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Kaptein FHJ, Stals MAM, Grootenboers M, Braken SJE, Burggraaf JLI, van Bussel BCT, Cannegieter SC, Ten Cate H, Endeman H, Gommers DAMPJ, van Guldener C, de Jonge E, Juffermans NP, Kant KM, Kevenaar ME, Koster S, Kroft LJM, Kruip MJHA, Leentjens J, Marechal C, Soei YL, Tjepkema L, Visser C, Klok FA, Huisman MV. Incidence of thrombotic complications and overall survival in hospitalized patients with COVID-19 in the second and first wave. Thromb Res 2021; 199:143-148. [PMID: 33535120 PMCID: PMC7832218 DOI: 10.1016/j.thromres.2020.12.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In the first wave, thrombotic complications were common in COVID-19 patients. It is unknown whether state-of-the-art treatment has resulted in less thrombotic complications in the second wave. METHODS We assessed the incidence of thrombotic complications and overall mortality in COVID-19 patients admitted to eight Dutch hospitals between September 1st and November 30th 2020. Follow-up ended at discharge, transfer to another hospital, when they died, or on November 30th 2020, whichever came first. Cumulative incidences were estimated, adjusted for competing risk of death. These were compared to those observed in 579 patients admitted in the first wave, between February 24th and April 26th 2020, by means of Cox regression techniques adjusted for age, sex and weight. RESULTS In total 947 patients with COVID-19 were included in this analysis, of whom 358 patients were admitted to the ICU; 144 patients died (15%). The adjusted cumulative incidence of all thrombotic complications after 10, 20 and 30 days was 12% (95% confidence interval (CI) 9.8-15%), 16% (13-19%) and 21% (17-25%), respectively. Patient characteristics between the first and second wave were comparable. The adjusted hazard ratio (HR) for overall mortality in the second wave versus the first wave was 0.53 (95%CI 0.41-0.70). The adjusted HR for any thrombotic complication in the second versus the first wave was 0.89 (95%CI 0.65-1.2). CONCLUSIONS Mortality was reduced by 47% in the second wave, but the thrombotic complication rate remained high, and comparable to the first wave. Careful attention to provision of adequate thromboprophylaxis is invariably warranted.
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Affiliation(s)
- F H J Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M Grootenboers
- Department of Pulmonology, Amphia Hospital Breda, the Netherlands
| | - S J E Braken
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L I Burggraaf
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - B C T van Bussel
- Department of Intensive Care Medicine, Maastricht, UMC+, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - S C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - H Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - H Endeman
- Department of Adult Intensive Care, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - D A M P J Gommers
- Department of Adult Intensive Care, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - C van Guldener
- Department of Internal Medicine, Amphia Hospital Breda, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - K M Kant
- Department of Intensive Care Medicine, Amphia Hospital Breda, the Netherlands
| | - M E Kevenaar
- Department of Internal Medicine, Franciscus Gasthuis& Vlietland, Rotterdam, the Netherlands
| | - S Koster
- Department of Intensive Care Medicine, Zaans Medical Center, Zaandam, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Leentjens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C Marechal
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Y L Soei
- Department of Internal Medicine, Franciscus Gasthuis& Vlietland, Rotterdam, the Netherlands
| | - L Tjepkema
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, Kaptein FHJ, van Paassen J, Stals MAM, Huisman MV, Endeman H. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020; 191:145-147. [PMID: 32291094 PMCID: PMC7146714 DOI: 10.1016/j.thromres.2020.04.013] [Citation(s) in RCA: 3225] [Impact Index Per Article: 806.3] [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] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION COVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not available. METHODS We evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital. RESULTS We studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications. CONCLUSION The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.
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Affiliation(s)
- F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - M J H A Kruip
- Department of Haematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - N J M van der Meer
- Department of Anesthesiology and Critical Care, Amphia Hospital Breda and Oosterhout the Netherlands and TIAS/Tilburg University, Tilburg, the Netherlands
| | - M S Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - D A M P J Gommers
- Department of Adult Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - K M Kant
- Department of Intensive Care, Amphia Hospital, Breda, the Netherlands
| | - F H J Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J van Paassen
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - H Endeman
- Department of Adult Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
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de Wee EM, van der Sar-van der Brugge S, Grootenboers M, Bentvelsen RG, Kant KM, van der Leest CH. [In-hospital treatment of COVID-19 patients]. Ned Tijdschr Geneeskd 2020; 164:D4965. [PMID: 32608926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Covid-19 infection is now a pandemic disease. Most patients have mild symptoms without the need for hospitalization. On average, 5% of the COVID-19-positive patients have severe respiratory symptoms. We present 3 patients aged 45, 67 and 75 years, who were admitted to the ICU with severe respiratory symptoms. We describe the presentation of the COVID-19 patients on the emergency department, the development of the disease, and the treatment of these patients on the ICU.
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Affiliation(s)
- E M de Wee
- Verbeeten Instituut Tilburg, Radiotherapie, Tilburg
| | | | | | | | - K M Kant
- Amphia, afd. Longgeneeskunde, Breda
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Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers D, Kant KM, Kaptein FHJ, van Paassen J, Stals MAM, Huisman MV, Endeman H. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis. Thromb Res 2020; 191:148-150. [PMID: 32381264 PMCID: PMC7192101 DOI: 10.1016/j.thromres.2020.04.041] [Citation(s) in RCA: 1132] [Impact Index Per Article: 283.0] [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] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION We recently reported a high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 admitted to the intensive care units (ICUs) of three Dutch hospitals. In answering questions raised regarding our study, we updated our database and repeated all analyses. METHODS We re-evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction and/or systemic arterial embolism in all COVID-19 patients admitted to the ICUs of 2 Dutch university hospitals and 1 Dutch teaching hospital from ICU admission to death, ICU discharge or April 22nd 2020, whichever came first. RESULTS We studied the same 184 ICU patients as reported on previously, of whom a total of 41 died (22%) and 78 were discharged alive (43%). The median follow-up duration increased from 7 to 14 days. All patients received pharmacological thromboprophylaxis. The cumulative incidence of the composite outcome, adjusted for competing risk of death, was 49% (95% confidence interval [CI] 41-57%). The majority of thrombotic events were PE (65/75; 87%). In the competing risk model, chronic anticoagulation therapy at admission was associated with a lower risk of the composite outcome (Hazard Ratio [HR] 0.29, 95%CI 0.091-0.92). Patients diagnosed with thrombotic complications were at higher risk of all-cause death (HR 5.4; 95%CI 2.4-12). Use of therapeutic anticoagulation was not associated with all-cause death (HR 0.79, 95%CI 0.35-1.8). CONCLUSION In this updated analysis, we confirm the very high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 pneumonia.
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Affiliation(s)
- F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - M J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - N J M van der Meer
- Department of Anesthesiology and Critical Care, Amphia Hospital Breda, Oosterhout, the Netherlands; TIAS/Tilburg University Tilburg, the Netherlands
| | - M S Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - D Gommers
- Department of Adult Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - K M Kant
- Department of Intensive Care, Amphia Hospital, Breda, the Netherlands
| | - F H J Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J van Paassen
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - H Endeman
- Department of Adult Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
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Janssen EHCC, de Bree LCJ, Kant KM, van Wijngaarden P. Spontaneous fracture of the femur due to osteomyelitis caused by the Streptococcus anginosus group. Neth J Med 2017; 75:121-124. [PMID: 28469049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A 57-year-old man was admitted because of pain in the right upper leg due to an osteolytic lesion of the femoral bone which was complicated by a spontaneous fracture. At first a malignancy was suspected. However, blood and bone cultures revealed the Streptococcus anginosus group. A diagnosis of acute osteomyelitis was made. In spite of extensive antibiotic and surgical treatment the patient developed severe septic shock with multiple organ failure and died. In the case of a pathological fracture, one should consider the broad differential diagnosis, including osteomyelitis, which should lead to a laboratory work-up and imaging studies. When bone biopsy for histological analysis is necessary, a microbiological culture to look for osteomyelitis should always be performed.
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Affiliation(s)
- E H C C Janssen
- Department of Internal Medicine, Amphia Hospital, Breda, the Netherlands
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