SARS-CoV-2 from a hematological perspective / SARS-CoV-2 desde una perspectiva hematológica

La infección viral respiratoria causada por el SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) produce la enfermedad por coronavirus 2019 o COVID-19. Hasta el 20% al 50% de los pacientes hospitalizados con COVID-19 tienen alteraciones de la coagulación (dímero D elevado, tiempo de protrombina prolongado, trombocitopenia y fibrinógeno bajo). Esta condición se caracteriza por eventos trombóticos más que hemorrágicos. De otro lado, se presenta disfunción endotelial, lo cual explica los niveles elevados de trombina, de dímero D y de otros productos de degradación de fibrina, la trombocitopenia y la prolongación de los tiempos de coagulación; estos cambios terminan por originar hipoxia, oclusión microvascular y congestión pulmonar mediada por trombosis [1]. Se ha demostrado que el tratamiento anticoagulante inicial con heparinas de bajo peso molecular reduce la mortalidad un 48% a los 7 días y un 37% a los 28 días, y logra una mejoría significativa del cociente presión arterial de oxígeno/fracción inspirada de O2 (PaO2/FiO2), al mitigar la formación de microtrombos y la coagulopatía pulmonar asociada, disminuyendo además la inflamación [2]. En el artículo titulado "Alteraciones hematológicas como consecuencia de COVID-19 y sus vacunas", se abordan las anormalidades en la coagulación como la trombocitopenia trombótica inmune inducida por las vacunas contra el SARS-CoV-2. Es importante anotar, que hoy en día la comunidad científica está de acuerdo en que sin la vacunación hubiera sido imposible lograr el control actual que se tiene de la pandemia, pero a la vez se debe tener en cuenta que cualquier inmunización tiene también efectos adversos que por lo general son leves, pero que en raras ocasiones se pueden presentar complicaciones de mayor magnitud

Characterization of Patients with Multisystem Inflammatory Syndrome Temporarily Associated with Covid 19 (Sims-Tac) Experience of the Fundacion Clinica Infantil Club Noel March 2020-December 2021

BACKGROUND AND AIM: descriptive, retrospective METHOD: 39 patients Variables gender, weight, age, mortality, treatment, biomarkers: D-dimer, Troponin, Atrial Natriuretic Peptide, Lactic Dehydrogenase, CRP, ESR, fibrinogen, hemofiltration, hemoadsorption, immunoglobulin pentaglobulin, ivermectin and steroids. RESULT(S): 39 patients were reviewed, 52% female, 48% male, one patient died, the most frequent age range was under 3 years (44%), followed by the age group 3-8 years (20%), weight average was 28.7 kg, 44% received ivermectin, EL 16% immunoglobulin and 56% pentaglobulin, 24% were in therapy. hemoadsorption with OXIRIS filter (oXiris hemofilter (Baxter, Meyzieu, France) to improve the adsorption properties of the AN69ST membrane, which was very impressive in the improvement of the inflammatory picture demonstrated radiologically, 40% of their presentation phenotype was sepsis (HYPERINFLAMATION) 100% received steroids. Regarding the most frequent biomarkers, the average was D-dimer: 1700 ng/dl, troponin I 3.31 ng/ml, Atrial Natriuretic Peptide 1817 pg/ml, procalcitonin 15.57 ng/ ml, C-Reactive Protein of 91 mg/dl and ESR of 65 mm/sec CONCLUSION(S): SIMS-CT is a serious alteration, but its evolution in this series of cases was favorable. The use of haemadsorption is effective in groups where there is severe inflammatory response syndrome and hyperinflammation and this decreases mortality.

Correlación entre el aumento del dímero D en sangre con el espacio muerto en pacientes con COVID 19 y síndrome de dificultad respiratoria aguda (SDRA)

Resumen Introducción: Desde diciembre de 2019, un número de casos de neumonía por Síndrome Respiratorio Agudo Severo (SARS) COV2/COVID-19 en Wuhan China se identificaron como causa de insuficiencia respiratoria aguda y se propagaron por el mundo a gran velocidad. Debido al gran nùmero de casos y la necesidad de entender más esta condición, surge la necesidad de identificar herramientas que gradúen la intensidad y el pronóstico vital de los pacientes. El objetivo de este estudio es determinar la relación entre el espacio muerto medido por capnografía volumétrica o por ventilatory ratio y el aumento de los niveles de dímero D en pacientes con diagnóstico de neumonía por COVID-19 y que cumplan los criterios de Berlín para Síndrome de Dificultad Respiratoria Aguda (SDRA). Materiales y métodos: Se realizó un estudio observacional de una cohorte prospectiva, monocéntrico, sobre el uso de dímero D y la correlación con el espacio muerto. Se incluyeron adultos mayores de 18 años con diagnóstico de neumonía por COVID-19 y SDRA hospitalizados en las unidades de cuidados intensivos del Hospital Santa Clara en Bogotá, Colombia, desde agosto de 2020 hasta julio de 2021. Resultados: El estudio incluyó 67 pacientes, con diagnóstico de SARS-CoV-2 confirmado en todos ellos, no se encontró asociación entre dímero D y espacio muerto en el día 1 y 3 de hospitalización en la UCI. Conclusión: El dímero D no se correlaciona con el aumento del espacio muerto en nuestro estudio y tampoco se asoció con los desenlaces clínicos relevantes en los pacientes con SDRA. Introduction: Since December 2019, a number of cases of COV2 / COVID-19 severe acute respiratory syndrome (SARS) pneumonia in Wuhan China have been identified as a cause of acute respiratory failure and have spread around the world at high speed. Due to the large number of cases and the need to better understand this condition, tools are required to grade the intensity and vital prognosis of patients. The objective of this study is to determine the relationship between the dead space measured by volumetric capnography or ventilatory ratio and the increase in D-dimer levels in patients diagnosed with COVID-19 pneumonia and who meet the Berlin criteria for Acute Respiratory Distress Syndrome (ARDS). Materials and methods: A single-centre observational study of a prospective cohort on the use of D-dimer and the correlation with dead space. Adults older than 18 years with a diagnosis of pneumonia due to COVID-19 and ARDS hospitalized in the intensive care units of Hospital Santa Clara in Bogotá, Colombia, from August 2020 to July 2021 were included. Results: The study included 67 patients, all with a confirmed SARS-CoV-2 diagnosis, no association was found between D-dimer and dead space on day 1 and 3 of hospitalization in the ICU. Conclusions: D-dimer was not correlated with increased dead space in our study and was not associated with relevant outcomes in patients with ARDS.

[Prediction of pulmonary embolism in patients with SARS-CoV-2 infection]. / Predicción del desarrollo de tromboembolia pulmonar en pacientes con infección por SARS-CoV-2.

OBJECTIVE: To determine the predictive factors of pulmonary thromboembolic (PTE) in patients with SARS-CoV-2 infection (COVID-19) assessed in the emergency department at a tertiary hospital during the first pandemic wave. METHODS: Observational single-center study conducted in a retrospective cohort of patients with confirmed SARS-CoV-2 infection (or high clinical-radiological suspicion) who underwent PTE screening by computed tomography pulmonary angiography (CTPA). Predictive factors of PTE were explored using logistic regression, creating two predictive models (without or with D-dimer values). RESULTS: Out of a total of 274 CTPA performed, 70 procedures presented diagnostic findings of PTE, representing a cumulative incidence of 25.54% (95% confidence interval [CI]: 20.49-31.14). In the non-D-dimer based model, respiratory rate>22bpm (odds ratio [OR]: 3.162; 95% CI: 1.627-6.148; p=0.001) and the absence of findings suggestive of COVID-19 in plain chest X-ray (OR: 3.869; 95% CI: 0.869-17.225; p=0.076) were predictors of PTE. In the D-dimer-based model, tachypnea remained as a predictive factor (OR: 4.967; 95% CI: 2.053-12.018; p<0.001), as well as D-dimers>3,000ng/ml (OR: 7.494; 95% CI: 3.038-18.485; p<0.001). CONCLUSIONS: The presence of tachypnea (>22bpm) and the absence of radiological findings suggestive of SARS-CoV-2 infection in the chest X-ray, in addition to D-dimer values>3,000 ng/mL, were identified as predictive factors of PTE in patients with COVID-19.

[Systematic review of the prognostic utility of D-dimer, disseminated intravascular coagulation, and anticoagulant therapy in COVID-19 critically ill patients]. / Revisión sistemática sobre la utilidad pronóstica del dímero-D, coagulación intravascular diseminada y tratamiento anticoagulante en pacientes graves con COVID-19.

During the new pandemic caused by SARS-CoV-2, there is short knowledge regarding the management of different disease areas, such as coagulopathy and interpretation of D-dimer levels, its association with disseminated intravascular coagulation (DIC) and controversy about the benefit of anticoagulation. Thus, a systematic review has been performed to define the role of D-dimer in the disease, the prevalence of DIC and the usefulness of anticoagulant treatment in these patients. A literature search was performed to analyze the studies of COVID-19 patients. Four recommendations were drawn based on expert opinion and scientific knowledge, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The present review suggests the presence of higher levels of D-dimer in those with worse prognosis, there may be an overdiagnosis of DIC in the course of the disease and there is no evidence on the benefit of starting anticoagulant treatment based only on isolated laboratory data.

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection.

PURPOSE: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters. METHODS: Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation<92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP). RESULTS: 80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer≥500ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH≥500U/L, CRP≥10mg/L and hypoxemia. CONCLUSIONS: COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.