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Tacquard C, Mansour A, Godon A, Godet J, Poissy J, Garrigue D, Kipnis E, Rym Hamada S, Mertes PM, Steib A, Ulliel-Roche M, Bouhemad B, Nguyen M, Reizine F, Gouin-Thibault I, Besse MC, Collercandy N, Mankikian S, Levy JH, Gruel Y, Albaladejo P, Susen S, Godier A. Impact of High-Dose Prophylactic Anticoagulation in Critically Ill Patients With COVID-19 Pneumonia. Chest 2021; 159:2417-2427. [PMID: 33465342 PMCID: PMC7832130 DOI: 10.1016/j.chest.2021.01.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [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: 09/22/2020] [Revised: 12/23/2020] [Accepted: 01/09/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Because of the high risk of thrombotic complications (TCs) during SARS-CoV-2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation, although arguments in favor of this strategy are inconsistent. RESEARCH QUESTION What is the incidence of TC in critically ill patients with COVID-19 and what is the relationship between the dose of anticoagulant therapy and the incidence of TC? STUDY DESIGN AND METHODS All consecutive patients referred to eight French ICUs for COVID-19 were included in this observational study. Clinical and laboratory data were collected from ICU admission to day 14, including anticoagulation status and thrombotic and hemorrhagic events. The effect of high-dose prophylactic anticoagulation (either at intermediate or equivalent to therapeutic dose), defined using a standardized protocol of classification, was assessed using a time-varying exposure model using inverse probability of treatment weight. RESULTS Of 538 patients included, 104 patients experienced a total of 122 TCs with an incidence of 22.7% (95% CI, 19.2%-26.3%). Pulmonary embolism accounted for 52% of the recorded TCs. High-dose prophylactic anticoagulation was associated with a significant reduced risk of TC (hazard ratio, 0.81; 95% CI, 0.66-0.99) without increasing the risk of bleeding (HR, 1.11; 95% CI, 0.70-1.75). INTERPRETATION High-dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill patients with COVID-19 without an increased risk of hemorrhage. Randomized controlled trials comparing prophylaxis with higher doses of anticoagulants are needed to confirm these results. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04405869; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Charles Tacquard
- Department of Anesthesiology and Intensive Care, Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alexandre Mansour
- Department of Anesthesiology Critical Care Medicine and Perioperative Medicine, CHU de Rennes, Rennes, France
| | - Alexandre Godon
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Julien Godet
- Groupe Méthodes en Recherche Clinique, Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Julien Poissy
- University of Lille, Inserm U1285, CHU Lille, Pôle de Réanimation, CNRS, UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Delphine Garrigue
- Department of Anesthesiology and Critical Care, Surgical Critical Care, Centre Hospitalier Universitaire Lille, Lille, France
| | - Eric Kipnis
- University of Lille, CNRS, Inserm, CHU Lille, Surgical Critical Care, Department of Anesthesiology and Critical Care, Institut Pasteur de Lille, U1019-UMR 9017-CIIL-Center for Infection and Immunity of Lille, Lille, France
| | - Sophie Rym Hamada
- Department of Anesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | - Paul Michel Mertes
- Department of Anesthesiology and Intensive Care, Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Annick Steib
- Department of Anesthesiology and Intensive Care, Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mathilde Ulliel-Roche
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Bélaïd Bouhemad
- Department of Anesthesiology and Intensive Care, Dijon University Hospital and University of Burgundy, Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, Dijon, France
| | - Maxime Nguyen
- Department of Anesthesiology and Intensive Care, Dijon University Hospital and University of Burgundy, Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, Dijon, France
| | - Florian Reizine
- Service des Maladies Infectieuses et Réanimation Médicale, Rennes University Hospital, Rennes, France
| | | | | | - Nived Collercandy
- Service de Médecine Intensive-Réanimation, CHU de Tours, Tours, France
| | - Stefan Mankikian
- Service de Médecine Intensive-Réanimation, CHU de Tours, Tours, France
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC
| | - Yves Gruel
- Department of Hematology-Hemostasis, Tours University Hospital, Tours, France
| | - Pierre Albaladejo
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Sophie Susen
- Hemostasis Department, Heart and Lung Institute, CHU Lille, Lille, France.
| | - Anne Godier
- Department of Anesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
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Bouadma L, Mankikian S, Darmon M, Argaud L, Vinclair C, Siami S, Garrouste-Orgeas M, Papazian L, Cohen Y, Marcotte G, Styfalova L, Reignier J, Lautrette A, Schwebel C, Timsit JF. Influence of dyskalemia at admission and early dyskalemia correction on survival and cardiac events of critically ill patients. Crit Care 2019; 23:415. [PMID: 31856891 PMCID: PMC6921444 DOI: 10.1186/s13054-019-2679-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/20/2019] [Indexed: 12/24/2022]
Abstract
Objectives Our objectives were (1) to characterize the distribution of serum potassium levels at ICU admission, (2) to examine the relationship between dyskalemia at ICU admission and occurrence of cardiac events, and (3) to study both the association between dyskalemia at ICU admission and dyskalemia correction by day 2 on 28-day mortality. Design Inception cohort study from the longitudinal prospective French multicenter OUTCOMEREA database (1999–2014) Setting 22 French OUTCOMEREA network ICUs Patients Patients were classified into six groups according to their serum potassium level at admission: three groups of hypokalemia and three groups of hyperkalemia defined as serious hypokalemia [K+] < 2.5 and serious hyperkalemia [K+] > 7 mmol/L, moderate hypokalemia 2.5 ≤ [K+] < 3 mmol/L and moderate hyperkalemia 6 < [K+] ≤ 7 mmol/L, and mild hypokalemia 3 ≤ [K+] < 3.5 mmol/L and mild hyperkalemia 5 < [K+] ≤ 6 mmol/L. We sorted evolution at day 2 of dyskalemia into three categories: balanced, not-balanced, and overbalanced. Intervention None Measurements and main results Of 12,090 patients, 2108 (17.4%) had hypokalemia and 1445 (12%) had hyperkalemia. Prognostic impact of dyskalemia and its correction was assessed using multivariate Cox models. After adjustment, hypokalemia and hyperkalemia were independently associated with a greater risk of 28-day mortality. Mild hyperkalemic patients had the highest mortality (hazard ratio (HR) 1.29, 95% confidence interval (CI) [1.13–1.47], p < 0.001). Adjusted 28-day mortality was higher if serum potassium level was not-balanced at day 2 (aHR = 1.51, 95% CI [1.30–1.76], p < 0.0001) and numerically higher but not significantly different if serum potassium level was overbalanced at day 2 (aHR = 1.157, 95% CI [0.84–1.60], p = 0.38). Occurrence of cardiac events was evaluated by logistic regression. Except for patients with serious hypokalemia at admission, the depth of dyskalemia was associated with increased risk of cardiac events. Conclusions Dyskalemia is common at ICU admission and associated with increased mortality. Occurrence of cardiac events increased with dyskalemia depth. A correction of serum potassium level by day 2 was associated with improved prognosis.
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Affiliation(s)
- Lila Bouadma
- UMR 1137, IAME, Université Paris Diderot, F75018, Paris, France. .,Medical and Infectious Diseases Care Unit, AP-HP, Bichat University Hospital, F75018, Paris, France. .,Service de Réanimation Médicale et des Maladies Infectieuses, Hôpital Bichat-Claude-Bernard, 46 rue Henri-Huchard, 75877, Paris Cedex 18, France.
| | - Stefan Mankikian
- AP-HP, Pitié-Salpêtrière University Hospital, Cardiology, Paris, France
| | - Michael Darmon
- APHP, Saint-Louis University Hospital, Medical Intensive Care Unit, Paris, France.,Paris-7 Paris Diderot University, Paris, France
| | - Laurent Argaud
- Medical ICU, Edouard Herriot University Hospital, Lyon, France
| | | | - Shidasp Siami
- Critical Care Medicine Unit CH Etampes-Dourdan, Etampes, France
| | | | - Laurent Papazian
- Respiratory and Infectious Diseases ICU, APHM Hôpital Nord, Aix Marseille University, Marseille, France
| | - Yves Cohen
- AP-HP, Avicenne Hospital, Intensive Care Unit, Paris, France.,Medicine University, Paris 13 University, Bobigny, France
| | | | | | - Jean Reignier
- Medical Intensive Care Unit and University Hospital Centre, Nantes, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Carole Schwebel
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
| | - Jean-Francois Timsit
- UMR 1137, IAME, Université Paris Diderot, F75018, Paris, France.,Medical and Infectious Diseases Care Unit, AP-HP, Bichat University Hospital, F75018, Paris, France
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