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Hosp Pract (1995) ; 49(5): 307-324, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1528104


Severe acute respiratory syndrome coronavirus 2 infections are associated with greater risk of both arterial and venous thromboembolic events.Pathophysiology and Clinical implications: This has been attributed to a florid proinflammatory state resulting in microvascular dysfunction, activation of platelets and procoagulant systems as well as possible direct endothelial injury. The associated morbidity and mortality of these events has prompted much speculation and varied anticoagulation and fibrinolytic strategies based on multiple criteria including disease severity and biomarkers. No clear definitive benefit has been established with these approaches, which have frequently led to greater bleeding complications without significant mortality benefit.Overview: In this review, we outline the burden of these thromboembolic events in coronavirus disease-2019 (COVID-19) as well as the hypothesized contributory biological mechanisms. Finally, we provide a brief overview of the major clinical studies on the topic, and end with a summary of major societal guideline recommendations on anticoagulation in COVID-19.

Blood Coagulation Disorders/etiology , Blood Coagulation , COVID-19/complications , Anticoagulants/therapeutic use , Blood Platelets/virology , COVID-19/drug therapy , COVID-19/virology , Humans , Risk Factors , Venous Thromboembolism/etiology , Venous Thrombosis/etiology
Ann Pharmacother ; 56(1): 73-82, 2022 01.
Article in English | MEDLINE | ID: covidwho-1197336


OBJECTIVE: To describe clinically pertinent challenges of managing sedation in COVID-19 patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) and describe considerations for enhanced safety and efficacy of pharmacological agents used. DATA SOURCES: A PubMed search was performed using the following search terms: ECMO, ARDS, sedation, COVID-19, coronavirus, opioids, analgesia, fentanyl, hydromorphone, morphine, oxycodone, methadone, ketamine, propofol, dexmedetomidine, clonidine, benzodiazepines, midazolam, lorazepam, and diazepam. STUDY SELECTION AND DATA EXTRACTION: Relevant clinical and pharmacokinetic studies were considered. All studies included were published between January 1988 and March 2021. DATA SYNTHESIS: Patients with acute respiratory distress syndrome secondary to COVID-19 may progress to requiring VV-ECMO support. Agents frequently used for sedation and analgesia in these patients have been shown to have significant adsorption to ECMO circuitry, leading to possible diminished clinical efficacy. Use of hydromorphone-based analgesia has been associated with improved clinical outcomes in patients on VV-ECMO. However, safety and efficacy regarding use of other agents in this patient population remains an area of further research. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This review addresses clinical challenges associated with sedation management in COVID-19 patients requiring VV-ECMO support and provides potential strategies to overcome these challenges. CONCLUSIONS: Historically, sedation and analgesia management in patients requiring ECMO support have posed a challenge for bedside clinicians given the unique physiological and pharmacokinetic changes in this patient population. A multimodal strategy to managing analgesia and sedation should be used, and the use of enteral agents may play a role in reducing parenteral agent requirements.

Analgesia , COVID-19 , Extracorporeal Membrane Oxygenation , Respiratory Distress Syndrome , Humans , SARS-CoV-2