ABSTRACT
Introduction: Venous thrombo-embolism (VTE) disease in critically ill COVID-19 patients is a remarkable issue, especially its relationship with bleeding events and mortality. The objective of this study was to describe the outcomes of critically ill patients with COVID-19 hospitalised in the intensive care unit (ICU) in relationship with VTE during their stay. The secondary objective was to describe prognostic factors in relation with these outcomes. Methods: This was a prospective cohort study of critically ill COVID-19 patients in two Spanish university hospitals that underwent, at the beginning of the study, venous ultrasound of both lower limbs in April 2020. When there was clinical suspicion of new VTE during the 30 day follow up, additional ultrasound or thoracic computed tomography were performed. Global VTE frequency, major bleeding events, and survival were collected, and their predictors were studied. Results: In total, 230 patients were included. Mean age was 60.1 ± 9.9 years and 77% of them were men. After 30 days of follow up, there were 95 VTE events in 86 patients (37.4%). Of these, 60 patients (69.8%) presented with deep vein thrombosis (DVT), 17 patients with pulmonary embolism (PE;19.8%), and nine patients with DVT and PE (10.5%). VTE was related to a longer hospital stay: 50.3 days in VTE patients and 47.2 days in non-VTE patients (p =.014). D-dimer at admission was significantly related to VTE development (p =.007). Major bleeding complications were found in 13 patients (5.7%). None of the demographic variables, treatments, or classic risk factors were related to a higher risk of major bleeding. During the 30 day follow up, 42 patients (18.3%) died. Variables related to mortality were older age (67.4 vs. 58.4 years;p <.001), lower weight (77.9 vs. 87.5 kg;p <.001), lower body mass index (28.2 vs. 30,8 kg/m2;p =.006), hypertension (43.1% vs. 69% of patients;p =.002), lymphocyte count at admission < 0.45 ×109/L (p =.003) and D-dimer at admission > 1 500 ng/mL (p =.014). Patients with VTE at any moment during the follow up tended to die more frequently (50%) than non-VTE patients (34.6%), but this difference was not statistically significant (p =.062). Independent predictors of mortality in the regression model were older age (> 66 years), D-dimer at admission (> 1 500 ng/mL), and low lymphocyte count (< 0.45 ×109/L) with an area under the receiver operating curve of 0.81 (95% confidence interval 0.73 – 0.89). Patients presenting these three conditions presented a mortality of a 100% in the predictive model. Conclusion: VTE frequency in ICU COVID-19 patients is high and the risk of major bleeding is low. Comorbidities and laboratory parameters of admission in these patients can be a useful tool to predict mortality.
ABSTRACT
Objectives: Analyze the outcomes of our series of patients with COVID-19 supported with ECMO during pandemic and to identify the variables associated with outcomes. Methods: Prospective observational study including all the COVID-19 patients with ECMO support in the ICU of the VHUH from 15 March to 30 July. ECMO was considered if PaO2/FIO2 <80 mmHg, refractory to prone position, and/or PaCO2 >80 mmHg and pH <7.25 for >6h. Continuous variables expressed as median (ICR) and categorical variables as number (percentage). Differences in variables were analyzed using Chi Square test or T-test, as appropriate. Univariate logistic regression analysis was used to determine predictors of ICU mortality. Results: Twenty-four patients [55 (46-57) years, 58% male, BMI 32.1 (27-35)] with a PaO2/FIO2 of 66 (60-71) mmHg received ECMO support, 23 (96%) venovenous. Mechanical ventilation (MV) time prior to cannulation ranged from 1 to 17 days. Fifteen (63%) patients suffered hemorrhagic complications and 12 (48%) thrombotic events. These complications were not associated with a significant increase of mortality (P=1.0 and P=0.6, respectively). Eighteen (75%) patients could be decannulated and 16 (67%) were discharged alive from the ICU. Longer time on MV before cannulation was associated with a higher risk for ICU death (OR 1.31 [ICR 1.11-1.67];p=0.02). We found an association between age and mortality, but it did not reach significance (OR 1.05 [ICR 1.0-1.25];p= 0.36). Conclusions: ECMO may be useful in those COVID-19 patients with refractory hypoxemia. Time on MV prior to cannulation should be considered when indicating the technique.