Thrombocytopenia in the ICU before and during the pandemic of the new coronavirus infection COVID-19…: a comparative retrospective cohort study

INTRODUCTION: Thrombocytopenia is common in critically ill patients. Its development is associated with a high risk of bleeding and other complications, including adverse out-comes. ОBJECTIVE: To analyze the incidence, severity, predictive significance of thrombocytopenia in critically ill patients before and during coronavirus infection. MATERIALS AND METHODS: The observational study included patients from intensive care units of a multidisciplinary hospital at different periods: before the COVID-19 and during the period when the hospital was operating as a СOVID hospital. Patients from all intensive care units, excluding the hematology unit, were analyzed. RESULTS: Non-infectious peri-od. Among 314 patients, 91 cases of thrombocytopenia were identified, representing 29 %. Severe thrombocytopenia among them was noted in 35 % (n = 32). The main etiological causes: performing extracorporeal procedures, liver disease, ischemic stroke, acute coronary syndrome. The infectious peri-od. Thrombocytopenia occurred more frequently than in non-COVID patients (in 209 of 396 patients — 52.8 %) and was more uniform in severity. The most frequent cause of throm-bocytopenia was a combination of sepsis, acute liver injury, performance of extracorporeal procedures and specific drug therapy of COVID-19 infection. CONCLUSIONS: According to our data, thrombocytopenia in the intensive care units of a multidisciplinary hospital (non-infectious period) occurred in one-third of critically ill patients. COVID 19 infection demonstrated an increased incidence of thrombocytopenia in critical patients (in the pres-ented study up to half of the pa-tients). Severe thrombocytopenia is more common in patients of non-infectious period (35 % vs 20 %). In patients with coro-navirus infection, thrombocytopenia was more frequently associated with a bleeding clinic (6.2 % vs 2.2 %), with less prognostic value as a criterion for adverse outcome: the presence of thrombocytopenia increased the risk of death by 5.5 times (95 % CI 2.979–10.031) in noninfectious and by 1.54 times (95 % CI 1.3–1.82) in COVID-19 infection. © 2022, Practical Medicine Publishing House LLC. All rights reserved.

Risk Factors of Severe Disease and Methods for Clinical Outcome Prediction in Patients with COVID-19 (Review)

Large population studies using statistical analysis and mathematical computer modeling could be an effective tool in studying COVID-19. The use of prognostic scales developed using correlation of changes in clinical and laboratory parameters and morphological data, can help in early prediction of disease progression and identification of patients with high risk of unfavorable outcome. Aim of the review. To assess the risk factors for severe course and unfavorable outcome of COVID-19 and to evaluate the existing tools for predicting the course and outcome of the novel coronavirus infection. PubMed, Medline, and Google Scholar were searched for the relevant sources. This review contains information on existing tools for assessing the prognosis and outcome of the disease, along with the brief data on the etiology, pathogenesis of the novel coronavirus infection and the known epidemiological, clinical and laboratory factors affecting its course. Conclusion. It is essential to develop predictive models tailored to specific settings and capable of continuous monitoring of the situation and making the necessary adjustments. The discovery of new and more sensitive early markers and developing marker-based predictive assessment tools could significantly impact improving the outcomes of COVID-19. © 2022, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved.

Pathogenetic mechanisms of hypofibrinogenemia in COVID-19

Background. Coagulopathy in patients with new coronavirus infection COVID-19 is important for the course and prognosis of the disease. Hypercoagulation, hyperfibrinogenemia and thrombosis are typical manifestations of coagulopathy in the acute phase of the disease. Hypofibrinogenemia in COVID-19 is not widely reported in the literature, and the frequency and reasons of its development are unknown. The use of genetically engineered biological drugs (GEBD) may be one of the possible causes of hypofibrinogenemia but the mechanisms of its development are not clear. Objectives: To determine the role of therapy with interleukin-6 receptor antagonists in the development of hypofibrinogenemia in patients with COVID-19-pneumonia, the clinical significance of hypofibrinogenemia and the mechanism of its occurrence. Patients/Methods. A randomized retrospective study included 239 patients aged 18 to 96 years with confirmed by polymerase chain reaction SARS-CoV-2 infection, computed tomography signs (upon admission to the hospital) of viral pneumonia (grade 2–4) and a duration of hospitalization of more than 2 days. All patients underwent laboratory monitoring, including the determination of hemoglobin, platelets, C-reactive protein (CRP), liver enzymes and fibrinogen according to Claus. All patients received initial therapy with hydroxychloroquine and azithromycin. At the time of the study, tocilizumab was the only GEBD drug used in the hospital. Therapy with tocilizumab was performed in 164 (68.6%) patients. The study took into account the maximum and minimum values of hemoglobin, platelet, fibrinogen and CRP levels during the hospitalization. Results. Hypofibrinogenemia of varying severity was observed in 39 patients treated with tocilizumab, that was significantly higher than hypofibrinogenemia frequency in 2 patients who did not receive tocilizumab (RR = 8.9;95% CI = 2.2–25.9). Conclusions. Tocilizumab usage in patients with COVID-19 significantly increases the risk of hypofibrinogenemia. © Gemostaz i Reologia LLC, 2021.

[Risk factors for the early development of septic shock in patients with severe COVID-19].

AIM: In a retrospective study, we evaluated factors associated with the early development of septic shock in patients with severe COVID-19. MATERIALS AND METHODS: We collected medical records of the intensive care unit patients submitted by the local COVID-19 hospitals across Russia to the Federal Center for the Critical Care at the Sechenov First Moscow State Medical University (Sechenov University). Septic shock in crticially ill patients requiring mechanical ventilation was defined as a need in vasopressors to maintain blood pressure. RESULTS: We studied 1078 patients with severe COVID-19 who were admitted to the intensive care units for respiratory support. There were 611 males and 467 females. The mean age was 61.013.7 years. Five hundred twenty five medical records (48.7%) were received from the Moscow hospitals, 159 (14.7%) from the Moscow region, and 394 (36.5%) from the hospitals located in 58 regions of the Russian Federation. In 613 (56.9%) patients, diagnosis of SARS-CoV-2 infection was confirmed by PCR, and in the other cases it was established on the basis of the clinical picture and the results of the chest CT scan. Septic shock developed in 214 (19.9%) of 1078 patients. In the logistic regression model, the risk of septic shock in patients older than 50 years was higher than in patients of a younger age (OR 2.34; 95% CI 1.533.67; p0.0001). In patients with more severe SARS-CoV-2 infection, there was an increase in the prevalence of cardiovascular diseases, including coronary heart disease and atrial fibrillation, type 2 diabetes and malignant tumors. The risk of septic shock in patients with three or more concomitant diseases was higher than in patients without any concomitant chronic diseases (OR 1.76; 95% CI 1.762.70). CONCLUSION: The risk of septic shock in patients with acute respiratory distress syndrome induced by SARS-CoV-2 is higher in patients older than 50 years with concomitant diseases, although a severe course of the disease is also possible in younger patients without any concomitant disorders.

Hemostasis system in covid-19 patients with heparin therapy

Blood coagulation abnormalities play an important role in the pathophysiology of COVID-19. However, the specific details of hy-per-coagulation and anticoagulant treatment require further investigations. The objective was to study the indicators of two global tests for the status of the hemostasis system assessment in patients with CO-VID-19 at the time of admission to the clinic (before the start of anticoagulant therapy) and in patients receiving heparin during treatment in the clinic. Material and methods. Global thrombodynamics (TD) and thromboelastography (TEG) tests, as well as coagulogram screening tests (APTT, PT, INR, and fibrinogen) were performed in 136 patients with COVID-19 observed in a hospital setting. All patients received low molecular weight heparins at therapeutic dosages relatively to body weight in accordance with the hospital proto-col for patients with COVID-19. Results. In patients prior to treatment, marked hypercoagulability was observed in all global tests. The main parameters of TD (clot growth rate Vi and Vs) exceeded the reference range in more than 83% and 75% of patients, respectively. Citrate native TEG parameters (R, K, angle α and MA) also showed hyper-coagulation before anticoagulant therapy initiation in 24%, 17%, 48% and 53% of patients, respectively. After the start of treatment, a significant heparin response was obtained for the Vs parameter (the most sensitive to heparin parameter of TD): in 75% of cases, TD recorded hypo-coagulation, in 15% — normocoagulation, and in 10% of measurements, TD parameters continued to be in the hyper-coagulation range. The TEG parameter most sensitive to heparin (angle α) showed a lower response to heparin: it registered hypo-coagulation only in 25% of measurements, in 60% — normoco-agulation, and in 15% the parameter was in the hyper-coagulation range. Conclusion. The significant share of hypercoagulant results (10-15%) may indicate that some patients have not achieved a suffi-cient anticoagulant effect under the therapy.