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Camporota L, Sanderson B, Worrall S, Ostermann M, Barrett NA, Retter A, Busana M, Collins P, Romitti F, Hunt BJ, Rose L, Gattinoni L, Chiumello D. Relationship between D-dimers and dead-space on disease severity and mortality in COVID-19 acute respiratory distress syndrome: A retrospective observational cohort study. J Crit Care 2023; 77:154313. [PMID: 37116437 PMCID: PMC10129848 DOI: 10.1016/j.jcrc.2023.154313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/13/2023] [Accepted: 04/11/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Despite its diagnostic and prognostic importance, physiologic dead space fraction is not included in the current ARDS definition or severity classification. ARDS caused by COVID-19 (C-ARDS) is characterized by increased physiologic dead space fraction and hypoxemia. Our aim was to investigate the relationship between dead space indices, markers of inflammation, immunothrombosis, severity and intensive care unit (ICU) mortality. RESULTS Retrospective data including demographics, gas exchange, ventilatory parameters, and respiratory mechanics in the first 24 h of invasive ventilation. Plasma concentrations of D-dimers and ferritin were not significantly different across C-ARDS severity categories. Weak relationships were found between D-dimers and VR (r = 0.07, p = 0.13), PETCO2/PaCO2 (r = -0.1, p = 0.02), or estimated dead space fraction (r = 0.019, p = 0.68). Age, PaO2/FiO2, pH, PETCO2/PaCO2 and ferritin, were independently associated with ICU mortality. We found no association between D-dimers or ferritin and any dead-space indices adjusting for PaO2/FiO2, days of ventilation, tidal volume, and respiratory system compliance. CONCLUSIONS We report no association between dead space and inflammatory markers in mechanically ventilated patients with C-ARDS. Our results support theories suggesting that multiple mechanisms, in addition to immunothrombosis, play a role in the pathophysiology of respiratory failure and degree of dead space in C-ARDS.
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Affiliation(s)
- Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK; Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Barnaby Sanderson
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Stephanie Worrall
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Marlies Ostermann
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Nicholas A Barrett
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Andrew Retter
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Patrick Collins
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Louise Rose
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Davide Chiumello
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Italy.
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Abstract
PURPOSE OF REVIEW More than 230 million people have tested positive for severe acute respiratory syndrome-coronavirus-2 infection globally by September 2021. The infection affects primarily the function of the respiratory system, where ∼20% of infected individuals develop coronavirus-19 disease (COVID-19) pneumonia. This review provides an update on the pathophysiology of the COVID-19 acute lung injury. RECENT FINDINGS In patients with COVID-19 pneumonia admitted to the intensive care unit, the PaO2/FiO2 ratio is typically <26.7 kPa (200 mmHg), whereas lung volume appears relatively unchanged. This hypoxaemia is likely determined by a heterogeneous mismatch of pulmonary ventilation and perfusion, mainly associated with immunothrombosis, endothelialitis and neovascularisation. During the disease, lung weight, elastance and dead space can increase, affecting respiratory drive, effort and dyspnoea. In some severe cases, COVID-19 pneumonia may lead to irreversible pulmonary fibrosis. SUMMARY This review summarises the fundamental pathophysiological features of COVID-19 in the context of the respiratory system. It provides an overview of the key clinical manifestations of COVID-19 pneumonia, including gas exchange impairment, altered pulmonary mechanics and implications of abnormal chemical and mechanical stimuli. It also critically discusses the clinical implications for mechanical ventilation therapy.
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Affiliation(s)
- Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust
| | - John N Cronin
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Department of Anaesthetics, Royal Brompton and Harefield, part of Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
- Department of Biomechanics, University of Nebraska Omaha, Omaha, Nebraska, USA
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3
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Santamarina MG, Beddings I, Lomakin FM, Boisier Riscal D, Gutiérrez Claveria M, Vidal Marambio J, Retamal Báez N, Pavez Novoa C, Reyes Allende C, Ferreira Perey P, Gutiérrez Torres M, Villalobos Mazza C, Vergara Sagredo C, Ahumada Bermejo S, Labarca Mellado E, Barthel Munchmeyer E, Marchant Ramos S, Volpacchio M, Vega J. Sildenafil for treating patients with COVID-19 and perfusion mismatch: a pilot randomized trial. Crit Care 2022; 26:1. [PMID: 34980198 PMCID: PMC8721481 DOI: 10.1186/s13054-021-03885-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/27/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND SARS-CoV-2 seems to affect the regulation of pulmonary perfusion. Hypoperfusion in areas of well-aerated lung parenchyma results in a ventilation-perfusion mismatch that can be characterized using subtraction computed tomography angiography (sCTA). This study aims to evaluate the efficacy of oral sildenafil in treating COVID-19 inpatients showing perfusion abnormalities in sCTA. METHODS Triple-blinded, randomized, placebo-controlled trial was conducted in Chile in a tertiary-care hospital able to provide on-site sCTA scans and ventilatory support when needed between August 2020 and March 2021. In total, 82 eligible adults were admitted to the ED with RT-PCR-confirmed or highly probable SARS-COV-2 infection and sCTA performed within 24 h of admission showing perfusion abnormalities in areas of well-aerated lung parenchyma; 42 were excluded and 40 participants were enrolled and randomized (1:1 ratio) once hospitalized. The active intervention group received sildenafil (25 mg orally three times a day for seven days), and the control group received identical placebo capsules in the same way. Primary outcomes were differences in oxygenation parameters measured daily during follow-up (PaO2/FiO2 ratio and A-a gradient). Secondary outcomes included admission to the ICU, requirement of non-invasive ventilation, invasive mechanical ventilation (IMV), and mortality rates. Analysis was performed on an intention-to-treat basis. RESULTS Totally, 40 participants were enrolled (20 in the placebo group and 20 in the sildenafil group); 33 [82.5%] were male; and median age was 57 [IQR 41-68] years. No significant differences in mean PaO2/FiO2 ratios and A-a gradients were found between groups (repeated-measures ANOVA p = 0.67 and p = 0.69). IMV was required in 4 patients who received placebo and none in the sildenafil arm (logrank p = 0.04). Patients in the sildenafil arm showed a significantly shorter median length of hospital stay than the placebo group (9 IQR 7-12 days vs. 12 IQR 9-21 days, p = 0.04). CONCLUSIONS No statistically significant differences were found in the oxygenation parameters. Sildenafil treatment could have a potential therapeutic role regarding the need for IMV in COVID-19 patients with specific perfusion patterns in sCTA. A large-scale study is needed to confirm these results. TRIAL REGISTRATION Sildenafil for treating patients with COVID-19 and perfusion mismatch: a pilot randomized trial, NCT04489446, Registered 28 July 2020, https://clinicaltrials.gov/ct2/show/NCT04489446 .
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Affiliation(s)
- Mario G Santamarina
- Radiology Department, Hospital Naval Almirante Nef, Subida Alesandri S/N., 254000, Viña del Mar, Provincia de Valparaíso, Chile. .,Radiology Department, Hospital Dr. Eduardo Pereira, Valparaiso, Chile.
| | - Ignacio Beddings
- Radiology Department, Hospital Clínico San Borja Arriarán, Santiago, Chile
| | - Felipe Martinez Lomakin
- Intensive Care Unit, Hospital Naval Almirante Nef, Viña del Mar, Chile.,Escuela de Medicina, Facultad de Medicina, Universidad Andres Bello, Viña del Mar, Chile
| | | | | | | | | | | | - César Reyes Allende
- Intensive Care Unit, Hospital Naval Almirante Nef, Viña del Mar, Chile.,Respiratory Department, Hospital Naval Almirante Nef, Viña del Mar, Chile
| | | | | | | | | | | | | | | | | | - Mariano Volpacchio
- Radiology Department, Centro de Diagnóstico Dr. Enrique Rossi, Buenos Aires, Argentina
| | - Jorge Vega
- General Internal Medicine Department, Hospital Naval Almirante Nef, Viña del Mar, Chile.,Departamento de Medicina, Escuela de Medicina, Universidad de Valparaíso, Viña del Mar, Chile
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4
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Jenner WJ, Gorog DA. Incidence of thrombotic complications in COVID-19 : On behalf of ICODE: The International COVID-19 Thrombosis Biomarkers Colloquium. J Thromb Thrombolysis 2021; 52:999-1006. [PMID: 34047938 PMCID: PMC8161345 DOI: 10.1007/s11239-021-02475-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
A high incidence of thrombosis in hospitalised patients with COVID-19 was identified early during the pandemic. Accurately quantifying thrombotic risk may assist prognosis and guide appropriate thromboprophylaxis. Observational studies have estimated the rate of thrombosis in both hospitalised and non-hospitalised patients with COVID-19, and how this corresponds to the severity of illness. In this review, we provide an overview of the incidence and prevalence of arterial and venous thrombotic events in patients with COVID-19 and highlight the limitations in the studies to date. Asymptomatic individuals with COVID-19 and those with mild symptoms are at very low risk of thrombotic complications. However, rates of thrombosis are substantially increased in hospitalised patients, and are strikingly high in those patients who are critically-ill requiring treatment on the intensive care unit and especially those requiring extracorporeal membrane oxygenation. Clinicians managing such patients need to be aware of these risks and take appropriate steps with respect to thromboprophylaxis and heightened clinical vigilance. Large prospective observational studies will more accurately quantify thrombotic rate, and randomized controlled trials are currently investigating optimal thromboprophylactic strategies.
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Affiliation(s)
- William J Jenner
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Diana A Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK.
- Faculty of Medicine, Imperial College, National Heart and Lung Institute, London, UK.
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK.
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5
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Goswami J, MacArthur TA, Sridharan M, Pruthi RK, McBane RD, Witzig TE, Park MS. A Review of Pathophysiology, Clinical Features, and Management Options of COVID-19 Associated Coagulopathy. Shock 2021; 55:700-716. [PMID: 33378321 PMCID: PMC8122038 DOI: 10.1097/shk.0000000000001680] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT There is increasing evidence that novel coronavirus disease 2019 (COVID-19) leads to a significant coagulopathy, a phenomenon termed "COVID-19 associated coagulopathy." COVID-19 has been associated with increased rates of both venous and arterial thromboembolic events, a source of significant morbidity and mortality in this disease. Further evidence suggests a link between the inflammatory response and coagulopathy associated with COVID-19. This presents a unique set of challenges for diagnosis, prevention, and treatment of thrombotic complications. In this review, we summarize and discuss the current literature on laboratory coagulation disruptions associated with COVID-19 and the clinical effects of thromboembolic events including pulmonary embolism, deep vein thrombosis, peripheral arterial thrombosis, and acute ischemic stroke in COVID-19. Endothelial injury and augmented innate immune response are implicated in the development of diffuse macro- and microvascular thrombosis in COVID-19. The pathophysiology of COVID-19 associated coagulopathy is an important determinant of appropriate treatment and monitoring of these complications. We highlight the importance of diagnosis and management of dysregulated coagulation in COVID-19 to improve outcomes in COVID-19 patients with thromboembolic complications.
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Affiliation(s)
- Julie Goswami
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Taleen A. MacArthur
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Meera Sridharan
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Rajiv K. Pruthi
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Robert D. McBane
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
- Division of Vascular Cardiology, Department of Cardiovascular Disease, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Thomas E. Witzig
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Myung S. Park
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
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6
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Abstract
Pulmonary thromboembolism and deep venous thrombosis occur frequently in hospitalised patients with COVID-19, the prevalence increases on the intensive care unit (ICU) and is very high in patients on extracorporeal membrane oxygenation (ECMO). We undertook a literature review to assess the usefulness of screening for peripheral venous thrombosis or pulmonary thrombosis in patients admitted with COVID-19. Outside of the ICU setting, D-dimer elevation on presentation or marked increase from baseline should alert the need for doppler ultrasound scan of the lower limbs. In the ICU setting, consideration should be given to routine screening with doppler ultrasound, given the high prevalence of thrombosis in this cohort despite standard anticoagulant thromboprophylaxis. However, absence of lower limb thrombosis on ultrasound does not exclude pulmonary venous thrombosis. Screening with CT pulmonary angiography (CTPA) is not justified in patients on the general wards, unless there are clinical features and/or marked elevations in markers of COVID-19-associated coagulopathy. However, the risk of pulmonary embolism or pulmonary thrombosis in ICU patients is very high, especially in patients on ECMO, where studies that employed routine screening for thrombosis with CT scanning have uncovered up to 100% incidence of pulmonary thrombosis despite standard anticoagulant thromboprophylaxis. Therefore, in patients at low bleeding risk and high clinical suspicion of venous thromboembolism, therapeutic anticoagulation should be considered even before screening, Our review highlights the need for increased vigilance for VTE, with a low threshold for doppler ultrasound and CTPA in high risk in-patient cohorts, where clinical features and D-dimer levels may not accurately reflect the occurrence of pulmonary thromboembolism.
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Affiliation(s)
- Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK. .,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.
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7
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Huang S, Zhao S, Luo H, Wu Z, Wu J, Xia H, Chen X. The role of extracorporeal membrane oxygenation in critically ill patients with COVID-19: a narrative review. BMC Pulm Med 2021; 21:116. [PMID: 33832474 PMCID: PMC8027981 DOI: 10.1186/s12890-021-01479-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal life support treatments such as extracorporeal membrane oxygenation (ECMO) have been recommended for the treatment of severe acute respiratory distress syndrome (ARDS) patients with coronavirus disease 2019 (COVID-19). To date, many countries, including China, have adopted ECMO as a treatment for severe COVID-19. However, marked differences in patient survival rates have been reported, and the underlying reasons are unclear. This study aimed to summarize the experience of using ECMO to treat severe COVID-19 and provide suggestions for improving ECMO management. The effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the pathophysiology of COVID-19 and the effects of ECMO on the clinical outcomes in patients with severe cases of COVID-19 were reviewed. Recent data from frontline workers involved in the use of ECMO in Wuhan, China, and those experienced in the implementation of artificial heart and lung support strategies were analysed. There is evidence that ECMO may complicate the pathophysiological state in COVID-19 patients. However, many studies have shown that the appropriate application of ECMO improves the prognosis of such patients. To expand our understanding of the benefits of ECMO for critically ill patients with COVID-19, further prospective, multicentre clinical trials are needed.
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Affiliation(s)
- Shiqian Huang
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277, Jiefang Avenue, Wuhan, 430022, China
| | - Shuai Zhao
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277, Jiefang Avenue, Wuhan, 430022, China
| | - Huilin Luo
- Department of Anaesthesiology, Wuhan Red Cross Hospital, Wuhan, 430015, China
| | - Zhouyang Wu
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277, Jiefang Avenue, Wuhan, 430022, China
| | - Jing Wu
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277, Jiefang Avenue, Wuhan, 430022, China
| | - Haifa Xia
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277, Jiefang Avenue, Wuhan, 430022, China.
| | - Xiangdong Chen
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277, Jiefang Avenue, Wuhan, 430022, China.
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8
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Jenner WJ, Kanji R, Mirsadraee S, Gue YX, Price S, Prasad S, Gorog DA. Thrombotic complications in 2928 patients with COVID-19 treated in intensive care: a systematic review. J Thromb Thrombolysis 2021; 51:595-607. [PMID: 33586113 PMCID: PMC7882250 DOI: 10.1007/s11239-021-02394-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
A prothrombotic state is reported with severe COVID-19 infection, which can manifest in venous and arterial thrombotic events. Coagulopathy is reflective of more severe disease and anticoagulant thromboprophylaxis is recommended in hospitalized patients. However, the prevalence of thrombosis on the intensive care unit (ICU) remains unclear, including whether this is sufficiently addressed by conventional anticoagulant thromboprophylaxis. We aimed to identify the rate of thrombotic complications in ICU-treated patients with COVID-19, to inform recommendations for diagnosis and management. A systematic review was conducted to assess the incidence of thrombotic complications in ICU-treated patients with COVID-19. Observational studies and registries reporting thrombotic complications in ICU-treated patients were included. Information extracted included patient demographics, use of thromboprophylaxis or anticoagulation, method of identifying thrombotic complications, and reported patient outcomes. In 28 studies including 2928 patients, thrombotic complications occurred in 34% of ICU-managed patients, with deep venous thrombosis reported in 16.1% and pulmonary embolism in 12.6% of patients, despite anticoagulant thromboprophylaxis, and were associated with high mortality. Studies adopting systematic screening for venous thrombosis with Duplex ultrasound reported a significantly higher incidence of venous thrombosis compared to those relying on clinical suspicion (56.3% vs. 11.0%, p < 0.001). Despite thromboprophylaxis, there is a very high incidence of thrombotic complications in patients with COVID-19 on the ICU. Systematic screening identifies many thrombotic complications that would be missed by relying on clinical suspicion and should be employed, with consideration given to increased dose anticoagulant thromboprophylaxis, whilst awaiting results of prospective trials of anticoagulation in this cohort.
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Affiliation(s)
- William J Jenner
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Saeed Mirsadraee
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ying X Gue
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Susanna Price
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Sanjay Prasad
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK.
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK.
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Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
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Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
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10
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Habashi NM, Camporota L, Gatto LA, Nieman G. Functional pathophysiology of SARS-CoV-2-induced acute lung injury and clinical implications. J Appl Physiol (1985) 2021; 130:877-891. [PMID: 33444117 PMCID: PMC7984238 DOI: 10.1152/japplphysiol.00742.2020] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 02/08/2023] Open
Abstract
The worldwide pandemic caused by the SARS-CoV-2 virus has resulted in over 84,407,000 cases, with over 1,800,000 deaths when this paper was submitted, with comorbidities such as gender, race, age, body mass, diabetes, and hypertension greatly exacerbating mortality. This review will analyze the rapidly increasing knowledge of COVID-19-induced lung pathophysiology. Although controversial, the acute respiratory distress syndrome (ARDS) associated with COVID-19 (CARDS) seems to present as two distinct phenotypes: type L and type H. The "L" refers to low elastance, ventilation/perfusion ratio, lung weight, and recruitability, and the "H" refers to high pulmonary elastance, shunt, edema, and recruitability. However, the LUNG-SAFE (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) and ESICM (European Society of Intensive Care Medicine) Trials Groups have shown that ∼13% of the mechanically ventilated non-COVID-19 ARDS patients have the type-L phenotype. Other studies have shown that CARDS and ARDS respiratory mechanics overlap and that standard ventilation strategies apply to these patients. The mechanisms causing alterations in pulmonary perfusion could be caused by some combination of 1) renin-angiotensin system dysregulation, 2) thrombosis caused by loss of endothelial barrier, 3) endothelial dysfunction causing loss of hypoxic pulmonary vasoconstriction perfusion control, and 4) hyperperfusion of collapsed lung tissue that has been directly measured and supported by a computational model. A flowchart has been constructed highlighting the need for personalized and adaptive ventilation strategies, such as the time-controlled adaptive ventilation method, to set and adjust the airway pressure release ventilation mode, which recently was shown to be effective at improving oxygenation and reducing inspiratory fraction of oxygen, vasopressors, and sedation in patients with COVID-19.
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Affiliation(s)
- Nader M Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, St Thomas' Hospital, London, United Kingdom
| | - Louis A Gatto
- Department of Surgery, Upstate Medical University, Syracuse, New York
| | - Gary Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York
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11
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Kwee RM, Adams HJA, Kwee TC. Pulmonary embolism in patients with COVID-19 and value of D-dimer assessment: a meta-analysis. Eur Radiol 2021; 31:8168-8186. [PMID: 33966132 PMCID: PMC8106765 DOI: 10.1007/s00330-021-08003-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/24/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE To investigate, in a meta-analysis, the frequency of pulmonary embolism (PE) in patients with COVID-19 and whether D-dimer assessment may be useful to select patients for computed tomography pulmonary angiography (CTPA). METHODS A systematic literature search was performed for original studies which reported the frequency of PE on CTPA in patients with COVID-19. The frequency of PE, the location of PE, and the standardized mean difference (SMD) of D-dimer levels between patients with and without PE were pooled by random effects models. RESULTS Seventy-one studies were included. Pooled frequencies of PE in patients with COVID-19 at the emergency department (ED), general wards, and intensive care unit (ICU) were 17.9% (95% CI: 12.0-23.8%), 23.9% (95% CI: 15.2-32.7%), and 48.6% (95% CI: 41.0-56.1%), respectively. PE was more commonly located in peripheral than in main pulmonary arteries (pooled frequency of 65.3% [95% CI: 60.0-70.1%] vs. 32.9% [95% CI: 26.7-39.0%]; OR = 3.540 [95% CI: 2.308-5.431%]). Patients with PE had significantly higher D-dimer levels (pooled SMD of 1.096 [95% CI, 0.844-1.349]). D-dimer cutoff levels which have been used to identify patients with PE varied between 1000 and 4800 μg/L. CONCLUSION The frequency of PE in patients with COVID-19 is highest in the ICU, followed by general wards and the ED. PE in COVID-19 is more commonly located in peripheral than in central pulmonary arteries, which suggests local thrombosis to play a major role. D-dimer assessment may help to select patients with COVID-19 for CTPA, using D-dimer cutoff levels of at least 1000 μg/L. KEY POINTS • The frequency of PE in patients with COVID-19 is highest in the ICU, followed by general wards and the ED. • PE in COVID-19 is more commonly located in peripheral than in central pulmonary arteries. • D-dimer levels are significantly higher in patients with COVID-19 who have PE.
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Affiliation(s)
- Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, The Netherlands.
| | | | - Thomas C Kwee
- Department of Radiology, Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Manolis AS, Manolis TA, Manolis AA, Papatheou D, Melita H. COVID-19 Infection: Viral Macro- and Micro-Vascular Coagulopathy and Thromboembolism/Prophylactic and Therapeutic Management. J Cardiovasc Pharmacol Ther 2021; 26:12-24. [PMID: 32924567 PMCID: PMC7492826 DOI: 10.1177/1074248420958973] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus-2019 (COVID-19) predisposes patients to arterial and venous thrombosis commonly complicating the clinical course of hospitalized patients and attributed to the inflammatory state, endothelial dysfunction, platelet activation and blood stasis. This viral coagulopathy may occur despite thromboprophylaxis and raises mortality; the risk appears highest among critically ill inpatients monitored in the intensive care unit. The prevalence of venous thromboembolism in COVID-19 patients has been reported to reach ∼10-35%, while autopsies raise it to nearly 60%. The most common thrombotic complication is pulmonary embolism, which though may occur in the absence of a recognizable deep venous thrombosis and may be due to pulmonary arterial thrombosis rather than embolism, resulting in thrombotic occlusion of small- to mid-sized pulmonary arteries and subsequent infarction of lung parenchyma. This micro-thrombotic pattern seems more specific for COVID-19 and is associated with an intense immuno-inflammatory reaction that results in diffuse occlusive thrombotic micro-angiopathy with alveolar damage and vascular angiogenesis. Furthermore, thrombosis has also been observed in various arterial sites, including coronary, cerebral and peripheral arteries. Biomarkers related to coagulation, platelet activation and inflammation have been suggested as useful diagnostic and prognostic tools for COVID-19-associated coagulopathy; among them, D-dimer remains a key biomarker employed in clinical practice. Various medical societies have issued guidelines or consensus statements regarding thromboprophylaxis and treatment of these thrombotic complications specifically adapted to COVID-19 patients. All these issues are detailed in this review, data from meta-analyses and current guidelines are tabulated, while the relevant mechanisms of this virus-associated coagulopathy are pictorially illustrated.
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Affiliation(s)
- Antonis S. Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
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Bozorgmehr R, Pishgahi M, Tajabadi Z, Aryafar M. Pulmonary Thromboembolism and Infarction Mimicking COVID-19 Symptoms; Report of three Cases. Arch Acad Emerg Med 2020; 8:e88. [PMID: 33244523 PMCID: PMC7682627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Since the novel coronavirus emerged in late December, 2019 in Wuhan, China, millions of people have been infected and thousands of patients have died. Fever and dyspnea are the most common symptoms of infection with SARS-CoV-2. However, these symptoms are neither specific nor diagnostic for COVID-19. Symptom overlap between COVID-19 and some other conditions may lead other diseases to be missed and underdiagnosed. Just like COVID-19, pulmonary thromboembolism (PTE) and pulmonary infarction may present with fever and respiratory symptoms. Since COVID-19 emerged and spread worldwide, many clinicians are focused on diagnosis and treatment of this novel viral infection. Hence, other diseases presenting with the same symptoms as COVID-19 may remain underdiagnosed. Here, we report three cases of PTE and pulmonary infarction presenting with fever and respiratory symptoms mimicking COVID-19.
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Affiliation(s)
- Rama Bozorgmehr
- Clinical Research Development Unit, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Pishgahi
- Cardiology Research Center, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zohreh Tajabadi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ,Corresponding author: Zohreh Tajabadi; Shahid Beheshti University of Medical Sciences, Faculty of Medicine, Evin, Tehran, Iran. Tel: +989399304075,
| | - Mohammad Aryafar
- 4. Department of Anesthesiology, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran.
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