in intensive care and high altitude medicine. This research study aimed to evaluate the effect of isolated hypobaric hypoxia (HH) on coagulation in females in a highly standardized setting. Methods: Twelve healthy female subjects were studied under HH (equivalent to 3,500 m) and normoxia (NX) during two 4-day sojourns, in a strictly controlled crossover design. Nutrition, fluid intake, hormonal status (i.e., menstrual cycle variation), and physical stress were standardized. Functional coagulation and blood lysis were measured by viscoelastometry and compared between HH and NX. In addition, plasma-based coagulation tests (PBCTs), namely prothrombin time, activated partial thromboplastin time, fibrinogen, factor VIII coagulation activity (FVIII:C), von Willebrand factor antigen (vWF:Ag), and von Willebrand factor ristocetin cofactor activity (vWF:RCo) were measured. Results: Neither for Viscoelastic Haemostatic Assays nor for PBCTs significant changes were found for HH compared with NX (all p > 0.05). Specifically, the lysis ability, as well as clotting time, clot formation, clot amplitude, and maximum clot firmness unchanged were similar between HH and NX. This also applied to all other variables. Conclusion: We demonstrate that moderate HH per se has no influence on blood coagulation in healthy females.
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Affiliation(s)
- Tobias Kammerer
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Anna Walzl
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Thomas Müller
- Department of Laboratory Medicine, Hospital Voecklabruck, Voecklabruck, Austria
| | - Philipp Groene
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Giulia Roveri
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Rachel Turner
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
| | - Johanna Roche
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
| | - Hannes Gatterer
- Eurac Research, Institute of Mountain Emergency Medicine, Bolzano, Italy
- Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT TIROL-Private University for Health Sciences and Health Technology, Hall in Tirol, Austria
| | | | - Simon T Schäfer
- Department of Anaesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, University Hospital, Carl-von-Ossietzky University Oldenburg, Klinikum Oldenburg AöR, Oldenburg, Germany
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10
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Wada H, Shiraki K, Shimpo H, Shimaoka M, Iba T, Suzuki-Inoue K. Thrombotic Mechanism Involving Platelet Activation, Hypercoagulability and Hypofibrinolysis in Coronavirus Disease 2019. Int J Mol Sci 2023; 24:ijms24097975. [PMID: 37175680 PMCID: PMC10178520 DOI: 10.3390/ijms24097975] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has spread, with thrombotic complications being increasingly frequently reported. Although thrombosis is frequently complicated in septic patients, there are some differences in the thrombosis noted with COVID-19 and that noted with bacterial infections. The incidence (6-26%) of thrombosis varied among reports in patients with COVID-19; the incidences of venous thromboembolism and acute arterial thrombosis were 4.8-21.0% and 0.7-3.7%, respectively. Although disseminated intravascular coagulation (DIC) is frequently associated with bacterial infections, a few cases of DIC have been reported in association with COVID-19. Fibrin-related markers, such as D-dimer levels, are extremely high in bacterial infections, whereas soluble C-type lectin-like receptor 2 (sCLEC-2) levels are high in COVID-19, suggesting that hypercoagulable and hyperfibrinolytic states are predominant in bacterial infections, whereas hypercoagulable and hypofibrinolytic states with platelet activation are predominant in COVID-19. Marked platelet activation, hypercoagulability and hypofibrinolytic states may cause thrombosis in patients with COVID-19.
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Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 5450-132, Japan
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 5450-132, Japan
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi 5450-132, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-0001, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8431, Japan
| | - Katsue Suzuki-Inoue
- Department of Clinical and Laboratory Medicine, Yamanashi Medical University, Yamanashi 409-3821, Japan
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11
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Yagi T, Fujita M, Harada K, Shin M, Esaki Y, Ayata R, Koga Y, Kaneda K, Tsuruta R. Time Course of Coagulopathy Evaluated with Rotational Thromboelastometry in Patients with Severe Coronavirus Disease 2019. Intern Med 2023; 62:717-722. [PMID: 36543214 PMCID: PMC10037019 DOI: 10.2169/internalmedicine.0993-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objectives Coronavirus disease 2019 (COVID-19) reportedly causes thromboembolic complications due to coagulopathy with hypercoagulability and a hypofibrinolytic state. We evaluated the time-course of coagulopathy in patients with severe COVID-19 from admission to discharge from our intensive-care unit (ICU). Methods We conducted a retrospective study of adults with severe COVID-19 admitted to our ICU between January 20, 2021, and March 31, 2022. We obtained clinical information, laboratory data, and rotational thromboelastometry (ROTEM) parameters at admission and discharge. Results Fifteen patients were included. Fibrinogen and D-dimer values did not change significantly but were above the normal ranges at admission and discharge. Regarding ROTEM parameters, the maximum clot firmness in fibrinogen function (FIBTEM), a marker of hypercoagulability, did not change significantly but was above the normal range at admission and discharge [median (interquartile range), admission vs. discharge: 31 (25-34) mm vs. 31 (27-32) mm, p=0.589]. The maximum lysis at 60 minutes in the extrinsic coagulation pathway (EXTEM) and intrinsic coagulation pathway (INTEM), as markers of the fibrinolytic function, were both significantly lower at discharge than at admission [median (interquartile range), admission vs. discharge: EXTEM, 3 (2-4) vs. 1 (0-2), p=0.011; INTEM, 3 (1-6) vs. 1 (0-2), p=0.008]. Conclusion This study revealed a persistent hypercoagulable state at ICU discharge and a worse hypofibrinolytic state at discharge than at admission. These results may contribute to a better understanding of coagulopathies in the acute to subacute phases of severe COVID-19.
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Affiliation(s)
- Takeshi Yagi
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Motoki Fujita
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kayoko Harada
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Masaru Shin
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Yusuke Esaki
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Ryo Ayata
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Yasutaka Koga
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kotaro Kaneda
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
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12
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Coupland LA, Rabbolini DJ, Schoenecker JG, Crispin PJ, Miller JJ, Ghent T, Medcalf RL, Aneman AE. Point-of-care diagnosis and monitoring of fibrinolysis resistance in the critically ill: results from a feasibility study. Crit Care 2023; 27:55. [PMID: 36765421 PMCID: PMC9912243 DOI: 10.1186/s13054-023-04329-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/22/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Fibrinolysisis is essential for vascular blood flow maintenance and is triggered by endothelial and platelet release of tissue plasminogen activator (t-PA). In certain critical conditions, e.g. sepsis, acute respiratory failure (ARF) and trauma, the fibrinolytic response is reduced and may lead to widespread thrombosis and multi-organ failure. The mechanisms underpinning fibrinolysis resistance include reduced t-PA expression and/or release, reduced t-PA and/or plasmin effect due to elevated inhibitor levels, increased consumption and/or clearance. This study in critically ill patients with fibrinolysis resistance aimed to evaluate the ability of t-PA and plasminogen supplementation to restore fibrinolysis with assessment using point-of-care ClotPro viscoelastic testing (VET). METHODS In prospective, observational studies, whole-blood ClotPro VET evaluation was carried out in 105 critically ill patients. In 32 of 58 patients identified as fibrinolysis-resistant (clot lysis time > 300 s on the TPA-test: tissue factor activated coagulation with t-PA accelerated fibrinolysis), consecutive experimental whole-blood VET was carried out with repeat TPA-tests spiked with additional t-PA and/or plasminogen and the effect on lysis time determined. In an interventional study in a patient with ARF and fibrinolysis resistance, the impact of a 24 h intravenous low-dose alteplase infusion on coagulation and fibrinolysis was prospectively monitored using standard ClotPro VET. RESULTS Distinct response groups emerged in the ex vivo experimental VET, with increased fibrinolysis observed following supplementation with (i) t-PA only or (ii) plasminogen and t-PA. A baseline TPA-test lysis time of > 1000 s was associated with the latter group. In the interventional study, a gradual reduction (25%) in serial TPA-test lysis times was observed during the 24 h low-dose alteplase infusion. CONCLUSIONS ClotPro viscoelastic testing, the associated TPA-test and the novel experimental assays may be utilised to (i) investigate the potential mechanisms of fibrinolysis resistance, (ii) guide corrective treatment and (iii) monitor in real-time the treatment effect. Such a precision medicine and personalised treatment approach to the management of fibrinolysis resistance has the potential to increase treatment benefit, while minimising adverse events in critically ill patients. TRIAL REGISTRATION VETtiPAT-ARF, a clinical trial evaluating ClotPro-guided t-PA (alteplase) administration in fibrinolysis-resistant patients with ARF, is ongoing (ClinicalTrials.gov NCT05540834 ; retrospectively registered September 15th 2022).
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Affiliation(s)
- Lucy A. Coupland
- grid.415994.40000 0004 0527 9653Intensive Care Unit, Liverpool Hospital, Liverpool, Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW 2170 Australia
| | - David J. Rabbolini
- grid.1013.30000 0004 1936 834XKolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, Australia ,grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan G. Schoenecker
- grid.412807.80000 0004 1936 9916Department of Orthopaedics and Pharmacology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Philip J. Crispin
- grid.413314.00000 0000 9984 5644Haematology Department, The Canberra Hospital, Canberra, Australia ,grid.1001.00000 0001 2180 7477The Australian National University Medical School, Canberra, Australia
| | - Jennene J. Miller
- grid.415994.40000 0004 0527 9653Intensive Care Unit, Liverpool Hospital, Liverpool, Australia
| | - Tony Ghent
- grid.413154.60000 0004 0625 9072Intensive Care Unit, Gold Coast University Hospital, South Port, Australia
| | - Robert L. Medcalf
- grid.1002.30000 0004 1936 7857Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Anders E. Aneman
- grid.415994.40000 0004 0527 9653Intensive Care Unit, Liverpool Hospital, Liverpool, Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW 2170 Australia
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13
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Xiang M, Wu X, Jing H, Novakovic VA, Shi J. The intersection of obesity and (long) COVID-19: Hypoxia, thrombotic inflammation, and vascular endothelial injury. Front Cardiovasc Med 2023; 10:1062491. [PMID: 36824451 PMCID: PMC9941162 DOI: 10.3389/fcvm.2023.1062491] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
The role of hypoxia, vascular endothelial injury, and thrombotic inflammation in worsening COVID-19 symptoms has been generally recognized. Damaged vascular endothelium plays a crucial role in forming in situ thrombosis, pulmonary dysfunction, and hypoxemia. Thrombotic inflammation can further aggravate local vascular endothelial injury and affect ventilation and blood flow ratio. According to the results of many studies, obesity is an independent risk factor for a variety of severe respiratory diseases and contributes to high mechanical ventilation rate, high mortality, and slow recovery in COVID-19 patients. This review will explore the mechanisms by which obesity may aggravate the acute phase of COVID-19 and delay long COVID recovery by affecting hypoxia, vascular endothelial injury, and thrombotic inflammation. A systematic search of PubMed database was conducted for papers published since January 2020, using the medical subject headings of "COVID-19" and "long COVID" combined with the following keywords: "obesity," "thrombosis," "endothelial injury," "inflammation," "hypoxia," "treatment," and "anticoagulation." In patients with obesity, the accumulation of central fat restricts the expansion of alveoli, exacerbating the pulmonary dysfunction caused by SARS-CoV-2 invasion, inflammatory damage, and lung edema. Abnormal fat secretion and immune impairment further aggravate the original tissue damage and inflammation diffusion. Obesity weakens baseline vascular endothelium function leading to an early injury and pre-thrombotic state after infection. Enhanced procoagulant activity and microthrombi promote early obstruction of the vascular. Obesity also prolongs the duration of symptoms and increases the risk of sequelae after hospital discharge. Persistent viral presence, long-term inflammation, microclots, and hypoxia may contribute to the development of persistent symptoms, suggesting that patients with obesity are uniquely susceptible to long COVID. Early interventions, including supplemental oxygen, comprehensive antithrombotic therapy, and anti-inflammatory drugs, show effectiveness in many studies in the prevention of serious hypoxia, thromboembolic events, and systemic inflammation, and are therefore recommended to reduce intensive care unit admission, mortality, and sequelae.
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Affiliation(s)
- Mengqi Xiang
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Haijiao Jing
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China,Department of Research, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA, United States,Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, United States,*Correspondence: Jialan Shi, ,
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14
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Hartmann J, Hermelin D, Levy JH. Viscoelastic testing: an illustrated review of technology and clinical applications. Res Pract Thromb Haemost 2022; 7:100031. [PMID: 36760779 PMCID: PMC9903681 DOI: 10.1016/j.rpth.2022.100031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 01/26/2023] Open
Abstract
Viscoelastic testing (VET), including thromboelastography and thromboelastometry, provides a rapid and comprehensive picture of whole blood coagulation dynamics and hemostasis that can be reviewed and evaluated at the point-of-care. This technology is over 50 years old; however, over the past few years, there has been a significant increase in research examining the use of VET. Best practice guidelines for the use of VET exist in both the United States and Europe, particularly for elective cardiac surgery, although recommendations for implementation are somewhat limited in some clinical areas by the lack of studies constituting high-grade evidence. Other challenges to implementation surround validation of the technology in some care settings as well as lack of training. Nevertheless, there is a wide range of potential clinical applications, such as treating coagulopathies in liver disease and transplant surgery, critical care, as well as within obstetrical hemorrhage. In this illustrated review, we provide an overview of viscoelastic testing technology (also called viscoelastic hemostatic assays) and describe how the assays can be used to provide a broad overview of hemostasis from clot formation to clot lysis, while highlighting the contribution of coagulation factors and platelets. We then summarize the major clinical applications for viscoelastic testing, including more recent applications, such as in COVID-19. Each section describes the clinical context, and key publications, followed by a representative algorithm and key guidelines.
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Affiliation(s)
- Jan Hartmann
- Haemonetics Corporation, Boston, Massachusetts, USA
- Correspondence Jan Hartmann, Haemonetics Corporation, Boston, MA 02110, USA. @JanHartmannMD
| | - Daniela Hermelin
- Department of Pathology Saint Louis University School of Medicine, Saint Louis, Missouri, USA
- Medical Affairs, ImpactLife, Davenport, Iowa, USA
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15
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Calvo A, Torrente MA, Görlinger K, Fernandez J, Reverter E, Vidal J, Tassies D, Colmenero J, Blasi A, Reverter JC. Haemostasis patterns in patients with acute-on-chronic liver failure and acute decompensation of cirrhosis including thromboelastometric tests with and without the addition of Protac: a pilot study. Thromb J 2022; 20:75. [PMID: 36510196 PMCID: PMC9744590 DOI: 10.1186/s12959-022-00438-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Thromboelastometry is considered the best method to assesses hemostasis in liver disease. Diagnostic performance could be improved by adding protein C activators such as thrombomodulin or Protac®. We assessed changes in ROTEM parameters after the addition of Protac® in patients with acute-on-chronic liver failure (ACLF), acute decompensation (AD), and healthy individuals (HI) to define different hemostasis patterns, considering standard and velocity ROTEM parameters, and assess whether Protac® can improve the definition of the pattern. METHODS Pre-test, we investigated whether diluted EXTEM reagent improved the effect of Protac® on the clotting time (CT)-ratio with and without Protac®. Ten ACLF and 20 AD patients and 21 HI were included in the main study. RESULTS Standard EXTEM was used in the main study. INTEM CFT, INTEM A5 (inverse), and INTEM TPI (inverse) were the parameters that best differentiated liver disease from HI (ROC AUC, 0.921, 0.906, and 0.928, respectively; all P-values < 0.001). Combining INTEM CFT with EXTEM LI60-ratio only slightly improved the diagnostic performance (ROC AUC, 0.948; P < 0.001). EXTEM LI60 and INTEM maxV-t were the parameters that best differentiated between ACLF and AD patients (ROC AUC, 0.743, P = 0.033; and 0.723, P = 0.050; respectively). Combining EXTEM LI60 + INTEM maxV-t moderately improved the diagnostic performance (ROC AUC, 0.81, P < 0.001). CONCLUSIONS ROTEM velocity, fibrinolysis parameters and the indices calculated improve the diagnosis in combination with standard parameters (e.g., CFT and A5). Ratios calculated with and without Protac® (e.g., EXTEM LI60-ratio) only slightly increased the diagnostic performance in discriminating hemostasis patterns.
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Affiliation(s)
- Andrea Calvo
- grid.5841.80000 0004 1937 0247Anaesthesiology and Critical Care Department, Hospital Clínic, Institute d’Investigacions Biomédica AgustPi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Miguel Angel Torrente
- grid.410458.c0000 0000 9635 9413Haematology Department, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Klaus Görlinger
- grid.5718.b0000 0001 2187 5445Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany ,Medical Department, Tem Innovations GmbH, Munich, Germany
| | - Javier Fernandez
- grid.410458.c0000 0000 9635 9413Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Liver Unit, Institut de Malalties Digestives I Metabòliques, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Enric Reverter
- grid.410458.c0000 0000 9635 9413Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Liver Unit, Institut de Malalties Digestives I Metabòliques, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Julia Vidal
- grid.410458.c0000 0000 9635 9413Anaesthesiology Department, Hospital Clínic, Barcelona, Spain
| | - Dolors Tassies
- grid.410458.c0000 0000 9635 9413Haematology Department, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Jordi Colmenero
- grid.410458.c0000 0000 9635 9413Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Liver Unit, Institut de Malalties Digestives I Metabòliques, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Annabel Blasi
- grid.10403.360000000091771775Anaesthesiology Department, Hospital Clínic and University of Barcelona, Spain, Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), 08036 Barcelona, Spain
| | - Juan Carlos Reverter
- grid.410458.c0000 0000 9635 9413Haematology Department, Hospital Clínic and University of Barcelona, Barcelona, Spain
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16
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Uzun G, Althaus K, Hammer S, Bakchoul T. Assessment and Monitoring of Coagulation in Patients with COVID-19: A Review of Current Literature. Hamostaseologie 2022; 42:409-419. [PMID: 35477118 DOI: 10.1055/a-1755-8676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Coagulation abnormalities are common in patients with COVID-19 and associated with high morbidity and mortality. It became a daily challenge to navigate through these abnormal laboratory findings and deliver the best possible treatment to the patients. The unique character of COVID-19-induced coagulopathy necessitates not only a dynamic follow-up of the patients in terms of hemostatic findings but also the introduction of new diagnostic methods to determine the overall function of the coagulation system in real time. After the recognition of the high risk of thromboembolism in COVID-19, several professional societies published their recommendations regarding anticoagulation in patients with COVID-19. This review summarizes common hemostatic findings in COVID-19 patients and presents the societal recommendations regarding the use of coagulation laboratory findings in clinical decision-making. Although several studies have investigated coagulation parameters in patients with COVID-19, the methodological shortcomings of published studies as well as the differences in employed anticoagulation regimens that have changed over time, depending on national and international guidelines, limit the applicability of these findings in other clinical settings. Accordingly, evidence-based recommendations for diagnostics during acute COVID-19 infection are still lacking. Future studies should verify the role of coagulation parameters as well as viscoelastic methods in the management of patients with COVID-19.
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Affiliation(s)
- Günalp Uzun
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
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17
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Peak Plasma Levels of mtDNA Serve as a Predictive Biomarker for COVID-19 in-Hospital Mortality. J Clin Med 2022; 11:jcm11237161. [PMID: 36498735 PMCID: PMC9740249 DOI: 10.3390/jcm11237161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Several predictive biomarkers for coronavirus disease (COVID-19)-associated mortality in critically ill patients have been described. Although mitochondrial DNA (mtDNA) is elevated in patients with COVID-19, the association with coagulation function and its predictive power for mortality is unclear. Accordingly, this study investigates the predictive power of mtDNA for in-hospital mortality in critically ill patients with COVID-19, and whether combining it with thromboelastographic parameters can increase its predictive performance. This prospective explorative study included 29 patients with COVID-19 and 29 healthy matched controls. mtDNA encoding for NADH dehydrogenase 1 (ND1) was quantified using a quantitative polymerase chain reaction analysis, while coagulation function was evaluated using thromboelastometry and impedance aggregometry. Receiver operating characteristic (ROC) curves were used for the prediction of in-hospital mortality. Within the first 24 h, the plasma levels of mtDNA peaked significantly (controls: 65 (28-119) copies/µL; patients: 281 (110-805) at t0, 403 (168-1937) at t24, and 467 (188-952) copies/µL at t72; controls vs. patients: p = 0.02 at t0, p = 0.03 at t24, and p = 0.44 at t72). The mtDNA levels at t24 showed an excellent predictive performance for in-hospital mortality (area under the ROC curve: 0.90 (0.75-0.90)), which could not be improved by the combination with thromboelastometric or aggregometric parameters. Critically ill patients with COVID-19 present an early increase in the plasma levels of ND1 mtDNA, lasting over 24 h. They also show impairments in platelet function and fibrinolysis, as well as hypercoagulability, but these do not correlate with the plasma levels of fibrinogen. The peak plasma levels of mtDNA can be used as a predictive biomarker for in-hospital mortality; however, the combination with coagulation parameters does not improve the predictive validity.
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18
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Matsuoka A, Koami H, Shinada K, Sakamoto Y. Investigation of differences in coagulation characteristics between hospitalized patients with SARS-CoV-2 Alpha, Delta, and Omicron variant infection using rotational thromboelastometry (ROTEM): A single-center, retrospective, observational study. J Clin Lab Anal 2022; 36:e24796. [PMID: 36441617 PMCID: PMC9756981 DOI: 10.1002/jcla.24796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/12/2022] [Accepted: 11/19/2022] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 Omicron variant has a low rate of serious illness, is highly contagious, and has spread rapidly since January 2022. The number of severe cases and deaths remains problematic. Here, we aimed to elucidate the coagulation pathology of Omicron-infected patients using rotational thromboelastometry. METHODS Patients with coronavirus disease 2019, hospitalized and treated from January 2021 to April 2022, were included. The Alpha-Delta and Omicron groups were defined during admission. Blood tests, clinical course, and rotational thromboelastometry measurements were compared using a propensity score-matched cohort. RESULTS Both groups had 21 patients each. Lactate dehydrogenase (Alpha-Delta group [interquartile range] vs. Omicron group [interquartile range]; 449 [368-518] U/L vs. 241 [196-398] U/L, p = 0.01) and ferritin (1428 [1145-3061] ng/dl vs. 481 [188-881] ng/dl, p = 0.0002) levels were significantly lower in the Omicron group. In rotational thromboelastometry, the thrombus hardness indexes FIBTEM A5 (29 [23-34] mm vs. 23 [18-28] mm, p = 0.034) and maximum clot firmness (34 [27-40] mm vs. 26 [21-33] mm, p = 0.021) were significantly lower in the Omicron group, whereas the fibrinolysis index FIBTEM LI60 (98 [92-100] % vs. 100 [100-100] %, p = 0.0082) was higher. CONCLUSION Severe coagulation abnormalities may be less likely in Omicron-infected patients than in those infected with the previous Alpha and Delta variants.
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Affiliation(s)
- Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
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19
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Hypercoagulability in critically ill patients with COVID 19, an observational prospective study. PLoS One 2022; 17:e0277544. [PMID: 36417476 PMCID: PMC9683576 DOI: 10.1371/journal.pone.0277544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/30/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE COVID 19 is often associated with hypercoagulability and thromboembolic (TE) events. The aim of this study was to assess the characteristics of hypercoagulability and its relationship with new-onset TE events and the composite outcome of need for intubation and/or death in intensive care unit (ICU) patients admitted for COVID. DESIGN Prospective observational study. SETTING Monocentric, intensive care, University Hospital of Clermont Ferrand, France. PATIENTS Patients admitted to intensive care from January 2020 to May 2021 for COVID-19 pneumonia. INTERVENTIONS Standard hemostatic tests and rotational thromboelastometry (ROTEM) were performed on admission and on day 4. Hypercoagulability was defined by at least one of the following criteria: D-dimers > 3000 μg/dL, fibrinogen > 8 g/L, EXTEM CFT below the normal range, EXTEM A5, MCF, Li 60 above the normal range, and EXTEM G-score ((5000 x MCF) / (100-MCF)) ≥ 11 dyne/cm2. MEASUREMENTS AND MAIN RESULTS Of the 133 patients included, 17 (12.7%) developed new-onset TE events, and 59 (44.3%) required intubation and/or died in the ICU. ROTEM was performed in 133 patients on day 1 and in 67 on day 4. Hypercoagulability was present on day 1 in 115 (86.4%) patients. None of the hypercoagulability indices were associated with subsequent new-onset TE events on days 1 and 4 nor with the need for intubation and/or ICU death. Hyperfibrinogenemia > 8g/dL, higher D-dimers and higher EXTEM Li 60 on day 4 were predictive of need for intubation and/or of ICU death. CONCLUSIONS Our study confirmed that most COVID-19 ICU patients have hypercoagulability on admission and almost all on day 4. Hyperfibrinogenemia or fibrinolysis shutdown on day 4 were associated with unfavorable outcome.
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20
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Heubner L, Petrick PL, Güldner A, Bartels L, Ragaller M, Mirus M, Rand A, Tiebel O, Beyer-Westendorf J, Rößler M, Schmitt J, Koch T, Spieth PM. Extreme obesity is a strong predictor for in-hospital mortality and the prevalence of long-COVID in severe COVID-19 patients with acute respiratory distress syndrome. Sci Rep 2022; 12:18418. [PMID: 36319681 PMCID: PMC9626466 DOI: 10.1038/s41598-022-22107-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/10/2022] [Indexed: 11/26/2022] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is common in COVID-19 patients and is associated with high mortality. The aim of this observational study was to describe patients' characteristics and outcome, identifying potential risk factors for in-hospital mortality and for developing Long-COVID symptoms. This retrospective study included all patients with COVID-19 associated ARDS (cARDS) in the period from March 2020 to March 2021 who were invasively ventilated at the intensive care unit (ICU) of the University Hospital Dresden, Germany. Between October 2021 and December 2021 patients discharged alive (at minimum 6 months after hospital discharge-midterm survival) were contacted and interviewed about persistent symptoms possibly associated with COVID-19 as well as the quality of their lives using the EQ-5D-5L-questionnaire. Long-COVID was defined as the occurrence of one of the symptoms at least 6 months after discharge. Risk factors for mortality were assessed with Cox regression models and risk factors for developing Long-COVID symptoms by using relative risk (RR) regression. 184 Patients were included in this study (male: n = 134 (73%), median age 67 (range 25-92). All patients were diagnosed with ARDS according to the Berlin Definition. 89% of patients (n = 164) had severe ARDS (Horovitz-index < 100 mmHg). In 27% (n = 49) extracorporeal membrane oxygenation was necessary to maintain gas exchange. The median length of in-hospital stay was 19 days (range 1-60). ICU mortality was 51%, hospital mortality 59%. Midterm survival (median 11 months) was 83% (n = 55) and 78% (n = 43) of these patients presented Long-COVID symptoms with fatigue as the most common symptom (70%). Extreme obesity (BMI > 40 kg/m2) was the strongest predictor for in-hospital mortality (hazard ratio: 3.147, confidence interval 1.000-9.897) and for developing Long-COVID symptoms (RR 1.61, confidence interval 1.26-2.06). In-hospital mortality in severe cARDS patients was high, but > 80% of patients discharged alive survived the midterm observation period. Nonetheless, most patients developed Long-COVID symptoms. Extreme obesity with BMI > 40 kg/m2 was identified as independent risk factor for in-hospital mortality and for developing Long-COVID symptoms.Trial registration DRKS-ID DRKS00027856.
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Affiliation(s)
- Lars Heubner
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Paul Leon Petrick
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Andreas Güldner
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Lea Bartels
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Maximillian Ragaller
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Axel Rand
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- grid.4488.00000 0001 2111 7257Institute of Clinical Chemistry, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- grid.4488.00000 0001 2111 7257Division of Hematology and Hemostasis, Department of Medicine I Thrombosis Research, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Martin Rößler
- grid.4488.00000 0001 2111 7257Center for Evidence-Based Healthcare (ZEGV), University Hospital “Carl Gustav Carus” and “Carl Gustav Carus” Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Jochen Schmitt
- grid.4488.00000 0001 2111 7257Center for Evidence-Based Healthcare (ZEGV), University Hospital “Carl Gustav Carus” and “Carl Gustav Carus” Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Thea Koch
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
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21
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van de Berg TW, Mulder MMG, Alnima T, Nagy M, van Oerle R, Beckers EAM, Hackeng TM, Hulshof AM, Sels JWEM, Henskens YMC, van der Horst ICC, ten Cate H, Spronk HMH, van Bussel BCT. Serial thrombin generation and exploration of alternative anticoagulants in critically ill COVID-19 patients: Observations from Maastricht Intensive Care COVID Cohort. Front Cardiovasc Med 2022; 9:929284. [PMID: 36277784 PMCID: PMC9582511 DOI: 10.3389/fcvm.2022.929284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background COVID-19 associated coagulopathy (CAC) is associated with an increase in thromboembolic events. Current guidelines recommend prophylactic heparins in the management of CAC. However, the efficacy of this strategy in the intensive care population remains uncertain. Objective We aimed to measure thrombin generation (TG) to assess CAC in intensive care unit (ICU) patients receiving thromboprophylaxis with low molecular weight heparin (LMWH) or unfractionated heparin (UFH). In addition, we performed statistical modeling to link TG parameters to patient characteristics and clinical parameters. Lastly, we studied the potency of different anticoagulants as an alternative to LMWH treatment in ex vivo COVID-19 plasma. Patients/Methods We included 33 patients with confirmed COVID-19 admitted at the ICU. TG was measured at least twice over the course of 6 weeks after admission. Thrombin generation parameters peak height and endogenous thrombin potential (ETP) were compared to healthy controls. Results were subsequently correlated with a patient characteristics and laboratory measurements. In vitro spiking in TG with rivaroxaban, dabigatran, argatroban and orgaran was performed and compared to LMWH. Results Anti-Xa levels of all patients remained within the therapeutic range throughout follow-up. At baseline, the mean (SE) endogenous thrombin potential (ETP) was 1,727 (170) nM min and 1,620 (460) nM min for ellagic acid (EA) and tissue factor (TF), respectively. In line with this we found a mean (SE) peak height of 353 (45) nM and 264 (96) nM for EA and TF. Although fluctuating across the weeks of follow-up, TG parameters remained elevated despite thromboprophylaxis. In vitro comparison of LMWHs and direct thrombin inhibitors (e.g., agratroban, dabigatran) revealed a higher efficacy in reducing coagulation potential for direct thrombin inhibition in both ellagic acid (EA) and tissue factor (TF) triggered TG. Conclusion In a sub-group of mechanically ventilated, critically ill COVID-19 patients, despite apparent adequate anti-coagulation doses evaluated by anti-Xa levels, thrombin generation potential remained high during ICU admission independent of age, sex, body mass index, APACHE II score, cardiovascular disease, and smoking status. These observations could, only partially, be explained by (anti)coagulation and thrombosis, inflammation, and multi-organ failure. Our in vitro data suggested that direct thrombin inhibition compared with LMWH might offer an alternate, more effective anticoagulant strategy in COVID-19.
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Affiliation(s)
- Tom W. van de Berg
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Mark M. G. Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,*Correspondence: Mark M. G. Mulder
| | - Teba Alnima
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Magdolna Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Rene van Oerle
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Erik A. M. Beckers
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Tilman M. Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jan-Willem E. M. Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Yvonne M. C. Henskens
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands,Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Iwan C. C. van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Hugo ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands,Thrombosis Expertise Centre Maastricht, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Henri M. H. Spronk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
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22
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Xiang M, Wu X, Jing H, Liu L, Wang C, Wang Y, Novakovic VA, Shi J. The impact of platelets on pulmonary microcirculation throughout COVID-19 and its persistent activating factors. Front Immunol 2022; 13:955654. [PMID: 36248790 PMCID: PMC9559186 DOI: 10.3389/fimmu.2022.955654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/15/2022] [Indexed: 12/05/2022] Open
Abstract
Patients with COVID-19 often have hypoxemia, impaired lung function, and abnormal imaging manifestations in acute and convalescent stages. Alveolar inflammation, pulmonary vasculitis, and thromboembolism synergistically damage the blood-air barrier, resulting in increased pulmonary permeability and gas exchange disorders. The incidence of low platelet counts correlates with disease severity. Platelets are also involved in the impairment of pulmonary microcirculation leading to abnormal lung function at different phases of COVID-19. Activated platelets lose the ability to protect the integrity of blood vessel walls, increasing the permeability of pulmonary microvasculature. High levels of platelet activation markers are observed in both mild and severe cases, short and long term. Therefore, the risk of thrombotic events may always be present. Vascular endothelial injury, immune cells, inflammatory mediators, and hypoxia participate in the high reactivity and aggregation of platelets in various ways. Microvesicles, phosphatidylserine (PS), platelets, and coagulation factors are closely related. The release of various cell-derived microvesicles can be detected in COVID-19 patients. In addition to providing a phospholipid surface for the synthesis of intrinsic factor Xase complex and prothrombinase complex, exposed PS also promotes the decryption of tissue factor (TF) which then promotes coagulant activity by complexing with factor VIIa to activate factor X. The treatment of COVID-19 hypercoagulability and thrombosis still focuses on early intervention. Antiplatelet therapy plays a role in relieving the disease, inhibiting the formation of the hypercoagulable state, reducing thrombotic events and mortality, and improving sequelae. PS can be another potential target for the inhibition of hypercoagulable states.
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Affiliation(s)
- Mengqi Xiang
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Haijiao Jing
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Langjiao Liu
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Chunxu Wang
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Yufeng Wang
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
- Department of Research, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
- *Correspondence: Jialan Shi, ;
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23
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Heubner L, Greiner M, Vicent O, Beyer-Westendorf J, Tiebel O, Scholz U, Güldner A, Mirus M, Fries D, Koch T, Spieth PM. Predictive ability of viscoelastic testing using ClotPro® for short-term outcome in patients with severe Covid-19 ARDS with or without ECMO therapy: a retrospective study. Thromb J 2022; 20:48. [PMID: 36038895 PMCID: PMC9421107 DOI: 10.1186/s12959-022-00403-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND SARS-CoV-2 infections are suspected to trigger the coagulation system through various pathways leading to a high incidence of thromboembolic complications, hypercoagulation and impaired fibrinolytic capacity were previously identified as potentially mechanisms. A reliable diagnostic tool for detecting both is still under discussion. This retrospective study is aimed to examine the prognostic relevance of early viscoelastic testing compared to conventional laboratory tests in COVID-19 patients with acute respiratory distress syndrome (ARDS). METHODS All mechanically ventilated patients with COVID-19 related ARDS treated in our intensive care unit (ICU) between January and March 2021 were included in this study. Viscoelastic testing (VET) was performed using the ClotPro® system after admission to our ICU. Prevalence of thromboembolic events was observed by standardized screening for venous and pulmonary thromboembolism using complete compression ultrasound and thoracic computed tomography pulmonary angiography at ICU admission, respectively. We examined associations between the severity of ARDS at admission to our ICU, in-hospital mortality and the incidence of thromboembolic events comparing conventional laboratory analysis and VET. ECMO related coagulopathy was investigated in a subgroup analysis. The data were analyzed using the Mann-Whitney U test. RESULTS Of 55 patients enrolled in this study, 22 patients required treatment with ECMO. Thromboembolic complications occurred in 51% of all patients. Overall hospital mortality was 55%. In patients with thromboembolic complications, signs of reduced fibrinolytic capacity could be detected in the TPA assay with prolonged lysis time, median 460 s (IQR 350-560) vs 359 s (IQR 287-521, p = 0.073). Patients with moderate to severe ARDS at admission to our ICU showed increased maximum clot firmness as a sign of hypercoagulation in the EX-test (70 vs 67 mm, p < 0.05), FIB-test (35 vs 24 mm, p < 0.05) and TPA-test (52 vs 36 mm, p < 0.05) as well as higher values of inflammatory markers (CRP, PCT and IL6). ECMO patients suffered more frequently from bleeding complications (32% vs 15%). CONCLUSION Although, the predictive value for thromboembolic complications or mortality seems limited, point-of-care viscoelastic coagulation testing might be useful in detecting hypercoagulable states and impaired fibrinolysis in critically ill COVID-19 ARDS patients and could be helpful in identifying patients with a potentially very severe course of the disease.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Marvin Greiner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I, Thrombosis Research University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Ute Scholz
- MVZ Labor Dr. Reising-Ackermann Und Kollegen, Center of Hemostasis, Leipzig, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany.
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24
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Role of Neuropilin 1 in COVID-19 Patients with Acute Ischemic Stroke. Biomedicines 2022; 10:biomedicines10082032. [PMID: 36009579 PMCID: PMC9405641 DOI: 10.3390/biomedicines10082032] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection can trigger the adaptive and innate immune responses, leading to uncontrolled inflammatory reactions and associated local and systematic tissue damage, along with thromboembolic disorders that may increase the risk of acute ischemic stroke (AIS) in COVID-19 patients. The neuropilin (NRP-1) which is a co-receptor for the vascular endothelial growth factor (VEGF), integrins, and plexins, is involved in the pathogenesis of AIS. NRP-1 is also regarded as a co-receptor for the entry of SARS-CoV-2 and facilitates its entry into the brain through the olfactory epithelium. NRP-1 is regarded as a cofactor for binding of SARS-CoV-2 with angiotensin-converting enzyme 2 (ACE2), since the absence of ACE2 reduces SARS-CoV-2 infectivity even in presence of NRP-1. Therefore, the aim of the present study was to clarify the potential role of NRP-1 in COVID-19 patients with AIS. SARS-CoV-2 may transmit to the brain through NRP-1 in the olfactory epithelium of the nasal cavity, leading to different neurological disorders, and therefore about 45% of COVID-19 patients had neurological manifestations. NRP-1 has the potential capability to attenuate neuroinflammation, blood–brain barrier (BBB) permeability, cerebral endothelial dysfunction (ED), and neuronal dysfunction that are uncommon in COVID-19 with neurological involvement, including AIS. Similarly, high NRP-1 serum level is linked with ED, oxidative stress, and the risk of pulmonary thrombosis in patients with severe COVID-19, suggesting a compensatory mechanism to overcome immuno-inflammatory disorders. In conclusion, NRP-1 has an important role in the pathogenesis of COVID-19 and AIS, and could be the potential biomarker linking the development of AIS in COVID-19. The present findings cannot provide a final conclusion, and thus in silico, experimental, in vitro, in vivo, preclinical, and clinical studies are recommended to confirm the potential role of NRP-1 in COVID-19, and to elucidate the pharmacological role of NRP-1 receptor agonists and antagonists in COVID-19.
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25
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Dujardin RWG, Garcia Rosenbaum G, Klercq TCJ, Thachil J, Nielsen ND, Juffermans NP. Rotational thromboelastometry in critically ill COVID-19 patients does not predict thrombosis. Res Pract Thromb Haemost 2022; 6:e12798. [PMID: 36090158 PMCID: PMC9448874 DOI: 10.1002/rth2.12798] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background Critically ill COVID‐19 patients are in a hypercoagulable state with increased risk of thrombotic complications. Rotational thromboelastometry (ROTEM) is a viscoelastic test with the potential to reflect COVID‐19‐associated hypercoagulability and may therefore be useful to predict thrombotic complications. Objective To investigate the potential of ROTEM profiles to predict thrombotic complications in critically ill COVID‐19 patients. Patients/Methods Retrospective multicenter cohort study in 113 adult patients with confirmed COVID‐19 infection admitted to the intensive care unit (ICU) of two large teaching hospitals in the United States and in the Netherlands. ROTEM profiles of the EXTEM, INTEM, and FIBTEM tracings were measured within 72 h of ICU admission. Thrombotic complications encompass both arterial and venous thromboembolic complications, diagnosed with electrocardiogram, ultrasound, or computed tomography. ROTEM profiles were compared between patients with and without thrombosis. Univariable logistic regression followed by receiver operating characteristic (ROC) curves analysis was performed to identify ROTEM parameters associated with thrombosis. Results and Conclusions Of 113 patients, 27 (23.9%) developed a thrombotic event. In the univariable analysis, EXTEM clot amplitude at 10 min (CA10) and EXTEM maximum clot formation (MCF) were associated with thrombosis with a p < 0.2 (p = 0.07 and p = 0.05, respectively). In ROC curve analysis, EXTEM CA10 had an area under the curve (AUC) of 0.58 (95% CI 0.47–0.70) and EXTEM MCF had an AUC of 0.60 (95% CI 0.49–0.71). Thereby, ROTEM profiles at ICU admission did not have the potential to differentiate between patients with a high and low risk for thrombotic complications.
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Affiliation(s)
- Romein W G Dujardin
- Department of Intensive Care OLVG Hospital Amsterdam The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam UMC Amsterdam The Netherlands
| | - Gabriel Garcia Rosenbaum
- Department of Internal Medicine University of New Mexico School of Medicine Albuquerque New Mexico USA
| | - Timo C J Klercq
- Department of Intensive Care OLVG Hospital Amsterdam The Netherlands
| | - Jecko Thachil
- Department of Haematology Manchester Royal Infirmary Manchester UK
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine University of New Mexico School of Medicine Albuquerque New Mexico USA.,Department of Pathology University of New Mexico School of Medicine Albuquerque New Mexico USA
| | - Nicole P Juffermans
- Department of Intensive Care OLVG Hospital Amsterdam The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam UMC Amsterdam The Netherlands
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26
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Snegovskikh D, Kendall MC, Levinson A, Sarpatwari R, Pisano D, Görlinger K, De Oliveira G. Thromboelastometry Predicts Thromboembolic Events, Hospital Length of Stay, and Mortality in Patients with COVID-19 Infection and Mild Hypoxemia: A Prospective Observational Study. J Blood Med 2022; 13:363-372. [PMID: 35789896 PMCID: PMC9250315 DOI: 10.2147/jbm.s363999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background The aim of this study was to assess changes in hemostasis and associated outcome of hospitalized patients with COVID-19 infection and mild hypoxemia. Methods Adult patients with COVID-19 infection and hypoxemia admitted to ICU were included in this prospective observational study. The primary outcome was defined as an unfavorable course of the disease if a patient: (1) developed a thromboembolic event while receiving anticoagulation prophylaxis, (2) had prolonged ICU stay, or (3) died. Demographic data, laboratory parameters and thromboelastometry (ROTEM) test results were collected. Results Twenty-five patients were recruited into the study. There were 16 patients with an unfavorable course of the disease. Compared to the 9 patients in the favorable course group, patients with an unfavorable course had a lower platelet count, median difference of 154 (95% CI, 26 to 223 x109/L), P = 0.012, and lower clot firmness parameters in EXTEM assay: amplitude at 20 minutes (A20), median difference of 7 (95% CI, 2 to 11) P = 0.006, maximum clot firmness (MCF), median difference of 6 (95% CI, 3 to 10) P = 0.006 and area under the curve (AUC) with a median difference of 671 (95% CI, 244 to 1029) P = 0.005. They also demonstrated suppression of fibrinolysis: higher lysis index 60, median difference of -3 (95% CI, -6 to 0), P = 0.023. Results of functional fibrinogen (FIBTEM) assay were similar between the groups. Conclusion The platelet count and the results of EXTEM assay, but not FIBTEM assay, were associated with the difference in clinical outcome among patients with COVID-19 infection and hypoxemia. The role of platelets in the outcome of COVID-19 infection calls for further investigation. Future studies on adjusting anticoagulant therapy based on the results of viscoelastic testing may be beneficial.
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Affiliation(s)
- Denis Snegovskikh
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mark C Kendall
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew Levinson
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ravi Sarpatwari
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Dominic Pisano
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Medical Department, Tem Innovations, Munich, Germany
| | - Gildasio De Oliveira
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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27
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Corey KM, Olson LB, Naqvi IA, Morrison SA, Davis C, Nimjee SM, Que LG, Bachelder RE, Kraft BD, Chen L, Nair SK, Levy JH, Sullenger BA. Suppression of Fibrinolysis and Hypercoagulability, Severity of Hypoxemia, and Mortality in COVID-19 Patients: A Retrospective Cohort Study. Anesthesiology 2022; 137:67-78. [PMID: 35412597 PMCID: PMC9250792 DOI: 10.1097/aln.0000000000004239] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND COVID-19 causes hypercoagulability, but the association between coagulopathy and hypoxemia in critically ill patients has not been thoroughly explored. This study hypothesized that severity of coagulopathy would be associated with acute respiratory distress syndrome severity, major thrombotic events, and mortality in patients requiring intensive care unit-level care. METHODS Viscoelastic testing by rotational thromboelastometry and coagulation factor biomarker analyses were performed in this prospective observational cohort study of critically ill COVID-19 patients from April 2020 to October 2020. Statistical analyses were performed to identify significant coagulopathic biomarkers such as fibrinolysis-inhibiting plasminogen activator inhibitor 1 and their associations with clinical outcomes such as mortality, extracorporeal membrane oxygenation requirement, occurrence of major thrombotic events, and severity of hypoxemia (arterial partial pressure of oxygen/fraction of inspired oxygen categorized into mild, moderate, and severe per the Berlin criteria). RESULTS In total, 53 of 55 (96%) of the cohort required mechanical ventilation and 9 of 55 (16%) required extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation-naïve patients demonstrated lysis indices at 30 min indicative of fibrinolytic suppression on rotational thromboelastometry. Survivors demonstrated fewer procoagulate acute phase reactants, such as microparticle-bound tissue factor levels (odds ratio, 0.14 [0.02, 0.99]; P = 0.049). Those who did not experience significant bleeding events had smaller changes in ADAMTS13 levels compared to those who did (odds ratio, 0.05 [0, 0.7]; P = 0.026). Elevations in plasminogen activator inhibitor 1 (odds ratio, 1.95 [1.21, 3.14]; P = 0.006), d-dimer (odds ratio, 3.52 [0.99, 12.48]; P = 0.05), and factor VIII (no clot, 1.15 ± 0.28 vs. clot, 1.42 ± 0.31; P = 0.003) were also demonstrated in extracorporeal membrane oxygenation-naïve patients who experienced major thrombotic events. Plasminogen activator inhibitor 1 levels were significantly elevated during periods of severe compared to mild and moderate acute respiratory distress syndrome (severe, 44.2 ± 14.9 ng/ml vs. mild, 31.8 ± 14.7 ng/ml and moderate, 33.1 ± 15.9 ng/ml; P = 0.029 and 0.039, respectively). CONCLUSIONS Increased inflammatory and procoagulant markers such as plasminogen activator inhibitor 1, microparticle-bound tissue factor, and von Willebrand factor levels are associated with severe hypoxemia and major thrombotic events, implicating fibrinolytic suppression in the microcirculatory system and subsequent micro- and macrovascular thrombosis in severe COVID-19. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Kristin M. Corey
- Department of Medicine, Duke University School of Medicine, Durham, NC 27710
| | - Lyra B. Olson
- Duke Medical Scientist Training Program, Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710
| | - Ibtehaj A. Naqvi
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Sarah A Morrison
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Connor Davis
- Duke Institute for Health Innovation, Duke University School of Medicine, Durham, NC 27710
| | - Shahid M. Nimjee
- Department of Neurosurgery, The Ohio State University Medical Center, Columbus, OH 43203
| | - Loretta G. Que
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Robin E. Bachelder
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Bryan D. Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Lingye Chen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Smita K. Nair
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Bruce A. Sullenger
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
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Abstract
During sepsis, an initial prothrombotic shift takes place, in which coagulatory acute-phase proteins are increased, while anticoagulatory factors and platelet count decrease. Further on, the fibrinolytic system becomes impaired, which contributes to disease severity. At a later stage in sepsis, coagulation factors may become depleted, and sepsis patients may shift into a hypo-coagulable state with an increased bleeding risk. During the pro-coagulatory shift, critically ill patients have an increased thrombosis risk that ranges from developing micro-thromboses that impair organ function to life-threatening thromboembolic events. Here, thrombin plays a key role in coagulation as well as in inflammation. For thromboprophylaxis, low molecular weight heparins (LMWH) and unfractionated heparins (UFHs) are recommended. Nevertheless, there are conditions such as heparin resistance or heparin-induced thrombocytopenia (HIT), wherein heparin becomes ineffective or even puts the patient at an increased prothrombotic risk. In these cases, argatroban, a direct thrombin inhibitor (DTI), might be a potential alternative anticoagulatory strategy. Yet, caution is advised with regard to dosing of argatroban especially in sepsis. Therefore, the starting dose of argatroban is recommended to be low and should be titrated to the targeted anticoagulation level and be closely monitored in the further course of treatment. The authors of this review recommend using DTIs such as argatroban as an alternative anticoagulant in critically ill patients suffering from sepsis or COVID-19 with suspected or confirmed HIT, HIT-like conditions, impaired fibrinolysis, in patients on extracorporeal circuits and patients with heparin resistance, when closely monitored.
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29
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Cardiovascular Tropism and Sequelae of SARS-CoV-2 Infection. Viruses 2022; 14:v14061137. [PMID: 35746609 PMCID: PMC9228192 DOI: 10.3390/v14061137] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 01/18/2023] Open
Abstract
The extrapulmonary manifestation of coronavirus disease-19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became apparent early in the ongoing pandemic. It is now recognized that cells of the cardiovascular system are targets of SARS-CoV-2 infection and associated disease pathogenesis. While some details are emerging, much remains to be understood pertaining to the mechanistic basis by which SARS-CoV-2 contributes to acute and chronic manifestations of COVID-19. This knowledge has the potential to improve clinical management for the growing populations of patients impacted by COVID-19. Here, we review the epidemiology and pathophysiology of cardiovascular sequelae of COVID-19 and outline proposed disease mechanisms, including direct SARS-CoV-2 infection of major cardiovascular cell types and pathogenic effects of non-infectious viral particles and elicited inflammatory mediators. Finally, we identify the major outstanding questions in cardiovascular COVID-19 research.
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30
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Matsuoka A, Koami H, Shinada K, Sasaki A, Yamazaki H, Mori K, Nakayama K, Asahi M, Yoshitake K, Narumi S, Koba M, Kawaguchi A, Sakamoto Y. Investigation of predictors of bleeding complications in COVID-19 using rotational thromboelastometry (ROTEM Ⓡ): A retrospective study. Health Sci Rep 2022; 5:e655. [PMID: 35620542 PMCID: PMC9125870 DOI: 10.1002/hsr2.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/18/2022] [Accepted: 05/06/2022] [Indexed: 01/08/2023] Open
Abstract
Background Hemorrhagic complications in patients with coronavirus 19 disease (COVID-19) are infrequent but associated with a prognosis. This study aimed to elucidate the risk factors for bleeding complications in patients with COVID-19 using rotational thromboelastometry (ROTEM) parameters and blood tests performed at admission. Methods In total, 31 patients with severe COVID-19 treated intensively at Saga University Hospital were included in this study. Patients were divided into two groups according to the presence or absence of hemorrhagic complications. Results from the blood tests performed at admission and during hospitalization, and ROTEM values acquired upon admission, were compared between the two groups. Results There were significant differences in ROTEM values upon admission between the bleeding and non-bleeding groups. Receiver operating curve analysis showed that the area under the curve for prothrombin time international normalized ratio (PT-INR) and extrinsically-activated test with tissue factor (EXTEM) amplitude at 10 min (A10) were 0.82 (0.52-0.92) and 0.81 (0.58-0.93), respectively. Logistic regression analysis with PT-INR and EXTEM A10 as factors calculated an odds ratio of 1.94 (1.04-3.62) and EXTEM A10 0.86 (0.71-1.05) for bleeding complications occurrence. Conclusion ROTEM may be a sensitive predictor for bleeding complications in patients with COVID-19.
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Affiliation(s)
- Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Akira Sasaki
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Hirotaka Yamazaki
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kosuke Mori
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kento Nakayama
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Miho Asahi
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kunimasa Yoshitake
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Shogo Narumi
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Mayuko Koba
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Atsushi Kawaguchi
- Education and Research Center for Community Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
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31
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Wickramasinghe W, Alvitigala BY, Perera T, Karunanayake P, Jayasinghe S, Rajapakse S, Weeratunga P, Wijewickrama A, Arya R, Goerlinger K, Gooneratne LV. Rotational thromboelastometry in critical phase of dengue infection: Association with bleeding. Res Pract Thromb Haemost 2022; 6:e12704. [PMID: 35475291 PMCID: PMC9033942 DOI: 10.1002/rth2.12704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/11/2022] [Accepted: 03/24/2022] [Indexed: 01/02/2023] Open
Abstract
Background The critical phase of dengue carries a high risk of bleeding. Associations of coagulation test parameters and the risk of bleeding in the critical phase is unclear. This study examines the association of rotational thromboelastometry (ROTEM delta and ROTEM platelet) with bleeding risk of patients with dengue in the critical phase. Methods A total of 105 patients with confirmed dengue in the critical phase were recruited, with two subsequent prospective time point analyses of ROTEM parameters and platelet count within 24 and 48 hours from the onset of the critical phase. Conventional coagulation tests were performed only at the initial time point. Results Twenty of 105 patients developed bleeding after onset of the critical phase. Within the first 24 hours of critical‐phase onset, platelet count, coagulation tests, and ROTEM delta were unable to differentiate patients with bleeding manifestations from those without (P < .05). Area under the curve of thrombin receptor activating peptide‐6 assay of ROTEM platelet (TRAPTEM) discriminated patients with bleeding manifestations from those without, at a cutoff value of <12.5 Ω*min at a sensitivity and specificity of 73.7%, and 60.2%. In patients who developed bleeding, the maximum lysis of extrinsic pathway of ROTEM was significantly lower in patients with severe bleeding compared to those with mild to moderate bleeding. (4.3 ± 3.4% vs 9.4 ± 7.5%; P = .01). Conclusion An association with bleeding manifestations and TRAPTEM suggest a potential role for defective platelet aggregation in the pathogenesis of bleeding in the critical phase of dengue.
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Affiliation(s)
| | | | - Thisarika Perera
- Department of Pathology Faculty of Medicine University of Colombo Colombo Sri Lanka
| | - Panduka Karunanayake
- Department of Clinical Medicine Faculty of Medicine University of Colombo Colombo Sri Lanka
| | - Saroj Jayasinghe
- Department of Clinical Medicine Faculty of Medicine University of Colombo Colombo Sri Lanka
| | - Senaka Rajapakse
- Department of Clinical Medicine Faculty of Medicine University of Colombo Colombo Sri Lanka
| | - Praveen Weeratunga
- Department of Clinical Medicine Faculty of Medicine University of Colombo Colombo Sri Lanka
| | | | - Roopen Arya
- Department of Haematological Medicine King's College Hospital London UK
| | - Klaus Goerlinger
- Department of Anesthesiology and Intensive Care Medicine University Hospital Essen University Duisburg-Essen Essen Germany.,Medical Department Tem Innovations Munich Germany
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32
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Xiang M, Jing H, Wang C, Novakovic VA, Shi J. Persistent Lung Injury and Prothrombotic State in Long COVID. Front Immunol 2022; 13:862522. [PMID: 35464473 PMCID: PMC9021447 DOI: 10.3389/fimmu.2022.862522] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/17/2022] [Indexed: 12/19/2022] Open
Abstract
Lung injury may persist during the recovery period of COVID-19 as shown through imaging, six-minute walk, and lung function tests. The pathophysiological mechanisms leading to long COVID have not been adequately explained. Our aim is to investigate the basis of pulmonary susceptibility during sequelae and the possibility that prothrombotic states may influence long-term pulmonary symptoms of COVID-19. The patient’s lungs remain vulnerable during the recovery stage due to persistent shedding of the virus, the inflammatory environment, the prothrombotic state, and injury and subsequent repair of the blood-air barrier. The transformation of inflammation to proliferation and fibrosis, hypoxia-involved vascular remodeling, vascular endothelial cell damage, phosphatidylserine-involved hypercoagulability, and continuous changes in serological markers all contribute to post-discharge lung injury. Considering the important role of microthrombus and arteriovenous thrombus in the process of pulmonary functional lesions to organic lesions, we further study the possibility that prothrombotic states, including pulmonary vascular endothelial cell activation and hypercoagulability, may affect long-term pulmonary symptoms in long COVID. Early use of combined anticoagulant and antiplatelet therapy is a promising approach to reduce the incidence of pulmonary sequelae. Essentially, early treatment can block the occurrence of thrombotic events. Because impeded pulmonary circulation causes large pressure imbalances over the alveolar membrane leading to the infiltration of plasma into the alveolar cavity, inhibition of thrombotic events can prevent pulmonary hypertension, formation of lung hyaline membranes, and lung consolidation.
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Affiliation(s)
- Mengqi Xiang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Haijiao Jing
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Chengyue Wang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Valerie A Novakovic
- Department of Research, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China.,Department of Research, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, United States.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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33
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Heubner L, Mirus M, Vicent O, Güldner A, Tiebel O, Beyer-Westendorf J, Fries D, Spieth PM. Point of care coagulation management in anesthesiology and critical care. Minerva Anestesiol 2022; 88:615-628. [PMID: 35416466 DOI: 10.23736/s0375-9393.22.16380-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Point of care (POC) devices are increasingly used in the ICU and in anesthesia. Besides POC-devices for blood gas analysis, several devices are available for coagulation measurements. Although basic principles for thromboelastographic measurements are not novel, some promising developments were made during the last decade improving both user-friendliness and measurement reliability. For instance, POC measurements of activated clotting time (ACT) for heparin monitoring is still regarded as standard-of-care in cardiac interventions and surgery. In the field of anesthesia and intensive care medicine, POC-devices for thromboelastographic and platelet aggregation measurements are widely used. Their impact in case of bleeding and patient blood management for cardiothoracic and trauma surgery is well known. Moreover, there are promising concepts for anticoagulation monitoring including new oral anticoagulant drugs. Coagulation POC-devices may also identify patients at specific risk for thromboembolic events quickly. On the other hand, benefits of POC-devices need to be balanced against limitations, which include technical restrictions and operator related errors, mainly affecting reproducibility and interpretation of results. Therefore, it is recommendable to consider results of POC-coagulation testing in comparison to standard laboratory tests (SLT). Nevertheless, in urgent or emergency situations POC results enable fast decision making to optimize patient care.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany. -
| | - Martin Mirus
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Peter M Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
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34
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Almskog LM, Wikman A, Svensson J, Bottai M, Kotormán M, Wahlgren CM, Wanecek M, van der Linden J, Ågren A. Hypercoagulation Detected by Rotational Thromboelastometry Predicts Mortality in COVID-19: A Risk Model Based on a Prospective Observational Study. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2022; 6:e50-e59. [PMID: 35265789 PMCID: PMC8901374 DOI: 10.1055/a-1725-9221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022]
Abstract
Background Severe disease due to the novel coronavirus disease 2019 (COVID-19) has been shown to be associated with hypercoagulation. The aim of this study was to assess the Rotational Thromboelastometry (ROTEM) as a marker of coagulopathy in hospitalized COVID-19 patients. Methods This was a prospective, observational study where patients hospitalized due to a COVID-19 infection were eligible for inclusion. Conventional coagulation tests and ROTEM were taken after hospital admission, and patients were followed for 30 days. A prediction model, including variables ROTEM EXTEM-MCF (Maximum Clot Firmness) which in previous data has been suggested a suitable marker of hypercoagulation, age, and respiratory frequency, was developed using logistic regression to evaluate the probability of death. Results Out of the 141 patients included, 18 (13%) died within 30 days. In the final prediction model, the risk of death within 30 days for a patient hospitalized due to COVID-19 was increased with increased EXTEM-MCF, age, and respiratory frequency. Longitudinal ROTEM data in the severely ill subpopulation showed enhanced hypercoagulation. In an in vitro analysis, no heparin effect on EXTEM-coagulation time (CT) was observed, supporting a severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) effect on prolonged initiation of coagulation. Conclusion Here, we show that hypercoagulation measured with ROTEM predicts 30-day mortality in COVID-19. Longitudinal ROTEM data strengthen the hypothesis of hypercoagulation as a driver of severe disease in COVID-19. Thus, ROTEM may be a useful tool to assess disease severity in COVID-19 and could potentially guide anticoagulation therapy.
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Affiliation(s)
- Lou M. Almskog
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, Sweden,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Address for correspondence Lou M. Almskog Department of Molecular Medicine and Surgery, Karolinska University HospitalStockholm, 171 67Sweden
| | - Agneta Wikman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden,Department of CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Svensson
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mariann Kotormán
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Wanecek
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, Sweden,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jan van der Linden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Ågren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,Coagulation Unit, Hematology Centre, Karolinska University Hospital, Stockholm, Sweden,Department of Clinical Sciences, Danderyd Hospital and Karolinska Institutet, Stockholm, Sweden
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Ning Q, Wu D, Wang X, Xi D, Chen T, Chen G, Wang H, Lu H, Wang M, Zhu L, Hu J, Liu T, Ma K, Han M, Luo X. The mechanism underlying extrapulmonary complications of the coronavirus disease 2019 and its therapeutic implication. Signal Transduct Target Ther 2022; 7:57. [PMID: 35197452 PMCID: PMC8863906 DOI: 10.1038/s41392-022-00907-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) is a highly transmissible disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that poses a major threat to global public health. Although COVID-19 primarily affects the respiratory system, causing severe pneumonia and acute respiratory distress syndrome in severe cases, it can also result in multiple extrapulmonary complications. The pathogenesis of extrapulmonary damage in patients with COVID-19 is probably multifactorial, involving both the direct effects of SARS-CoV-2 and the indirect mechanisms associated with the host inflammatory response. Recognition of features and pathogenesis of extrapulmonary complications has clinical implications for identifying disease progression and designing therapeutic strategies. This review provides an overview of the extrapulmonary complications of COVID-19 from immunological and pathophysiologic perspectives and focuses on the pathogenesis and potential therapeutic targets for the management of COVID-19.
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Affiliation(s)
- Qin Ning
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Di Wu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Wang
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dong Xi
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Chen
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guang Chen
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongwu Wang
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huiling Lu
- National Medical Center for Major Public Health Events, Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Wang
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Zhu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junjian Hu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Liu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Ma
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meifang Han
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xiaoping Luo
- National Medical Center for Major Public Health Events, Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Zeng J, Liu F, Wang Y, Gao M, Nasr B, Lu C, Zhang Q. The effect of previous oral anticoagulant use on clinical outcomes in COVID-19: A systematic review and meta-analysis. Am J Emerg Med 2022; 54:107-110. [PMID: 35152118 PMCID: PMC8810267 DOI: 10.1016/j.ajem.2022.01.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/16/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023] Open
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Xiao D, Tang F, Chen L, Gao H, Li X. Cumulative Evidence for the Association of Thrombosis and the Prognosis of COVID-19: Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:819318. [PMID: 35146009 PMCID: PMC8821518 DOI: 10.3389/fcvm.2021.819318] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/22/2021] [Indexed: 01/14/2023] Open
Abstract
Background Although thrombosis events have been reported in patients with coronavirus disease 2019 (COVID-19), the association between thrombosis and COVID-19-related critical status or risk of mortality in COVID-19 has been inconsistent. Objective We conducted a meta-analysis of reports assessing the association between thrombosis and the prognosis of COVID-19. Methods The EMBASE, Ovid-MEDLINE, and Web of Science databases were searched up to December 9, 2021, and additional studies were retrieved via manual searching. Studies were included if they reported the risk of COVID-19-related critical status or COVID-19-related mortality in relation to thrombosis. The related data were extracted by two authors independently, and a random effects model was conducted to pool the odds ratios (ORs). In addition, stratified analyses were conducted to evaluate the association. Results Among 6,686 initially identified studies, we included 25 studies published in 2020 and 2021, with a total of 332,915 patients according to predefined inclusion criteria. The associations between thrombosis and COVID-19-related mortality and COVID-19-related critical status were significant, with ORs of 2.61 (95% CI, 1.91–3.55, p < 0.05) and 2.9 (95% CI, 1.6–5.24, p < 0.05), respectively. The results were statistically significant and consistent in stratified analyses. Conclusions Thrombosis is associated with an increased risk of mortality and critical status induced by COVID-19. Further prospective studies with large sample sizes are required to establish whether these associations are causal by considering more confounders and to clarify their mechanisms. Observational studies cannot prove causality. However, autopsy studies show thrombosis events preceding COVID-19-related deaths. The results of this meta-analysis reported that thrombosis was associated with a 161% increased risk of mortality from COVID-19 and a 190% increased risk of COVID-19-related critical status. The type of thrombosis included in the original studies also seemed to be related to the results.
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Affiliation(s)
- Dongqiong Xiao
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Fajuan Tang
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- *Correspondence: Fajuan Tang
| | - Lin Chen
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Hu Gao
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xihong Li
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Xihong Li
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Current and novel biomarkers of thrombotic risk in COVID-19: a Consensus Statement from the International COVID-19 Thrombosis Biomarkers Colloquium. Nat Rev Cardiol 2022; 19:475-495. [PMID: 35027697 PMCID: PMC8757397 DOI: 10.1038/s41569-021-00665-7] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) predisposes patients to thrombotic and thromboembolic events, owing to excessive inflammation, endothelial cell activation and injury, platelet activation and hypercoagulability. Patients with COVID-19 have a prothrombotic or thrombophilic state, with elevations in the levels of several biomarkers of thrombosis, which are associated with disease severity and prognosis. Although some biomarkers of COVID-19-associated coagulopathy, including high levels of fibrinogen and D-dimer, were recognized early during the pandemic, many new biomarkers of thrombotic risk in COVID-19 have emerged. In this Consensus Statement, we delineate the thrombotic signature of COVID-19 and present the latest biomarkers and platforms to assess the risk of thrombosis in these patients, including markers of platelet activation, platelet aggregation, endothelial cell activation or injury, coagulation and fibrinolysis as well as biomarkers of the newly recognized post-vaccine thrombosis with thrombocytopenia syndrome. We then make consensus recommendations for the clinical use of these biomarkers to inform prognosis, assess disease acuity, and predict thrombotic risk and in-hospital mortality. A thorough understanding of these biomarkers might aid risk stratification and prognostication, guide interventions and provide a platform for future research.
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Sibiya N, Mbatha B, Arineitwe C, Onyekwuluje C, Ngubane P, Khathi A. Covid 19 May Limit the Use of Anti-hyperglycemic Agents. Does it Call for the Development of New Anti-hyperglycemic Agents? Curr Diabetes Rev 2022; 18:e060821195364. [PMID: 34365928 DOI: 10.2174/1573399817666210806114200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/10/2021] [Accepted: 06/15/2021] [Indexed: 01/08/2023]
Abstract
Diabetes mellitus has been identified as a major risk factor for developing severe COVID 19 complications. In this review article, the efforts were directed to provide insights and the possible extent to which some diabetic pharmacological interventions may exacerbate COVID 19 or may not be idyllic options for COVID 19 patients. Articles reviewed were identified using the Google scholar database, and search was done using the English language. Anti-hyperglycemic is associated with undesirable effects including episodes of hypoglycemia, diarrhea, lactic acidosis, and increased risks of cardiovascular and hepatic hazards. These undesirable effects associated with the anti-hyperglycemic agents possess a threat of developing severe COVID19 complications Therefore, this calls for more studies to understand the extent of the risks these agents possess in diabetic COVID 19 patients. Almost all the anti-hyperglycemic agents have the potential to worsen COVID 19, despite their class. COVID 19 may limit the options in terms of available anti-hyperglycemic agents which may not heighten the risk of developing severe COVID 19 complications. The research towards the discovery and development of new compounds and also new therapeutic targets for hyperglycemia should be encouraged and welcome.
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Affiliation(s)
- Ntethelelo Sibiya
- Pharmacology Division, Faculty of Pharmacy, Rhodes University, Grahamstown, South Africa
| | - Bonisiwe Mbatha
- School of Laboratory Medicine, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
| | - Charles Arineitwe
- Pharmacology Division, Faculty of Pharmacy, Rhodes University, Grahamstown, South Africa
| | - Chiamaka Onyekwuluje
- Pharmacology Division, Faculty of Pharmacy, Rhodes University, Grahamstown, South Africa
| | - Phikelelani Ngubane
- School of Laboratory Medicine, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
| | - Andile Khathi
- School of Laboratory Medicine, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
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Fibrinolysis Shutdown in Severe COVID-19: Highly Prevalent but not Independently Predictive of Thrombosis or Poorer Outcomes. J Am Coll Surg 2022; 234:97-98. [PMID: 35213468 DOI: 10.1097/xcs.0000000000000007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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42
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Infanger L, Dibiasi C, Schaden E, Ulbing S, Wiegele M, Lacom C, Gratz J. Comparison of the New Viscoelastic Coagulation Analyzer ClotPro® With ROTEM® Delta and Conventional Coagulation Tests in Critically Ill Patients With COVID-19. Front Med (Lausanne) 2021; 8:777145. [PMID: 34869496 PMCID: PMC8635118 DOI: 10.3389/fmed.2021.777145] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Viscoelastic coagulation testing has been suggested to help manage coagulopathy in critically ill patients with COVID-19. However, results from different viscoelastic devices are not readily comparable. ClotPro® is a novel thromboelastometry analyzer offering a wider range of commercially available assays. Methods: We compared the results from ClotPro with results from the well-established ROTEM® Delta device and conventional coagulation tests in critically ill patients with COVID-19. Results: Viscoelastic parameters indicated the presence of a potentially hypercoagulable state in the majority of patients. In up to 95 paired measurements, we found strong correlations between several parameters routinely used in clinical practice: (i) EX test vs. EXTEM CT, A5, A10, MCF, (ii) IN test vs. INTEM A5, A10, MCF, and (iii) FIB test vs. FIBTEM A5, A10, MCF (all R > 0.7 and p < 0.001). In contrast, IN test CT vs. INTEM CT showed only a moderate correlation (R = 0.53 and p < 0.001). Clot strength parameters of both devices exhibited strong correlations with platelet counts and fibrinogen levels (all R > 0.7 and p < 0.001). Divergent correlations of intrinsically activated assays with aPTT and anti-factor Xa activity were visible. Regarding absolute differences of test results, considerable delta occurred in CT, CFT, and clot strength parameters (all p < 0.001) between both devices. Conclusions: Several parameters obtained by ClotPro show strong correlations with ROTEM Delta. Due to weak correlations of intrinsically activated clotting times and considerable absolute differences in a number of parameters, our findings underline the need for device-specific algorithms in this patient cohort.
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Affiliation(s)
- Lukas Infanger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph Dibiasi
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Ulbing
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Marion Wiegele
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Conrad Lacom
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Johannes Gratz
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Gryczyńska W, Litvinov N, Bitew B, Bartosz Z, Kośmider W, Bogdański P, Skrypnik D. Excess Body Mass-A Factor Leading to the Deterioration of COVID-19 and Its Complications-A Narrative Review. Viruses 2021; 13:v13122427. [PMID: 34960696 PMCID: PMC8708912 DOI: 10.3390/v13122427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/30/2021] [Indexed: 01/08/2023] Open
Abstract
Currently, the world is facing two serious pandemics: obesity and COVID-19. It is well-established that the prevalence of obesity has risen dramatically, causing a deterioration in the health quality of the population and increasing susceptibility for the unfavourable course of acute infections. It has been observed that excess body mass significantly influences the COVID-19 outcome. The aim of this review is to present the latest scientific reports on the impact of excess body mass on the course and complications of COVID-19. The Web of Science, PubMed, and Google Scholar databases were searched. Only studies reporting patients stated to be COVID-19 positive based on the results of a nasopharyngeal swab and the ribonucleic acid test were included. It is shown that thromboembolic and ischemic complications, namely stroke, disseminated intravascular coagulation, severe hyperglycaemia, and leukoencephalopathy are more likely to appear in COVID-19 positive patients with obesity compared to non-obese subjects. COVID-19 complications such as cardiomyopathy, dysrhythmias, endothelial dysfunction, acute kidney injury, dyslipidaemia, lung lesions and acute respiratory distress syndrome have a worse outcome among obese patients.
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Affiliation(s)
- Weronika Gryczyńska
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.G.); (N.L.); (B.B.); (Z.B.); (W.K.)
| | - Nikita Litvinov
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.G.); (N.L.); (B.B.); (Z.B.); (W.K.)
| | - Bezawit Bitew
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.G.); (N.L.); (B.B.); (Z.B.); (W.K.)
- Ethiopian Medical Students’ Association, Zambia Street, Addis Ababa P.O. Box 9302, Ethiopia
| | - Zuzanna Bartosz
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.G.); (N.L.); (B.B.); (Z.B.); (W.K.)
| | - Weronika Kośmider
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.G.); (N.L.); (B.B.); (Z.B.); (W.K.)
| | - Paweł Bogdański
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland;
| | - Damian Skrypnik
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland;
- Correspondence:
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Thapa K, Verma N, Singh TG, Kaur Grewal A, Kanojia N, Rani L. COVID-19-Associated acute respiratory distress syndrome (CARDS): Mechanistic insights on therapeutic intervention and emerging trends. Int Immunopharmacol 2021; 101:108328. [PMID: 34768236 PMCID: PMC8563344 DOI: 10.1016/j.intimp.2021.108328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 02/07/2023]
Abstract
AIMS The novel Coronavirus disease 2019 (COVID-19) has caused great distress worldwide. Acute respiratory distress syndrome (ARDS) is well familiar but when it happens as part of COVID-19 it has discrete features which are unmanageable. Numerous pharmacological treatments have been evaluated in clinical trials to control the clinical effects of CARDS, but there is no assurance of their effectiveness. MATERIALS AND METHODS A systematic review of the literature of the Medline, Scopus, Bentham, PubMed, and EMBASE (Elsevier) databases was examined to understand the novel therapeutic approaches used in COVID-19-Associated Acute Respiratory Distress Syndrome and their outcomes. KEY FINDINGS Current therapeutic options may not be enough to manage COVID-19-associated ARDS complications in group of patients and therefore, the current review has discussed the pathophysiological mechanism of COVID-19-associated ARDS, potential pharmacological treatment and the emerging molecular drug targets. SIGNIFICANCE The rationale of this review is to talk about the pathophysiology of CARDS, potential pharmacological treatment and the emerging molecular drug targets. Currently accessible treatment focuses on modulating immune responses, rendering antiviral effects, anti-thrombosis or anti-coagulant effects. It is expected that considerable number of studies conducting globally may help to discover effective therapies to decrease mortality and morbidity occurring due to CARDS. Attention should be also given on molecular drug targets that possibly will help to develop efficient cure for COVID-19-associated ARDS.
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Affiliation(s)
- Komal Thapa
- Chitkara School of Pharmacy, Chitkara University, Himachal Pradesh, India; Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India
| | - Nitin Verma
- Chitkara School of Pharmacy, Chitkara University, Himachal Pradesh, India
| | | | | | - Neha Kanojia
- Chitkara School of Pharmacy, Chitkara University, Himachal Pradesh, India
| | - Lata Rani
- Chitkara School of Pharmacy, Chitkara University, Himachal Pradesh, India
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Plasma Fibrinogen Independently Predicts Hypofibrinolysis in Severe COVID-19. Metabolites 2021; 11:metabo11120826. [PMID: 34940584 PMCID: PMC8708410 DOI: 10.3390/metabo11120826] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/18/2021] [Accepted: 11/25/2021] [Indexed: 01/08/2023] Open
Abstract
High rates of thrombosis are present in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Deeper insight into the prothrombotic state is essential to provide the best thromboprophylaxis care. Here, we aimed to explore associations among platelet indices, conventional hemostasis parameters, and viscoelastometry data. This pilot study included patients with severe COVID-19 (n = 21) and age-matched controls (n = 21). Each patient received 100 mg aspirin therapy at the time of blood sampling. Total platelet count, high immature platelet fraction (H-IPF), fibrinogen, D-dimer, Activated Partial Thromboplastin Time, von Willebrand factor antigen and von Willebrand factor ristocetin cofactor activity, plasminogen, and alpha2-antiplasmin were measured. To monitor the aspirin therapy, a platelet function test from hirudin anticoagulated whole blood was performed using the ASPI test by Multiplate analyser. High on-aspirin platelet reactivity (n = 8) was defined with an AUC > 40 cut-off value by ASPI tests. In addition, in vitro viscoelastometric tests were carried out using a ClotPro analyser in COVID-associated thromboembolic events (n = 8) (p = 0.071) nor the survival rate (p = 0.854) showed associations with high on-aspirin platelet reactivity status. The platelet count (p = 0.03), all subjects. COVID-19 patients presented with higher levels of inflammatory markers, compared with the controls, along with evidence of hypercoagulability by ClotPro. H-IPF (%) was significantly higher among non-survivors (n = 18) compared to survivors (p = 0.011), and a negative correlation (p = 0.002) was found between H-IPF and plasminogen level in the total population. The platelet count was significantly higher among patients with high on-aspirin platelet reactivity (p = 0.03). Neither the ECA-A10 (p = 0.008), and ECA-MCF (p = 0.016) were significantly higher, while the tPA-CFT (p < 0.001) was significantly lower among patients with high on-aspirin platelet reactivity. However, only fibrinogen proved to be an independent predictor of hypofibrinolysis in severe COVID-19 patients. In conclusion, a faster developing, more solid clot formation was observed in aspirin ‘non-responder’ COVID-19 patients. Therefore, an individually tailored thromboprophylaxis is needed to prevent thrombotic complications, particularly in the hypofibrinolytic cluster.
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Rajsic S, Breitkopf R, Bachler M, Treml B. Diagnostic Modalities in Critical Care: Point-of-Care Approach. Diagnostics (Basel) 2021; 11:diagnostics11122202. [PMID: 34943438 PMCID: PMC8700511 DOI: 10.3390/diagnostics11122202] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 02/07/2023] Open
Abstract
The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.
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Affiliation(s)
- Sasa Rajsic
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
| | - Robert Breitkopf
- Transplant Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria;
| | - Mirjam Bachler
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
| | - Benedikt Treml
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
- Correspondence:
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Relationship of the pulmonary disease severity scoring with thromboembolic complications in COVID-19. Emerg Radiol 2021; 29:9-21. [PMID: 34802067 PMCID: PMC8605895 DOI: 10.1007/s10140-021-01998-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022]
Abstract
Purpose To correlate thromboembolic (TE) complications secondary to COVID-19 with the extent of the pulmonary parenchymal disease using CT severity scores and other comorbidities. Methods In total, 185 patients with COVID-19 and suspected thromboembolic complications were classified into two groups based on the presence or absence of thromboembolic complications. Thromboembolic complications were categorized based on location. Chest CT severity scoring system was used to assess the pulmonary parenchymal disease severity in all patients. Based into severity scores, patients were categorized into three groups (mild, moderate, and sever disease). Results The final study cohort consisted of 171 patients (99 male and 72 female) after excluding 14 patients with non-diagnostic CT pulmonary angiography. The TE group included 53 patients with a mean age of 55.1 ± 7.1, while the non-TE group included 118 patients with a mean age of 52.9 ± 10.8. Patients with BMI > 30 kg/m2 or having a history of smoking and HTN were found more frequently in the TE group (p < 0.05). Patients admitted to ICU were significantly higher in the TE group (p < 0.001). There was statistically significant difference (p = 0.002) in chest CT-SS between the TE group (22.8 ± 11.4) and non-TE group (17.6 ± 10.7). The percentage of severe parenchymal disease in the TE group was significantly higher compared to the non-TE group (p < 0.05). Severe parenchymal disease, BMI > 30 kg/m2, smoking, and HTN had a higher and more significant odds ratio for developing TE complications. Conclusion The present data suggest that severe pulmonary parenchymal disease secondary to COVID-19 is associated with a higher incidence of thromboembolic complications.
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Efficacy and complications of regional citrate anticoagulation during continuous renal replacement therapy in critically ill patients with COVID-19. J Crit Care 2021; 67:126-131. [PMID: 34768173 PMCID: PMC8576341 DOI: 10.1016/j.jcrc.2021.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/23/2021] [Accepted: 10/16/2021] [Indexed: 12/23/2022]
Abstract
Background We compared filter survival and citrate-induced complications during continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in COVID-19 and Non-COVID-19 patients. Methods In this retrospective study we included all consecutive adult patients (n = 97) treated with RCA-CRRT. Efficacy and complications of RCA-CRRT were compared between COVID-19 and Non-COVID-19 patients. Results Mean filter run-time was significantly higher in COVID-19 patients compared to Non-COVID-19 patients (68.4 (95%CI 67.0–69.9) vs. 65.2 (95%CI 63.2–67.2) hours, respectively; log-rank 0.014). COVID-19 patients showed significantly higher activated partial thromboplastin time (aPTT) throughout the CRRT due to intensified systemic anticoagulation compared to Non-COVID-19 patients (54 (IQR 45–61) vs. 47 (IQR 41–58) seconds, respectively; p < 0.001). A significantly higher incidence of metabolic alkalosis, hypercalcemia and hypernatremia, consistent with reduced filter patency and citrate overload, was observed in COVID-19 patients compared to Non-COVID-19 patients (19.1% vs. 12.7%, respectively; p = 0.04). These metabolic disarrangements were resistant to per-protocol adjustments and disappeared after replacement of the CRRT-filter. Conclusions RCA-CRRT in COVID-19 patients with intensified systemic anticoagulation provides an adequate filter lifespan. However, close monitoring of the acid-base balance appears warranted, as these patients tend to develop reduced filter patency leading to a higher incidence of citrate overload and metabolic disturbances. Trial registration (local authority) EA1/285/20 (Ethikkommission der Charité - Universitätsmedizin Berlin); date of registration 08.10.2020.
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Neethling C, Calligaro G, Miller M, Opie JJS. The evolution of clot strength in critically-ill COVID-19 patients: a prospective observational thromboelastography study. Thromb J 2021; 19:83. [PMID: 34742307 PMCID: PMC8572064 DOI: 10.1186/s12959-021-00331-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few studies detail the evolution of COVID-19 associated coagulopathy. We performed serial thromboelastography (TEG) and laboratory coagulation studies in 40 critically-ill, mechanically ventilated COVID-19 patients over a 14-day period and analysed differences between 30-day survivors and non-survivors. METHODS Single-center prospective, observational study including 40 patients with severe COVID-19 pneumonia admitted to the intensive care unit (ICU) for mechanical ventilation. TEG analysis was performed on days 1, 7 and 14 of ICU admission and laboratory coagulation studies were performed on days 1 and 14. Coagulation variables were evaluated for change over the 14-day observation period. Differences between survivors and non-survivors at 30-days were analysed and compared. RESULTS On admission, TEG maximum amplitude (MA) with heparinase correction was above the upper limit of the reference range in 32 (80%) patients while 33 (82.5%) presented with absent clot lysis at 30 min. The functional fibrinogen MA was also elevated above the upper limit of the reference range in 37 (92.5%) patients. All patients had elevated D-dimer and fibrinogen levels, mildly prolonged prothrombin times (PT), normal platelet counts and normal activated partial thromboplastin times (aPTT). The heparinase MA decreased significantly with time and normalised after 14 days (p = < 0.001) while the increased fibrin contribution to clot strength persisted with time (p = 0.113). No significant differences in TEG analysis were noted between 30-day survivors and non-survivors at all time points. No patients developed disseminated intravascular coagulopathy (DIC) after 14-days, however thrombosis and bleeding were each reported in 3 (7.5%) patients. CONCLUSION Critically-ill patients with COVID-19 present in a hypercoagulable state characterised by an increased clot strength. This state normalises after 14 days despite a persistently increased fibrin contribution to clot strength. We were unable to demonstrate any significant differences in TEG parameters between 30-day survivors and non-survivors at all time points.
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Affiliation(s)
- Colette Neethling
- Department of Anaesthesia & Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Drive, Observatory, Cape Town, 7925, South Africa.
| | - Gregory Calligaro
- Division of Pulmonology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Malcolm Miller
- Department of Anaesthesia & Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Drive, Observatory, Cape Town, 7925, South Africa
| | - Jessica J S Opie
- Division of Haematology, Department of Pathology, University of Cape Town & National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
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Caesario J, Hertanto DM, Hernugrahanto KD, Utomo DN, Budhiparama NC, Santoso D, Hogendoorn PC. Case Report: Asymptomatic COVID-19 patient with a subtle hypercoagulable state and fluctuating D-dimer level. F1000Res 2021; 10:1112. [PMID: 35251595 PMCID: PMC8861469 DOI: 10.12688/f1000research.74009.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 11/20/2022] Open
Abstract
Background: COVID-19 can infect an asymptomatic person silently without any overt symptoms despite diffuse blood clots throughout the body. Clot formation is induced by COVID-19 associated coagulopathy that can cause a high mortality rate. D-dimer, a fairly decisive marker for the coagulopathy event, is physiologically a marker of the fibrinolysis process. The increase of D-dimers in COVID-19 cases must be followed up because it relates to the initiation of a cytokine storm. Case presentation: We report an asymptomatic patient with sudden D-dimer elevation who received anticoagulant therapy. After three days of heparin administration, D-dimer results became normal and anticoagulant therapy was stopped. However, on the 12th day, the D-dimer level rebounded back and was followed by an increase of hs-C-reactive protein, erythrocyte sedimentation rate, IL-6, although SARS-CoV-2 PCR result became negative. A hyperglycaemic reaction and a sudden increase of HbA1C was observed in the patient. After three weeks D-dimer had returned to normal levels, and so did the other markers. The patient recovered fully and still no symptoms were obvious. Conclusion: COVID-19 patients without symptoms may be at risk of an asymptomatic coagulopathy process. The decreasing level of D-dimer erroneously cannot ensure that the coagulopathy process stops.
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Affiliation(s)
| | - Decsa M. Hertanto
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, 60286, Indonesia
| | - Kukuh D. Hernugrahanto
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Airlangga University, Surabaya, 60286, Indonesia
| | - Dwikora N. Utomo
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Airlangga University, Surabaya, 60286, Indonesia
| | - Nicolaas C. Budhiparama
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Medistra Hospital, Jakaarta, 12950, Indonesia
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, 2333, The Netherlands
- Faculty of Vocational Studies, Airlangga University, Surabaya, 60286, Indonesia
| | - Djoko Santoso
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, 60286, Indonesia
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