Treatment Dose Anticoagulation Research Articles

Initiating versus delaying treatment-dose anticoagulation in suspected venous thromboembolism (VTE) in post-operative hip and knee arthroplasty patients: Outcomes and risks

BackgroundHip and knee arthroplasty is a risk factor for venous thromboembolism (VTE). Initiation of treatment-dose anticoagulation in the post-operative period in suspected cases prior to confirmed diagnosis involves balancing increased bleeding risk to VTE-associated morbidity. MethodsA single-centre retrospective cohort study was undertaken comparing outcomes of empirical treatment of suspected VTE in post-operative elective lower-limb arthroplasty patients as opposed to delaying treatment until diagnosis is confirmed. All patients undergoing ultrasonography (US) or CT-pulmonary-angiogram (CTPA) for suspected VTE following elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 05/05/17 and 19/07/21 were identified. Primary outcomes were surgical site infection (SSI), readmission, and other wound problems within 30-days of surgery. Results107 patients were included for analysis. 93 patients had suspected deep venous thrombosis (DVT), 21 had suspected pulmonary embolism (PE), and 7 were investigated for both DVT and PE. Empirical treatment-dose anticoagulation was initiated in 4 patients with suspected pulmonary embolism (PE) prior to CTPA, and 34 patients with suspected deep venous thrombosis (DVT) prior to US. No significant differences were noted in 30-day readmission rate ([DVT: 12 % vs 23 %, p = 0.41], [PE: 50 % vs 33 %, p = 1.00]), SSI rate ([DVT: 6 % vs 3 %, p = 1.00], [PE: 0 % vs 11 %, p = 1.00]) or other wound complication rate ([DVT: 3 % vs 3 %, p = 1.00), [PE 0 % vs 11 %, p = 1.00]) between empirically and non-empirically treated groups respectively. ConclusionEmpirical initiation of therapeutic anticoagulation in post-operative lower limb arthroplasty patients with suspected VTE appears to be safe practice prior to a definitive diagnosis.

445 Endovascular treatment of acute mesenteric ischemia: An option to consider in patients unfit for major surgery

Abstract Introduction The number of embolectomies for superior mesenteric arterial occlusion has increased over the years. Endovascular embolectomies in acute mesenteric ischemia continue to be performed only in a smaller proportion of cases despite multiple studies reporting promising results. Case description An 85-year-old lady presented to the emergency surgical unit with an acute onset of severe abdominal pain and vomiting. She has a background of atrial fibrillation and hypertension and has been a chronic smoker for the past 50 years. One month before her presentation, she stopped taking her anticoagulation due to intermittent per-rectal bleeding attributed to diverticular disease. Initial CT demonstrated an SMA embolus extending from the first bifurcation approximately 4.5cm distally. In addition, there were features of bowel ischaemia with abnormal thickening of the small bowel loops in that vascular territory. She was deemed too frail for a laparotomy by the surgical and anaesthetic team, and the patient preferred to explore a non-operative approach. Despite treatment dose anticoagulation, her clinical condition deteriorated, with a rise in inflammatory markers, intolerance of food, and worsening abdominal pain. Unfortunately, thrombolysis was not an option because of the large size of the embolus and PR bleeding. She underwent an endovascular vacuum-assisted thrombectomy. The procedure achieved near-complete revascularisation, and the patient sustained a good recovery and was discharged on day 8 of admission. Discussion Available literature has shown promising results with endovascular treatment of acute mesenteric ischemia. The successful revascularisation, in this case, confirms that endovascular techniques are a viable option to consider in acute mesenteric ischemia.

PD08-09 INTERIM ANALYSIS OF A NATIONAL RETROSPECTIVE STUDY OF cT3b+ RENAL CELL CARCINOMA PATIENTS’ PULMONARY EMBOLISM RISK AND THROMBOPROPHYLAXIS MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023PD08-09 INTERIM ANALYSIS OF A NATIONAL RETROSPECTIVE STUDY OF cT3b+ RENAL CELL CARCINOMA PATIENTS’ PULMONARY EMBOLISM RISK AND THROMBOPROPHYLAXIS MANAGEMENT Osman El-Koubani, James Blackmur, Flora Rodgers, Gianluca Maresca, Lucy Drummond, Caroline Bradley, Siobhan Duffy, Satchi Swami, Khalid Janjua, Steve Leung, Ross Clark, Gavin Lamb, Alex Chapman, James Donaldson, Grenville Oades, and Alexander Laird Osman El-KoubaniOsman El-Koubani More articles by this author , James BlackmurJames Blackmur More articles by this author , Flora RodgersFlora Rodgers More articles by this author , Gianluca MarescaGianluca Maresca More articles by this author , Lucy DrummondLucy Drummond More articles by this author , Caroline BradleyCaroline Bradley More articles by this author , Siobhan DuffySiobhan Duffy More articles by this author , Satchi SwamiSatchi Swami More articles by this author , Khalid JanjuaKhalid Janjua More articles by this author , Steve LeungSteve Leung More articles by this author , Ross ClarkRoss Clark More articles by this author , Gavin LambGavin Lamb More articles by this author , Alex ChapmanAlex Chapman More articles by this author , James DonaldsonJames Donaldson More articles by this author , Grenville OadesGrenville Oades More articles by this author , and Alexander LairdAlexander Laird More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003239.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Up to 10% of patients with renal cell carcinoma (RCC) have venous tumour thrombus at diagnosis. The incidence of PE in patients with RCC invading the venous system is unknown. The role of anticoagulation to prevent PE in such patients is also unknown and there is currently no guidance on whether patients should receive anticoagulation at diagnosis. We aimed to determine the incidence of PE is patients with RCC invading the inferior vena cava, understand the pattern of prophylactic anticoagulation prescribing in such patients and assess the effect of anticoagulation of PE risk. METHODS: We performed a retrospective review of records for all consecutive patients with cT3b, cT3c or cT4 with associated IVC thrombus (T3b+) RCC from 9 centres across a nation between Jan 2017 and Dec 2020. Patient demographics, comorbidities, anticoagulation prescription and outcomes were recorded. RESULTS: Data from 6 of 9 units was available for analysis, including 162 patients with RCC and IVC thrombus. 94(58%) patients were male and the median age was 68yrs (range: 31-93yrs). 112 (69.1%) patients died during follow-up.42(25.9%) patients developed a PE during the study period. PE was more common with larger venous tumour thrombus (10/64 patients [15.5%] level 1, 32/98 patients [32.7%] level 2+; p=0.17). 27(16.7%) patients had a PE at initial RCC diagnosis while 15 (11.1%) of the remaining 135 patients subsequently developed a PE during their management. Of the 135 patients, 11 (8.1%) patients, 27(20%) patients, and 97(71.9%) patients were commenced on prophylactic dose, treatment dose or no anticoagulation respectively. While not significant, there was a trend for higher rate of PE in the non-anticoagulated group, compared with those receiving prophylactic anticoagulation and treatment dose anticoagulation after diagnosis of T3b+ RCC (13[13.4%], 1[9.0%] and 1[3.7%] respectively, p=0.357). There was a higher rate of post-diagnosis haematuria in the anticoagulated group compared to the non-anticoagulated group (15.4% and 7.7%, p=0.122). CONCLUSIONS: In this interim analysis, we demonstrate a significant risk of concurrent or subsequent diagnosis of PE in those patients with cT3b+ RCC, which is related to venous tumour thrombus level. There is heterogeneity in the approach to prescribing anticoagulant prophylaxis in these patients. However, there is a trend for a reduction in the diagnosis of PE in those patients who receive anticoagulation following diagnosis of cT3b+ RCC, although this may result in higher rates of haematuria. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e236 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Osman El-Koubani More articles by this author James Blackmur More articles by this author Flora Rodgers More articles by this author Gianluca Maresca More articles by this author Lucy Drummond More articles by this author Caroline Bradley More articles by this author Siobhan Duffy More articles by this author Satchi Swami More articles by this author Khalid Janjua More articles by this author Steve Leung More articles by this author Ross Clark More articles by this author Gavin Lamb More articles by this author Alex Chapman More articles by this author James Donaldson More articles by this author Grenville Oades More articles by this author Alexander Laird More articles by this author Expand All Advertisement PDF downloadLoading ...

Intracerebral Hemorrhage in Patients with COVID-19 Infection

Introduction: Thrombotic manifestations, such as deep vein thrombosis, pulmonary embolism, and rarely ischemic stroke, have been identified as disease complications of COVID-19. However, less is known about bleeding complications of COVID-19. While COVID-19-related intracerebral hemorrhage (ICH) has been described in the literature, the underlying risk factors are poorly understood. Methods: We performed a retrospective observational study of consecutively admitted ICH patients in the Mount Sinai Health System in New York, NY. We compared demographic variables, medical comorbidities, in-hospital treatments, and time to diagnosis between COVID-19-positive and COVID-19-negative cohorts. Results: Forty-seven patients were diagnosed with ICH, and of these, 31.9% (n=15) were COVID-19-positive. There were no significant differences in age, race-ethnicity, or cardiovascular risk factors. However, a higher proportion of patients with COVID-19 had a history of obesity, defined as BMI ≥ 30 (73.3% vs. 30.0%, p=0.01). For the COVID-19-negative cohort mean days from presenting symptom onset to ICH diagnosis was 1.4 (95% CI -1.3-3.9). For the COVID-19-positive cohort, ICH was diagnosed an average of 7.9 days from hospital admission (95% CI 2.6-13.3) and 12.3 days from presenting symptom onset (95% CI 5.6-19.0). Of the COVID-19-negative patients, 94% had an admitting diagnosis of ICH, while only 40% of COVID-19-positive patients had an admitting diagnosis of ICH. At the time of this study, the MSHS used a COVID-19 anticoagulation algorithm that recommended consideration of treatment-dose anticoagulation for patients with moderate or severe COVID-19. Patients with severe or worsening respiratory status (based on oxygen requirement, elevations in D-dimer, creatinine, or C-reactive protein) were recommended to be treated with moderate dose anticoagulation (enoxaparin 1 mg/kg every 24 hours) and the recommendation for all COVID-19 ICU patients was treatment dose anticoagulation (enoxaparin 1 mg/kg every 12 hours or apixaban). Forty percent (40%) of patients in the COVID-19-positive cohort were on full-dose anticoagulation at the time of ICH compared to <10% in the COVID-19-negative cohort. Of the COVID-19-positive cohort on full-dose anticoagulation, one-third were on full-dose anticoagulation due to institutional COVID-19 treatment protocols. The rest were treated with anticoagulation for other indications, most commonly atrial fibrillation. Nearly 60% of COVID-19 patients who suffered ICH were not taking full dose anticoagulation. Table 1 summarizes laboratory values among the COVID-19-positive cohort compared to the COVID-19-negative cohort. At the time closest to ICH discovery, mean coagulation markers were slightly elevated (PT 16.5±4.2, PTT 42.9±23.3) compared to the COVID-19-negative cohort (PT 14.6±2.1, PTT 29.0±7.0, p=0.06 and 0.003 respectively), although INR did not significantly differ between the two groups (1.4±0.4 vs. 2.1±4.9). Hemoglobin, hematocrit, white blood cell, and platelet counts were abnormal in >50% of COVID-19-positive patients, compared to approximately 50% or less in COVID-19-negative patients. Inflammatory parameters were elevated in the majority of COVID-19 patients, including C-reactive protein, erythrocyte sedimentation rate, d-dimer, lactate dehydrogenase, fibrinogen, and interleukin-6. The peak CRP in COVID-19 patients (150.5±133.7) was markedly elevated compared to COVID-19-negative patients (42.9±95.2, p=0.06). Conclusions: The admitting diagnosis and time to ICH diagnosis suggest that ICH in COVID-19 is not typically the presenting manifestation of the disease and is more commonly seen in severe disease requiring prolonged hospitalization. Patients with COVID-19 and ICH were more likely to be receiving full-dose anticoagulation than their COVID-19 negative counterparts. ICH in COVID-19 patients is potentially related to anticoagulation, not an underlying inflammatory state or consumptive coagulopathy, and underscores the need for careful consideration of anticoagulation in COVID-19 patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

COVID-19 Thrombotic Complications and Therapeutic Strategies.

Shortly after the emergence of coronavirus disease 2019 (COVID-19) in late 2019, clinicians rapidly recognized an apparent association between the disease and both arterial and venous thrombotic complications, which was confirmed in epidemiologic studies. Based on these data, hospitals empirically developed and implemented protocols with different strategies for anticoagulation of hospitalized COVID-19 patients. Subsequent randomized controlled trials (RCTs) clarified the role of anticoagulation in patients hospitalized with COVID-19 and recently discharged from the hospital. In this review, we discuss the epidemiology and pathophysiology of thrombosis in patients with COVID-19, observational comparative effectiveness analyses that provided hints of a benefit from anticoagulation, and finally the RCTs that established which patients with COVID-19 benefit from treatment-dose anticoagulation. These RCTs have demonstrated that hospitalized, noncritically ill patients with COVID-19 benefit from treatment-dose anticoagulation, but patients who are hospitalized and critically ill, discharged from the hospital, or not hospitalized do not benefit.

Anticoagulation as secondary prevention of massive lung thromboses in hospitalized patients with COVID-19

Anticoagulation as secondary prevention of massive lung thromboses in hospitalized patients with COVID-19

241 Is There a Role for Empirical Treatment of Orthopaedic Patients with Suspected, but Not Confirmed, VTE in the Post-Operative Period?

Abstract Introduction Major surgery, including major orthopaedic surgery, is a key risk factor for developing venous thromboembolism (VTE). This poses a challenge in the post-operative phase when considering initiation of therapeutic-dose anticoagulation for suspected VTE due to the risk of major bleeding. Method A search strategy was developed with inclusion criteria involving all studies relating to the treatment of suspected VTE in the post-operative orthopaedic patient. Journal articles predating 3rd June 2021 were searched for in Medline, Embase and PubMed. Titles and s were reviewed based on clinical relevance. Results 56 articles were generated using this search strategy. 22 results were excluded as conference papers and/or case reports. Title and review of the remaining 34 studies did not identify any relevant articles reporting outcomes. Conclusions No evidence is available to guide recommendations for the empirical treatment of suspected VTE in the post-operative orthopaedic patient prior to a confirmed VTE diagnosis. This is therefore a risk-benefit clinical decision to be undertaken based on individual patient factors. Current American College of Chest Physicians guidelines advise initiation of anticoagulation for suspected acute VTE in cases with a high clinical suspicion, or intermediate clinical suspicion with expected delay in diagnostic imaging for at least 4 hours. However, this does not apply to patients following recent surgery who are at increased risk of bleeding post-operatively. Empirical systemic treatment dose anticoagulation for VTE in the post-operative period should therefore only be initiated when timely image-based diagnosis cannot be achieved.

Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit.

BackgroundRegional citrate anticoagulation (RCA) is the recommended standard for continuous renal replacement therapy (CRRT). This study assesses its efficacy in patients admitted to critical care following cardiovascular surgery and the influence of standard antithrombotic agents routinely used in this specific group.MethodsConsecutive cardiovascular surgery patients treated with postdilution hemofiltration with RCA were included in this prospective observational study. The primary outcome of the study was CRRT circuit life-span adjusted for reasons other than clotting. The secondary outcome evaluated the influence of standard antithrombotic agents (acetylsalicylic acid [ASA], low molecular weight heparin [LMWH] or fondaparinux as thromboprophylaxis or treatment dose with or without ASA) on filter life.ResultsFifty-two patients underwent 193 sessions of continous veno-venous hemofiltration, after exclusion of 15 sessions where unfractionated heparin was administered. The median filter life span was 58 hours. Filter life span was significantly longer in patients receiving therapeutic dose of LMWH or fondaparinux (79 h [2–110]), in comparison to patients treated with prophylactic dose of LMWH or fondaparinux (51 h [7–117], p < 0.001), and patients without antithrombotic prophylaxis (42 h [2–91], p < 0.0001). 12 bleeding episodes were observed; 8 occurred in patients receiving treatment dose anticoagulation, 3 in patients receiving prophylactic dose anticoagulation and 1 in a patient with no antithrombotic prophylaxis.ConclusionsA postdilution hemofiltration with RCA provides prolonged filter life span when adjusted for reasons other than clotting. Patients receiving treatment dose anticoagulation had a significantly longer filter life span than those who were on prophylactic doses or ASA alone.

The argument against everyone with hyperosmolar hyperglycaemic syndrome being given prophylactic treatment dose anticoagulation

The argument against everyone with hyperosmolar hyperglycaemic syndrome being given prophylactic treatment dose anticoagulation

Trends in Venous Thromboembolism Anticoagulation in Patients Hospitalized With COVID-19

Venous thromboembolism (VTE) is a common complication of COVID-19. It is not well understood how hospitals have managed VTE prevention and the effect of prevention strategies on mortality. To characterize frequency, variation across hospitals, and change over time in VTE prophylaxis and treatment-dose anticoagulation in patients hospitalized for COVID-19, as well as the association of anticoagulation strategies with in-hospital and 60-day mortality. This cohort study of adults hospitalized with COVID-19 used a pseudorandom sample from 30 US hospitals in the state of Michigan participating in a collaborative quality initiative. Data analyzed were from patients hospitalized between March 7, 2020, and June 17, 2020. Data were analyzed through March 2021. Nonadherence to VTE prophylaxis (defined as missing ≥2 days of VTE prophylaxis) and receipt of treatment-dose or prophylactic-dose anticoagulants vs no anticoagulation during hospitalization. The effect of nonadherence and anticoagulation strategies on in-hospital and 60-day mortality was assessed using multinomial logit models with inverse probability of treatment weighting. Of a total 1351 patients with COVID-19 included (median [IQR] age, 64 [52-75] years; 47.7% women, 48.9% Black patients), only 18 (1.3%) had a confirmed VTE, and 219 (16.2%) received treatment-dose anticoagulation. Use of treatment-dose anticoagulation without imaging ranged from 0% to 29% across hospitals and increased over time (adjusted odds ratio [aOR], 1.46; 95% CI, 1.31-1.61 per week). Of 1127 patients who ever received anticoagulation, 392 (34.8%) missed 2 or more days of prophylaxis. Missed prophylaxis varied from 11% to 61% across hospitals and decreased markedly over time (aOR, 0.89; 95% CI, 0.82-0.97 per week). VTE nonadherence was associated with higher 60-day (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.03-1.67) but not in-hospital mortality (aHR, 0.97; 95% CI, 0.91-1.03). Receiving any dose of anticoagulation (vs no anticoagulation) was associated with lower in-hospital mortality (only prophylactic dose: aHR, 0.36; 95% CI, 0.26-0.52; any treatment dose: aHR, 0.38; 95% CI, 0.25-0.58). However, only the prophylactic dose of anticoagulation remained associated with lower mortality at 60 days (prophylactic dose: aHR, 0.71; 95% CI, 0.51-0.90; treatment dose: aHR, 0.92; 95% CI, 0.63-1.35). This large, multicenter cohort of patients hospitalized with COVID-19, found evidence of rapid dissemination and implementation of anticoagulation strategies, including use of treatment-dose anticoagulation. As only prophylactic-dose anticoagulation was associated with lower 60-day mortality, prophylactic dosing strategies may be optimal for patients hospitalized with COVID-19.

P.115 Timing is everything: Labour epidurals and anticoagulants

Introduction: The latest MBRRACE report advocates the need for pregnant women on prophylactic and treatment dose anticoagulation to have a structured management plan during the peripartum period. [1] Knight M, Bunch K, Tuffnell D, et al. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016 – 18. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2020. Google Scholar In our district general hospital, peripartum documentation is a mix of paper and electronic records. Further to this all drug prescriptions are charted on an electronic system. An Association of Anaesthetists guideline exists for the timing of neuraxial anaesthesia and anticoagulants. [2] AAGBI: Regional anaesthesia and patients with abnormalities of coagulation 2013. https://anaesthetists.org/Home/Resources-publications/Guidelines. Google Scholar This is pertinent on the labour ward where epidurals are commonplace and patients are often prescribed anticoagulation. Clear communication within the labour ward multidisciplinary team (MDT) is paramount in ensuring the safe timing of neuraxial anaesthesia. There are serious implications if these guidelines are not followed which could have devastating consequences for the patient.

513 Continuous Heparin Infusion in Burn Patients on Continuous Renal Replacement Therapy

Abstract Introduction Hyper-coagulopathy has been widely described in patients following burn injury. In burn patients with renal dysfunction requiring continuous renal replacement therapy (CRRT), citrate is commonly used to anticoagulate the circuit. However, if venous thromboembolism develops, or if the patient requires treatment-dose anticoagulation for acute coronary syndrome or atrial fibrillation, an unfractionated heparin (UFH) infusion can be used for anticoagulation. This study reviewed the use of heparin infusion in burned patients on concomitant continuous renal replacement therapy. Methods This study was a retrospective review of patients in a single burn center over six years. Patients were included if they were 18 years or older and receiving UFH as a continuous infusion for VTE, acute coronary syndrome (ACS), or new onset atrial fibrillation while on concomitant CRRT. Results Eight patients were included. Seven of eight patients reached a therapeutic aPTT level. The maximum rate of heparin infusion which was required to produce a therapeutic aPTT was 34 units/kg/hr while the minimum was 9 units/kg/hr. The patient requiring the highest heparin infusion rate met criteria for heparin resistance. Four of eight patients developed clinically significant bleeding while on heparin infusion. All four patients had some duration of concomitant citrate infusion during heparin infusion and all four were receiving heparin for VTE. Each of these patients required a heparin infusion rate of 24 units/kg/hr or greater to obtain therapeutic aPTT levels. Patients who did not have clinically significant bleeding had a maximum therapeutic heparin infusion rate of 22 units/kg/hr or less. Conclusions Heparin infusion can be used successfully in burn patients who are receiving concomitant CRRT, with the majority (7 of 8) of the patients in this study able to achieve a therapeutic aPTT level. Clinically significant bleeding occurred in 50% of patients and was associated with higher rates of heparin infusion (&amp;gt; 24 units/kg/hr) and the use of concomitant citrate infusion to anticoagulate the CRRT circuit. Heparin resistance appeared to be present in at least one patient in the study, with high doses of heparin required to achieve a therapeutic aPTT level.

Prevalence and Predictors of Venous Thromboembolism or Mortality in Hospitalized COVID-19 Patients.

We aimed to identify the prevalence and predictors of venous thromboembolism (VTE) or mortality in hospitalized coronavirus disease 2019 (COVID-19) patients. A retrospective cohort study of hospitalized adult patients admitted to an integrated health care network in the New York metropolitan region between March 1, 2020 and April 27, 2020. The final analysis included 9,407 patients with an overall VTE rate of 2.9% (2.4% in the medical ward and 4.9% in the intensive care unit [ICU]) and a VTE or mortality rate of 26.1%. Most patients received prophylactic-dose thromboprophylaxis. Multivariable analysis showed significantly reduced VTE or mortality with Black race, history of hypertension, angiotensin converting enzyme/angiotensin receptor blocker use, and initial prophylactic anticoagulation. It also showed significantly increased VTE or mortality with age 60 years or greater, Charlson Comorbidity Index (CCI) of 3 or greater, patients on Medicare, history of heart failure, history of cerebrovascular disease, body mass index greater than 35, steroid use, antirheumatologic medication use, hydroxychloroquine use, maximum D-dimer four times or greater than the upper limit of normal (ULN), ICU level of care, increasing creatinine, and decreasing platelet counts. In our large cohort of hospitalized COVID-19 patients, the overall in-hospital VTE rate was 2.9% (4.9% in the ICU) and a VTE or mortality rate of 26.1%. Key predictors of VTE or mortality included advanced age, increasing CCI, history of cardiovascular disease, ICU level of care, and elevated maximum D-dimer with a cutoff at least four times the ULN. Use of prophylactic-dose anticoagulation but not treatment-dose anticoagulation was associated with reduced VTE or mortality.

Incidence of symptomatic, image-confirmed venous thromboembolism following hospitalization for COVID-19 with 90-day follow-up.

Although COVID-19 has been reported to be associated with high rates of venous thromboembolism (VTE), the risk of VTE and bleeding after hospitalization for COVID-19 remains unclear, and the optimal hospital VTE prevention strategy is not known. We collected retrospective observational data on thrombosis and bleeding in 303 consecutive adult patients admitted to the hospital for at least 24 hours for COVID-19. Patients presenting with VTE on admission were excluded. Data were collected until 90 days after admission or known death by using medical records and an established national VTE network. Maximal level of care was ward based in 78% of patients, with 22% requiring higher dependency care (12% noninvasive ventilation, 10% invasive ventilation). Almost all patients (97.0%) received standard thromboprophylaxis or were already receiving therapeutic anticoagulation (17.5%). Symptomatic image-confirmed VTE occurred in 5.9% of patients during index hospitalization, and in 7.2% at 90 days after admission (23.9% in patients requiring higher dependency care); half the events were isolated segmental or subsegmental defects on lung imaging. Bleeding occurred in 13 patients (4.3%) during index hospitalization (1.3% had major bleeding). The majority of bleeds occurred in patients on the general ward, and 6 patients were receiving treatment-dose anticoagulation, highlighting the need for caution in intensifying standard thromboprophylaxis strategies. Of 152 patients discharged from the hospital without an indication for anticoagulation, 97% did not receive thromboprophylaxis after discharge, and 3% received 7 days of treatment with low molecular weight heparin after discharge. The rate of symptomatic VTE in this group at 42 days after discharge was 2.6%, highlighting the need for large prospective randomized controlled trials of extended thromboprophylaxis after discharge in COVID-19.

Outcomes in COVID-19 Patients on Treatment Dose Anti-Coagulation Compared to Prophylactic Dose Anti-Coagulation

IntroductionThe outcomes related to different anticoagulation doses in Coronavirus disease 2019 (COVID-19) patients are not well established. COVID-19 is associated with increased thrombotic events and early coagulopathy as reported by a large New York City health system.Initial studies on patients in Wuhan, China showed anticoagulant therapy mainly with low molecular weight heparin was reported to be associated with better prognosis in severe COVID‐19 patients meeting sepsis‐induced coagulopathy criteria or with markedly elevated D‐dimer. These studies fueled the need for anticoagulation protocols to be institutionalized broadly.Here we report the outcomes of patients on prophylactic compared to treatment dose anticoagulation early in the COVID-19 pandemic. This data reflects results before broad institutionalization of anticoagulation protocols for this novel disease in a Brooklyn, New York population.MethodsThis is a retrospective chart review of all laboratory confirmed COVID-19 patients who were admitted to New York-Presbyterian Brooklyn Methodist Hospital between March and April, 2020. Patient clinical characteristics were manually extracted from electronic medical records. Patients were divided into 2 groups: patients on treatment dose anticoagulation and patients on prophylactic dose anticoagulation. Primary outcome of this study was inpatient mortality among the two groups. Secondary outcomes were thromboembolisms (both arterial and venous), myocardial infarction (MI), major bleeding, ICU admission, ICU length of stay, invasive mechanical ventilation and initiation of dialysis. Odds ratio and p-values were obtained using univariate analysis.ResultsWe analyzed 580 hospitalized patients with confirmed nasopharyngeal COVID19 infection. Of these, 82 patients were on treatment dose anticoagulation 498 patients were on prophylactic dose. Median age was 70 years in treatment dose group and 66 years in prophylactic dose group. Percentage of males were similar between both groups (53%). African American race(56% vs 46%) was the predominant race in both groups. Median BMI was 28.1 in both groups. Percentage of smokers was higher in the treatment dose group (34% compared to 21%). Patients in the treatment dose group had a higher rate of all the comorbidities. Median D-Dimer (630 vs 590) was higher in the treatment dose group.Rates of ICU admission in treatment dose group and prophylactic dose group was 44% and 22% respectively. Patients requiring intubation (43% vs 24%) and transfusion (24% and 7%) were higher in the treatment dose group. There was an increased incidence of thromboembolic events in the treatment dose group as compared to prophylactic dose group with DVT (15.6% vs 1.6%) PE (3.7% vs 0.2%), arterial thrombosis (1.2% vs 0%) and MI (6.1% vs 1.6%). Incidence of major bleeding was higher in the treatment group (10% vs3.5%)DiscussionOur study found increased inpatient mortality with treatment dose anticoagulation and increased risk of bleeding when compared with prophylactic dose anticoagulation. These findings may be due to higher rates of comorbidities, smoking and older age when compared to the prophylactic anticoagulation group. Higher rates of bleeding raises concern for the safety of treatment dose anticoagulation in these populations.Some limitations of this study include: uneven sample size between the two groups and data was collected from patients before anticoagulation dose recommendations were standardized and officially implemented. Further randomized control trials are needed to evaluate the dose- dependent relationship between anticoagulation and mortality.Our study suggests that the treatment dose anticoagulation may adversely affect the outcomes in COVID-19 patients who are older and have multiple comorbidities. Therefore, the anticoagulation dose must be chosen carefully given the overall clinical picture.DisclosuresNo relevant conflicts of interest to declare.

Hypercoagulability in ICU Patients With Coronavirus Disease 2019 With Respiratory Failure Results in Increased Prevalence of Venous Thromboembolic Disease

Hypercoagulability in ICU Patients With Coronavirus Disease 2019 With Respiratory Failure Results in Increased Prevalence of Venous Thromboembolic Disease

Unusual arterial thrombotic events in Covid-19 patients

IntroductionCOVID-19 infection is commonly complicated with pro-thrombotic state and endothelial dysfunction. While several studies reported a high incidence of venous thromboembolic events. The occurrence of arterial thromboses are yet rarely described and could be underestimated. ObjectivesTo describe the clinical and biological characteristics of COVID-19 patients presenting with an associated arterial thromboembolic event. Material and methodsWe performed a retrospective multicentric study in 3 centers between France and Italy. All patients with a confirmed SARS-CoV-2 infection and arterial thromboembolic events were included in the analysis. ResultsFrom March 8th to April 25th 2020, we identified 20 patients (24 events) with arterial thromboembolic events over 209 admitted patients (9.6%) with severe COVID-19 infection. Arterial thrombotic events included acute coronary occlusions (n = 9), stroke (n = 6), limb ischemia (n = 3), splenic infarcts (n = 3), aortic thrombosis (n = 2) and occlusive mesenteric ischemia (n = 1). At the time of the event, 10/20 (50%) of patients received thromboprohylaxis, 2/20 (10%) were receiving treatment dose anticoagulation and 5/20 (25%) were receiving antiplatelet therapy. ConclusionOur observations suggest that serious arterial thrombotic events might occur in Covid-19 patients. However, the exact incidence of such events and the best way to prevent them yet remains to be investigated.

Characterization of Patients Who Return to Hospital Following Discharge from Hospitalization for COVID-19.

BackgroundData on patients with coronavirus disease 2019 (COVID-19) who return to hospital after discharge are scarce. Characterization of these patients may inform post-hospitalization care.ObjectiveTo describe clinical characteristics of patients with COVID-19 who returned to the emergency department (ED) or required readmission within 14 days of discharge.DesignRetrospective cohort study of SARS-COV-2-positive patients with index hospitalization between February 27 and April 12, 2020, with ≥ 14-day follow-up. Significance was defined as P < 0.05 after multiplying P by 125 study-wide comparisons.ParticipantsHospitalized patients with confirmed SARS-CoV-2 discharged alive from five New York City hospitals.Main MeasuresReadmission or return to ED following discharge.ResultsOf 2864 discharged patients, 103 (3.6%) returned for emergency care after a median of 4.5 days, with 56 requiring inpatient readmission. The most common reason for return was respiratory distress (50%). Compared with patients who did not return, there were higher proportions of COPD (6.8% vs 2.9%) and hypertension (36% vs 22.1%) among those who returned. Patients who returned also had a shorter median length of stay (LOS) during index hospitalization (4.5 [2.9,9.1] vs 6.7 [3.5, 11.5] days; Padjusted = 0.006), and were less likely to have required intensive care on index hospitalization (5.8% vs 19%; Padjusted = 0.001). A trend towards association between absence of in-hospital treatment-dose anticoagulation on index admission and return to hospital was also observed (20.9% vs 30.9%, Padjusted = 0.06). On readmission, rates of intensive care and death were 5.8% and 3.6%, respectively.ConclusionsReturn to hospital after admission for COVID-19 was infrequent within 14 days of discharge. The most common cause for return was respiratory distress. Patients who returned more likely had COPD and hypertension, shorter LOS on index-hospitalization, and lower rates of in-hospital treatment-dose anticoagulation. Future studies should focus on whether these comorbid conditions, longer LOS, and anticoagulation are associated with reduced readmissions.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06120-6) contains supplementary material, which is available to authorized users.

Anticoagulation, immortality, and observations of COVID‐19

Anticoagulation, immortality, and observations of COVID‐19

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Introduction: Although venous thromboembolism (VTE) risk factors for pediatric trauma patients have been identified in recent literature, overall low occurrence rates have resulted in minimal guidance on risk assessments and prophylaxis regimens. Methods: A single center retrospective chart review of patients 17 years of age and younger admitted to the Pediatric Trauma Service between July 1, 2008 and December 1, 2011 was conducted. A VTE risk assessment was developed and retrospectively applied to each patient to determine appropriateness of VTE prophylaxis. Results: Eight hundred four patients met initial inclusion criteria. Of these, 200 were evaluated with the VTE risk assessment and included for review. The median age was 11 years (IQR 5–16). One hundred twenty-five patients (62%) received appropriate prophylaxis. Reasons for inappropriate prophylaxis were a lack of sequential compression device (SCD) orders in 55 patients (73%), lack of pharmacologic prophylaxis orders in 14 patients (19%), and pharmacologic prophylaxis orders when not indicated by the risk assessment in six patients (8%). Pharmacologic prophylaxis was prescribed in 28% of patients. VTE occurred in four patients. Risk factors for VTE were an elevated Injury Severity score (p=0.03), lower Glasgow Coma Scale score (p=0.03), and the presence of central venous lines (p=0.004). Median ICU length of stay for patients with and without a VTE was nine (IQR 7–45) vs two days (IQR 0–4), respectively (p=0.006). Median hospital length of stay was 25 (IQR 14–51) vs six days (IQR 4–11), respectively (p=0.008). One bleeding event occurred (0.5%) in a patient receiving treatment dose anticoagulation. There was one death unrelated to VTE events. Conclusions: Though VTE prophylaxis is commonly administered to pediatric patients at this trauma center, adherence (62%) has room for improvement according to the study VTE risk assessment and recommendations. A standard VTE risk assessment and protocol may be beneficial in this population to ensure consistent prophylaxis.