ABSTRACT
Background: HIT is an intensely procoagulant disorder and in patients on ECMO it is associated with a high thrombotic morbidity and mortality, thus is crucial to intervene early. Aim(s): To present a case of a COVID-19 patient on ECMO who was diagnosed HIT. To describe evolution on Rivaroxaban treatment due to the unavailability of parenteral non-heparin anticoagulants in our country. Method(s): Not applicable. Result(s): A 60-year- old female patient was admitted to our hospital for ECMO support. She was diagnosed with SARS-CoV2, her condition quickly worsened with pneumothorax and refractory hypoxemia hence she was referred to our Institution. ECMO and hemodialysis were required. Unfractionated heparin (UFH) was given to achieve goal anti-Xa 0.3-0.7 units/mL. Platelet count (PLT) was 278,000 / mm3 and D dimer 1844 ng/mL FEU. Next day UFH was stopped because of haemothorax. Five days after restart anticoagulation an increased transmembrane pressure and a trombi was observed in the system. PLT were 12,000/mm3 and Ddimer 8500 ng/mL FEU. HIT was suspected;4Ts score = 7 and anti-FP4 antibodies positive (5.7 UA/mL). UFH was stopped and due to inaccessibility to other intravenous anticoagulant rivaroxaban 15 mg twice daily was started. Rivaroxaban calibrated anti-Xa assay was twice daily performed to monitor trough and peak levels, 30 mg twice daily was necessary to achieve therapeutic plasma concentration. Patient's PLT recovered after 7 days. No thrombotic event was recorded during rivaroxaban use. After ECMO was weaning-off rivaroxaban dose was reduced to 10 mg/day. Ten days later she had an upper gastrointestinal bleeding because gastric ulcer and rivaroxaban was stopped. With clinical stability and non evidence of bleeding, thromboprophylaxis with rivaroxaban was restarted and continued until discharged. Conclusion(s): Our case highlights the difficulties on management of HIT in patients on ECMO support and the need for consented guidelines in this specific situation, particularly for countries without access to parenteral non-heparin anticoagulants.
ABSTRACT
Background : Since the beginning of the SARS-CoV 2 pandemic, there have been many reports of increased incidence of VTE (venous thromboembolism) and arterial events as a complication, which were the basis for the hypothesis that patients should receive higher doses of thromboprophylaxis (TP) or full anticoagulation. Aims : To determine the incidence of thrombotic events (TE) in patients hospitalized for moderate or severe SARS-CoV2 disease (Covid-19). Methods : Retrospective single center cohort study with adult patients with a positive rt-PCR for SARS-CoV2 , included as from the date of hospital admission due to Covid-19 and followed for 90 days or until death. Results : A total of 1621 patients were included. The mean age was 68.7 years (SD 21.1) and 57% (913) were female, of which 6.5% (59) were pregnant. Overall mortality was 21.6% (348). The overall incidence of symptomatic thrombotics events within 90 days was 1.72% (28/1621, 95%CI 1.19-2.49%), whereas the incidence of pulmonary embolism (PE) was 0.98% (15, 95%CI 0.60-0.16%), deep venous thrombosis (DVT) 0.74% (11, 95%CI 0.42-0.12%), ischemic stroke 0.24% (4, 95%CI 0.09-0.65%) and ischemic arterial events 0.06% (1, 95%CI 0.008-0.43%). No acute coronary syndrome events were recorded. Median hospital stay length percentage under adequate TP was 78%. The median time since positive rt-PCR for the thrombotic event to develop was 22 days (IQR 25th-75th 19-43 days). Median hospital stay length percentage under adequate thromboprophylaxis was 78% (IQR 25th-75th 50-89%). Conclusions : Unlike previous reports, the incidence of thrombotic events was low among our patients with moderate or severe Covid-19.
ABSTRACT
Background : High prevalence of Lupus anticoagulant (LA) has been reported in COVID-19 infection. Aims : To determine the presence and the evolution of LA in COVID-19 pneumonia en the first 10 days at Intensive Care Unit (UCI). Methods : Prospective observational cohort study: Consecutive adult COVID-19 patients admitted to ICU. Exclusion criteria: age > 80 years, anticoagulation, tocilizumab, convalescent plasma transfusion, thrombophilia, pregnancy and cancer.Blood samples on day 1, 5 and 10 from UCI admission. Studies: PT, APTT, silica clotting time [HemosILSCT, Instrumentation laboratory(IL)], diluted Russell viper venom time HemosILDRVVT(IL) and STADRVVT(STAGO Diagnostic). Screening. Mixing with normal pooled plasma (NP) and confirmatory tests should be above their cur off points to be consider LA+. Biomarkers: D Dimer(DD), Reactive Protein C high sentitivity(cRP-H), Ferritina, LDH and interleukin 6(IL 6). Results : Patients included: 23, age 57 y (IQR52-71), 70% male, 15 required mechanical ventilation(MV).Twelve(52.1%) had LA+ by HemosILDRVVT in at least one time point, 3 in 3, 1 in 2(T5,10) and 8 in one(7/8 T1, 1/8 T5);4/5 patients with hospital discharge before T10 presented LA+ only at T1. LA prevalence was lower with STADRVVT(Table 1). SCT was negative in all samples. CRP-H, IL6 and Ferritin were higher in LA+, particularly at T5 and T10(Table 2). We cannot exclude CRP interference in DRVVT many samples had CRP > 126 (maximum concentration tested in vitro on NP). Patients received prophylactic enoxaparin, samples were taken at through, antiXa = 0.08 (0.04-0.12)U/mL, ruling out interference. LA+ was not associated with death ( n = 4) or VM requirement. Only one LA-patient developed pulmonary thromboembolism after leaving ICU. Conclusions : LA presence was demonstrated in this cohort of COVID-19 Pneumonia patients. Its presence was transient during the short period evaluated, LA was diagnosed through DRVVT with differences between regents. LA presence was associated with inflammatory biomarkers but not with MV requirement or death. These results confirm that LA is probably an epiphenomena.
ABSTRACT
Background : SARs-CoV-2 and DENGUE share clinical symptoms triggering inflammatory processes with high biomarkers levels that can hinder their differentiation in periods of double viral circulation. Aims : To compare levels of D-dimer(DD), High Sentivity C-reactive protein(CRP-H), Ferritin, Lactic-Dehydrogenase(LDH) and haematological parameters among patients with COVID-19 or DENGUE at first hospital consultation in emergency department(FCED). Methods : Retrospective cohort study: consecutive patients (Age > 18y.o.) at FCED on suspicion of symptomatic COVID-19 infection (March-June 2020), in which DD (VIDAS-Exclusion II, Biomerieux) was measured. Only dengue or COVID-19 positive patients were included and classified as Dengue, Mild upper airway infection (MUAI) by COVID-19 and COVID-19 pneumonia. DD(ng/ mL FEU), CRP-H, ferritin and LDH(Beckman-Coulter), PT and APTT(ACLTOP, Instrumentation Laboratory) and haematological parameters( DxH800, Beckman Coulter), were compared. Statistics: SPSS-23 Software Results : A total of 229 patients were included. Non severe Dengue patients presented significantly higher DD levels than MUAI, but not different to COVID-19-positive pneumonia at FCED (Table 1). The leukocytes, neutrophils, lymphocytes, and platelets count(both considering FCED and nadir) were lower in DENGUE, compared to COVID-19 patients (Table 2). CRP-H levels were higher in DENGUE than in Covid-19 MUAI, but lower than COVID-19 pneumonia. DENGUE LDH and ferritin levels were higher than those of MUAI but comparable to those of Covid-19 pneumonia (Table 1). Ferritin and LDH show a statistically correlation to DD in DENGUE and COVID-19-positive patients, but DD and CRP-H only correlated in COVID-19 patients( r :0.567). Platelets correlated negatively( r :-0.437) with DD only in dengue. Dengue patients with platelets nadir<100 × 109/L and elevated liver transaminases have higher DD levels than those with higher platelels count and not liver inflamation. Conclusions : Dengue and COVID-19 infections can trigger inflammatory processes with increased biomarkers, including DD. We showed that in non severe dengue the magnitude of response may be greater than in MUAI and similar to pneumonia COVID-19 positive. Studies are needed to define and compare the prognostic role of biomarkers in these entities.