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1.
J Thromb Thrombolysis ; 2022 May 17.
Article in English | MEDLINE | ID: covidwho-1844435

ABSTRACT

Thromboembolism is a common and deadly consequence of COVID-19 infection for hospitalized patients. Based on clinical evidence pre-dating the COVID-19 pandemic and early observational reports, expert consensus and guidance documents have strongly encouraged the use of prophylactic anticoagulation for patients hospitalized for COVID-19 infection. More recently, multiple clinical trials and larger observational studies have provided evidence for tailoring the approach to thromboprophylaxis for patients with COVID-19. This document provides updated guidance for the use of anticoagulant therapies in patients with COVID-19 from the Anticoagulation Forum, the leading North American organization of anticoagulation providers. We discuss ambulatory, in-hospital, and post-hospital thromboprophylaxis strategies as well as provide guidance for patients with thrombotic conditions who are considering COVID-19 vaccination.

2.
Chest ; 161(2): 418-428, 2022 02.
Article in English | MEDLINE | ID: covidwho-1363121

ABSTRACT

BACKGROUND: Critically ill adults are at increased risk of VTE, including DVT, and pulmonary embolism. Various agents exist for venous thromboprophylaxis in this population. RESEARCH QUESTION: What is the comparative efficacy and safety of prophylaxis agents for prevention of VTE in critically ill adults? STUDY DESIGN AND METHODS: Systematic review and network meta-analysis of randomized clinical trials (RCTs) evaluating efficacy of thromboprophylaxis agents among critically ill patients. We searched six databases (including PubMed, EMBASE, and Medline) from inception through January 2021 for RCTs of patients in the ICU receiving pharmacologic, mechanical, or combination therapy (pharmacologic agents and mechanical devices) for thromboprophylaxis. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation to rate certainty of effect estimates. RESULTS: We included 13 RCTs (9,619 patients). Compared with control treatment (a composite of no prophylaxis, placebo, or compression stockings only), low-molecular-weight heparin (LMWH) reduced the incidence of DVT (OR, 0.59 [95% credible interval [CrI], 0.33-0.90]; high certainty) and unfractionated heparin (UFH) may reduce the incidence of DVT (OR, 0.82 [95% CrI, 0.47-1.37]; low certainty). LMWH probably reduces DVT compared with UFH (OR, 0.72 [95% CrI, 0.46-0.98]; moderate certainty). Compressive devices may reduce risk of DVT compared with control treatments; however, this is based on low-certainty evidence (OR, 0.85 [95% CrI, 0.50-1.50]). Combination therapy showed unclear effect on DVT compared with either therapy alone (very low certainty). INTERPRETATION: Among critically ill adults, compared with control treatment, LMWH reduces incidence of DVT, whereas UFH and mechanical compressive devices may reduce the risk of DVT. LMWH is probably more effective than UFH in reducing incidence of DVT and should be considered the primary pharmacologic agent for thromboprophylaxis. The efficacy and safety of combination pharmacologic therapy and mechanical compressive devices were unclear. TRIAL REGISTRY: Open Science Framework; URL: https://osf.io/694aj.


Subject(s)
Anticoagulants/therapeutic use , Critical Illness , Intermittent Pneumatic Compression Devices , Venous Thromboembolism/prevention & control , Adult , Heparin/therapeutic use , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Pulmonary Embolism/prevention & control , Randomized Controlled Trials as Topic
3.
Blood ; 136(Supplement 1):21-22, 2020.
Article in English | PMC | ID: covidwho-1339049

ABSTRACT

Background: Patients infected with coronavirus 2 (SARS-CoV-2) appear to be at increased risk for venous thromboembolism (VTE), especially if they become critically ill with coronavirus disease 2019 (COVID-19). Some centers have reported very high rates of thrombosis despite anticoagulant prophylaxis.Methods: The electronic health record (EHR) of a New Orleans-based health system was searched for all patients with PCR-confirmed SARS-CoV-2 infection who were either admitted to hospital or treated and discharged from an emergency department between March 1 and May 1, 2020. From this cohort, patients with confirmed VTE (either during or after their hospital encounter) were identified by administrative query of the EHR.Results: Between March 1, 2020 and May 1, 2020, 6,153 patients with COVID-19 were identified;2,748 of these patients were admitted, while 3,405 received care exclusively through the emergency department. Data on patient outcomes were determined up until and including May 21, 2020. In total, 637 patients required mechanical ventilation and 206 required renal replacement therapy. Within the hospitalized cohort, the overall mortality rate was 24.5% and VTE occurred in 86 patients (3.1%). In the 637 patients who required mechanical ventilation at some point during their hospital stay, 45 developed VTE (7.2%). After a median follow-up of 14.6 days, VTE had been diagnosed in 3 of the 2,075 admitted who were discharged alive (0.14%).Conclusions: Among 6,153 patients with COVID-19 who were hospitalized or treated in emergency departments, we did not find evidence of unusually high VTE risk. Pending further evidence from prospective, controlled trials, our findings support a traditional approach to primary VTE prevention in patients with COVID-19.

5.
Crit Care Med ; 49(3): e219-e234, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1069322

ABSTRACT

BACKGROUND: The coronavirus disease 2019 pandemic continues to affect millions worldwide. Given the rapidly growing evidence base, we implemented a living guideline model to provide guidance on the management of patients with severe or critical coronavirus disease 2019 in the ICU. METHODS: The Surviving Sepsis Campaign Coronavirus Disease 2019 panel has expanded to include 43 experts from 14 countries; all panel members completed an electronic conflict-of-interest disclosure form. In this update, the panel addressed nine questions relevant to managing severe or critical coronavirus disease 2019 in the ICU. We used the World Health Organization's definition of severe and critical coronavirus disease 2019. The systematic reviews team searched the literature for relevant evidence, aiming to identify systematic reviews and clinical trials. When appropriate, we performed a random-effects meta-analysis to summarize treatment effects. We assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach, then used the evidence-to-decision framework to generate recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS: The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued nine statements (three new and six updated) related to ICU patients with severe or critical coronavirus disease 2019. For severe or critical coronavirus disease 2019, the panel strongly recommends using systemic corticosteroids and venous thromboprophylaxis but strongly recommends against using hydroxychloroquine. In addition, the panel suggests using dexamethasone (compared with other corticosteroids) and suggests against using convalescent plasma and therapeutic anticoagulation outside clinical trials. The Surviving Sepsis Campaign Coronavirus Diease 2019 panel suggests using remdesivir in nonventilated patients with severe coronavirus disease 2019 and suggests against starting remdesivir in patients with critical coronavirus disease 2019 outside clinical trials. Because of insufficient evidence, the panel did not issue a recommendation on the use of awake prone positioning. CONCLUSION: The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued several recommendations to guide healthcare professionals caring for adults with critical or severe coronavirus disease 2019 in the ICU. Based on a living guideline model the recommendations will be updated as new evidence becomes available.


Subject(s)
Adrenal Cortex Hormones/therapeutic use , COVID-19/therapy , Critical Care , Dexamethasone/therapeutic use , Disease Management , Intensive Care Units , Practice Guidelines as Topic , Adenosine Monophosphate/analogs & derivatives , Adenosine Monophosphate/therapeutic use , Alanine/analogs & derivatives , Alanine/therapeutic use , Anticoagulants , Evidence-Based Medicine , Hemodynamics , Humans , Hydroxychloroquine , Immunization, Passive , Patient Positioning , Ventilation
6.
Musculoskelet Surg ; 105(2): 125-130, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1053111

ABSTRACT

The current COVID-19 global pandemic presents a major challenge and unprecedented pressures on health systems. The national guidelines in the UK advise non-operative treatment of fractures whenever possible to reduce the risk of surgical intervention to both patient and healthcare staff. The elderly population over 70 years are highlighted as a high-risk group in this pandemic as well as being often high risk for surgery in general due to co-morbidities. This article reviews the current literature regarding treatment of displaced olecranon fractures in the elderly. Literature search of the available databases. One randomised controlled trial has been published, comparing operative versus non-operative treatments of olecranon fractures in this age group. The study was terminated prematurely due to the high complication rate in the operative group. No difference in functional scores was recorded. Other published retrospective case series report good functional outcome scores and high satisfaction rates in the majority of patients in whom olecranon fractures were treated non-operatively. Non-operative treatment of olecranon fractures in elderly patients seems to be safe and an acceptable management option in these unprecedented times.


Subject(s)
COVID-19 , Fractures, Bone/therapy , Olecranon Process/injuries , Aged , Humans
7.
Blood Adv ; 4(21): 5373-5377, 2020 11 10.
Article in English | MEDLINE | ID: covidwho-901820

ABSTRACT

Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appear to be at increased risk for venous thromboembolism (VTE), especially if they become critically ill with COVID-19. Some centers have reported very high rates of thrombosis despite anticoagulant prophylaxis. The electronic health record (EHR) of a New Orleans-based health system was searched for all patients with polymerase chain reaction-confirmed SARS-CoV-2 infection who were either admitted to hospital or treated and discharged from an emergency department between 1 March 2020 and 1 May 2020. From this cohort, patients with confirmed VTE (either during or after their hospital encounter) were identified by administrative query of the EHR.: Between 1 March 2020 and 1 May 2020, 6153 patients with COVID-19 were identified; 2748 of these patients were admitted, while 3405 received care exclusively through the emergency department. In total, 637 patients required mechanical ventilation and 206 required renal replacement therapy. Within the hospitalized cohort, the overall mortality rate was 24.5% and VTE occurred in 86 patients (3.1%). In the 637 patients who required mechanical ventilation at some point during their hospital stay, 45 developed VTE (7.2%). After a median follow-up of 14.6 days, VTE had been diagnosed in 3 of the 2075 admitted who were discharged alive (0.14%). Among 6153 patients with COVID-19 who were hospitalized or treated in emergency departments, we did not find evidence of unusually high VTE risk. Pending further evidence from prospective, controlled trials, our findings support a traditional approach to primary VTE prevention in patients with COVID-19.


Subject(s)
COVID-19/pathology , Venous Thromboembolism/diagnosis , Adult , Aged , Anticoagulants/therapeutic use , COVID-19/complications , COVID-19/virology , Female , Humans , International Normalized Ratio , Length of Stay , Louisiana/epidemiology , Male , Middle Aged , Renal Replacement Therapy , Respiration, Artificial , Retrospective Studies , SARS-CoV-2/isolation & purification , Venous Thromboembolism/complications , Venous Thromboembolism/drug therapy , Venous Thromboembolism/epidemiology
8.
Thromb Res ; 194: 240-245, 2020 10.
Article in English | MEDLINE | ID: covidwho-776618

ABSTRACT

BACKGROUND: Direct oral anticoagulants (DOACs) have emerged as safe and effective alternatives to Vitamin-K antagonists for treatment and prevention of arterial and venous thrombosis. Due to their novelty, pharmacokinetic DOAC drug-drug interactions (DDIs) that result in clinical adverse events have not been well-documented. OBJECTIVE: This study aims to systematically review reported pharmacokinetic DDIs resulting in clinical adverse events through documented observational evidence to better inform clinicians in clinical practice. METHODS: A comprehensive literature review of EMBASE, MEDLINE, and Ovid HealthStar was conducted through March 10th, 2020. Two independent reviewers screened and extracted data from eligible articles according to pre-established inclusion and exclusion criteria. Articles reporting bleeding or thrombotic outcomes in non-controlled (observational) settings resulting from suggested pharmacokinetic DOAC DDIs were included. RESULTS: A total of 5567 citations were reviewed, of which 24 were included following data extraction. The majority were case reports (n = 21) documenting a single adverse event resulting from a suspected DOAC DDI, while the remaining papers were a case series (n = 1) and cohort studies (n = 2). The most commonly reported interacting drugs were amiodarone and ritonavir (bleeding), and phenobarbital, phenytoin, and carbamazepine (thrombosis). Bleeding events more often resulted from a combined mechanism (P-glycoprotein AND CYP3A4 inhibition), whereas thrombotic events resulted from either combined OR single P-glycoprotein/CYP3A4 induction. CONCLUSION: Current literature evaluating the real-world risk of DOAC DDIs is limited to few case reports and retrospective observational analyses. Clinicians are encouraged to continue to report suspected drug interactions resulting in adverse events.


Subject(s)
Anticoagulants , Pharmaceutical Preparations , Administration, Oral , Anticoagulants/adverse effects , Drug Interactions , Hemorrhage/chemically induced , Hemorrhage/drug therapy , Humans , Observational Studies as Topic , Retrospective Studies
9.
Cureus ; 12(8): e9943, 2020 Aug 22.
Article in English | MEDLINE | ID: covidwho-740575

ABSTRACT

Introduction The coronavirus disease 2019 (COVID-19) pandemic has been unprecedented in recent history. The rapid global spread has demonstrated how the emergence of a novel pathogen necessitates new information to advise both healthcare systems and policy-makers. The directives for the management of COVID-19 have been limited to infection control measures and treatment of patients, which has left physicians and researchers alone to navigate the massive amount of research being published while searching for evidence-based strategies to care for patients. To tackle this barrier, we launched CovidReview.ca, an open-access, continually updated, online platform that screens available COVID-19 research to determine higher quality publications. This paper uses data from this review process to explore the activity and trends of COVID-19 research worldwide over time, while specifically looking at the types of studies being published. Materials and Methods The literature search was conducted on PubMed. Search terms included "COVID-19", "severe acute respiratory syndrome coronavirus 2", "coronavirus 19", "SARS-COV-2", and "2019-nCoV". All articles captured by this strategy were reviewed by a minimum of two reviewers and categorized by type of research, relevant medical specialties, and type of publication. Criteria were developed to allow for inclusion or exclusion to the website. Due to the volume of research, only a level 1 (title and abstract) screen was performed. Results The time period for the analysis was January 17, 2020, to May 10, 2020. The total number of papers captured by the search criteria was 10,685, of which 2,742 were included on the website and 7,943 were excluded. The greatest increase in the types of studies over the 16 weeks was narrative review/expert opinion papers followed by case series/reports. Meta-analyses, systematic reviews, and randomized controlled trials remained the least published types of studies. Conclusions The surge of research that accompanied the COVID-19 pandemic is unparalleled in recent years. From our analysis, it is clear that case reports and narrative reviews were the most widely published, particularly in the earlier days of this pandemic. Continued research that falls higher on the evidence pyramid and is more applicable to clinical settings is warranted.

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