Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center
Introduction: Thrombosis and bleeding are recognized complications of the novel coronavirus infection (COVID-19), with a higher incidence described particularly in the critically ill. Methods: A retrospective review of COVID-19 patients admitted to our intensive care units (ICU) between 1 January 20...
| Main Authors: | , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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MDPI AG
2021-11-01
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| Series: | Journal of Clinical Medicine |
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| Online Access: | https://www.mdpi.com/2077-0383/10/23/5652 |
| _version_ | 1797507677179346944 |
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| author | Thejus Jayakrishnan Aaron Haag Shane Mealy Corbyn Minich Abraham Attah Michael Turk Nada Alrifai Laith Alhuneafat Fadi Khoury Adeel Nasrullah Patrick Wedgeworth Melissa Mosley Kirtivardan Vashistha Veli Bakalov Abhishek Chaturvedi Swathi Sangli |
| author_facet | Thejus Jayakrishnan Aaron Haag Shane Mealy Corbyn Minich Abraham Attah Michael Turk Nada Alrifai Laith Alhuneafat Fadi Khoury Adeel Nasrullah Patrick Wedgeworth Melissa Mosley Kirtivardan Vashistha Veli Bakalov Abhishek Chaturvedi Swathi Sangli |
| author_sort | Thejus Jayakrishnan |
| collection | DOAJ |
| description | Introduction: Thrombosis and bleeding are recognized complications of the novel coronavirus infection (COVID-19), with a higher incidence described particularly in the critically ill. Methods: A retrospective review of COVID-19 patients admitted to our intensive care units (ICU) between 1 January 2020 and 31 December 2020 was performed. Primary outcomes included clinically significant thrombotic and bleeding events (according to the ISTH definition) in the ICU. Secondary outcomes included mortality vis-a-vis the type of anticoagulation. Results: The cohort included 144 consecutive COVID-19 patients with a median age of 64 years (IQR 54.5–75). The majority were male (85 (59.0%)) and Caucasian (90 (62.5%)) with a median BMI of 30.5 kg/m<sup>2</sup> (IQR 25.7–36.1). The median APACHE score at admission to the ICU was 12.5 (IQR 9.5–22). The coagulation parameters at admission were a d-dimer level of 109.2 mg/mL, a platelet count of 217.5 k/mcl, and an INR of 1.4. The anticoagulation strategy at admission included prophylactic anticoagulation for 97 (67.4%) patients and therapeutic anticoagulation for 35 (24.3%) patients, while 12 (8.3%) patients received no anticoagulation. A total of 29 patients (20.1%) suffered from thrombotic or major bleeding complications. These included 17 thrombus events (11.8%)—8 while on prophylactic anticoagulation (7 regular dose and 1 intermediate dose) and 9 while on therapeutic anticoagulation (<i>p</i>-value = 0.02)—and 19 major bleeding events (13.2%) (4 on no anticoagulation, 7 on prophylactic (6 regular dose and 1 intermediate dose), and 8 on therapeutic anticoagulation (<i>p</i>-value = 0.02)). A higher thrombosis risk among patients who received remdesivir (18.8% vs. 5.3% (<i>p</i>-value = 0.01)) and convalescent serum (17.3% vs. 5.8% (<i>p</i>-value = 0.03%)) was noted, but no association with baseline characteristics (age, sex, race, comorbidity), coagulation parameters, or treatments (steroids, mechanical ventilation) could be identified. There were 10 pulmonary embolism cases (6.9%). A total of 99 (68.8%) patients were intubated, and 66 patients (45.8%) died. Mortality was higher, but not statistically significant, in patients with thrombotic or bleeding complications—58.6% vs. 42.6% (<i>p</i>-value = 0.12)—and higher in the bleeding (21.2%) vs. thrombus group (12.1%), <i>p</i>-value = 0.06. It did not significantly differ according to the type of anticoagulation used or the coagulation parameters. Conclusions: This study describes a high incidence of thrombotic and bleeding complications among critically ill COVID-19 patients. The findings of thrombotic events in patients on anticoagulation and major bleeding events in patients on no or prophylactic anticoagulation pose a challenging clinical dilemma in the issue of anticoagulation for COVID-19 patients. The questions raised by this study and previous literature on this subject demonstrate that the role of anticoagulation in COVID-19 patients is worthy of further investigation. |
| first_indexed | 2024-03-10T04:51:50Z |
| format | Article |
| id | doaj.art-ee23b3ad62c840608a12879022bf6dad |
| institution | Directory Open Access Journal |
| issn | 2077-0383 |
| language | English |
| last_indexed | 2024-03-10T04:51:50Z |
| publishDate | 2021-11-01 |
| publisher | MDPI AG |
| record_format | Article |
| series | Journal of Clinical Medicine |
| spelling | doaj.art-ee23b3ad62c840608a12879022bf6dad2023-11-23T02:37:20ZengMDPI AGJournal of Clinical Medicine2077-03832021-11-011023565210.3390/jcm10235652Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical CenterThejus Jayakrishnan0Aaron Haag1Shane Mealy2Corbyn Minich3Abraham Attah4Michael Turk5Nada Alrifai6Laith Alhuneafat7Fadi Khoury8Adeel Nasrullah9Patrick Wedgeworth10Melissa Mosley11Kirtivardan Vashistha12Veli Bakalov13Abhishek Chaturvedi14Swathi Sangli15Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH 44104, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Bioinformatics, University of Washington, Seattle, WA 98195, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USADepartment of Cardiology, Virginia Commonwealth University, Richmond, VA 23284, USADepartment of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USAIntroduction: Thrombosis and bleeding are recognized complications of the novel coronavirus infection (COVID-19), with a higher incidence described particularly in the critically ill. Methods: A retrospective review of COVID-19 patients admitted to our intensive care units (ICU) between 1 January 2020 and 31 December 2020 was performed. Primary outcomes included clinically significant thrombotic and bleeding events (according to the ISTH definition) in the ICU. Secondary outcomes included mortality vis-a-vis the type of anticoagulation. Results: The cohort included 144 consecutive COVID-19 patients with a median age of 64 years (IQR 54.5–75). The majority were male (85 (59.0%)) and Caucasian (90 (62.5%)) with a median BMI of 30.5 kg/m<sup>2</sup> (IQR 25.7–36.1). The median APACHE score at admission to the ICU was 12.5 (IQR 9.5–22). The coagulation parameters at admission were a d-dimer level of 109.2 mg/mL, a platelet count of 217.5 k/mcl, and an INR of 1.4. The anticoagulation strategy at admission included prophylactic anticoagulation for 97 (67.4%) patients and therapeutic anticoagulation for 35 (24.3%) patients, while 12 (8.3%) patients received no anticoagulation. A total of 29 patients (20.1%) suffered from thrombotic or major bleeding complications. These included 17 thrombus events (11.8%)—8 while on prophylactic anticoagulation (7 regular dose and 1 intermediate dose) and 9 while on therapeutic anticoagulation (<i>p</i>-value = 0.02)—and 19 major bleeding events (13.2%) (4 on no anticoagulation, 7 on prophylactic (6 regular dose and 1 intermediate dose), and 8 on therapeutic anticoagulation (<i>p</i>-value = 0.02)). A higher thrombosis risk among patients who received remdesivir (18.8% vs. 5.3% (<i>p</i>-value = 0.01)) and convalescent serum (17.3% vs. 5.8% (<i>p</i>-value = 0.03%)) was noted, but no association with baseline characteristics (age, sex, race, comorbidity), coagulation parameters, or treatments (steroids, mechanical ventilation) could be identified. There were 10 pulmonary embolism cases (6.9%). A total of 99 (68.8%) patients were intubated, and 66 patients (45.8%) died. Mortality was higher, but not statistically significant, in patients with thrombotic or bleeding complications—58.6% vs. 42.6% (<i>p</i>-value = 0.12)—and higher in the bleeding (21.2%) vs. thrombus group (12.1%), <i>p</i>-value = 0.06. It did not significantly differ according to the type of anticoagulation used or the coagulation parameters. Conclusions: This study describes a high incidence of thrombotic and bleeding complications among critically ill COVID-19 patients. The findings of thrombotic events in patients on anticoagulation and major bleeding events in patients on no or prophylactic anticoagulation pose a challenging clinical dilemma in the issue of anticoagulation for COVID-19 patients. The questions raised by this study and previous literature on this subject demonstrate that the role of anticoagulation in COVID-19 patients is worthy of further investigation.https://www.mdpi.com/2077-0383/10/23/5652COVID19SARS-CoV-2ICUthrombosisbleeding mortality |
| spellingShingle | Thejus Jayakrishnan Aaron Haag Shane Mealy Corbyn Minich Abraham Attah Michael Turk Nada Alrifai Laith Alhuneafat Fadi Khoury Adeel Nasrullah Patrick Wedgeworth Melissa Mosley Kirtivardan Vashistha Veli Bakalov Abhishek Chaturvedi Swathi Sangli Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center Journal of Clinical Medicine COVID19 SARS-CoV-2 ICU thrombosis bleeding mortality |
| title | Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center |
| title_full | Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center |
| title_fullStr | Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center |
| title_full_unstemmed | Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center |
| title_short | Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center |
| title_sort | novel coronavirus infection covid 19 related thrombotic and bleeding complications in critically ill patients experience from an academic medical center |
| topic | COVID19 SARS-CoV-2 ICU thrombosis bleeding mortality |
| url | https://www.mdpi.com/2077-0383/10/23/5652 |
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