Abstract
IntroductionCritical illness from SARS-CoV-2 infection (COVID-19) is associated with a high burden of pulmonary embolism (PE) and thromboembolic events despite standard thromboprophylaxis. Available guidance is discordant, ranging from standard care to the use of therapeutic anticoagulation for enhanced thromboprophylaxis (ET). Local ET protocols have been empirically determined and are generally intermediate between standard prophylaxis and full anticoagulation. Concerns have been raised in regard to the potential risk of haemorrhage associated with therapeutic anticoagulation. This report describes the prevalence and safety of ET strategies in European Intensive Care Unit (ICUs) and their association with outcomes during the first wave of the COVID pandemic, with particular focus on haemorrhagic complications and ICU mortality.MethodsRetrospective, observational, multi-centre study including adult critically ill COVID-19 patients. Anonymised data included demographics, clinical characteristics, thromboprophylaxis and/or anticoagulation treatment. Critical haemorrhage was defined as intracranial haemorrhage or bleeding requiring red blood cells transfusion. Survival was collected at ICU discharge. A multivariable mixed effects generalised linear model analysis matched for the propensity for receiving ET was constructed for both ICU mortality and critical haemorrhage.ResultsA total of 852 (79% male, age 66 [37–85] years) patients were included from 28 ICUs. Median body mass index and ICU length of stay were 27.7 (25.1–30.7) Kg/m2 and 13 (7–22) days, respectively. Thromboembolic events were reported in 146 patients (17.1%), of those 78 (9.2%) were PE. ICU mortality occurred in 335/852 (39.3%) patients. ET was used in 274 (32.1%) patients, and it was independently associated with significant reduction in ICU mortality (log odds = 0.64 [95% CIs 0.18–1.1; p = 0.0069]) but not an increased risk of critical haemorrhage (log odds = 0.187 [95%CI − 0.591 to − 0.964; p = 0.64]).ConclusionsIn a cohort of critically ill patients with a high prevalence of thromboembolic events, ET was associated with reduced ICU mortality without an increased burden of haemorrhagic complications. This study suggests ET strategies are safe and associated with favourable outcomes. Whilst full anticoagulation has been questioned for prophylaxis in these patients, our results suggest that there may nevertheless be a role for enhanced / intermediate levels of prophylaxis. Clinical trials investigating causal relationship between intermediate thromboprophylaxis and clinical outcomes are urgently needed.
Highlights
Critical illness from SARS-CoV-2 infection (COVID-19) is associated with a high burden of pulmonary embolism (PE) and thromboembolic events despite standard thromboprophylaxis
In a cohort of critically ill patients with a high prevalence of thromboembolic events, enhanced thromboprophylaxis (ET) was associated with reduced intensive care unit (ICU) mortality without an increased burden of haemorrhagic complications
Whilst full anticoagulation has been questioned for prophylaxis in these patients, our results suggest that there may be a role for enhanced / intermediate levels of prophylaxis
Summary
Critical illness from SARS-CoV-2 infection (COVID-19) is associated with a high burden of pulmonary embolism (PE) and thromboembolic events despite standard thromboprophylaxis. The burden of thrombotic complications—primarily pulmonary embolism (PE)—remains high in COVID-19 patients, in particular among those requiring intensive care unit (ICU) admission. Observational clinical data suggest that the use of either prophylactic to increased doses of low molecular weight heparins (LMWH) in high-risk patients may be associated with better prognosis, the optimal thromboprophylaxis strategy in the critically ill COVID-19 patient population remains uncertain [7]. In the absence of evidence from randomised controlled trials, published guidance based on observational data and expert opinion has been heterogeneous and sometimes contradictory, ranging from standard treatment to a variety of ET protocols with varying levels of anticoagulation from enoxaparin 40 mg BD to full therapeutic anticoagulation with unfractionated heparin [8,9,10,11]. Three randomised clinical trials aimed to test the effects of full doses of anticoagulants in COVID-19 patients have paused enrolment for futility, questioning the benefit of giving full dose anticoagulants routinely in critically ill COVID-19 patients and raising concerns regarding the safety of widespread ET protocols [12]
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