Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

doi:10.1186/s13054-020-03260-3

Observational Study

. 2020 Sep 18;24(1):561.

doi: 10.1186/s13054-020-03260-3.

Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

Akshay Shah^{1

2}, Killian Donovan³, Anna McHugh⁴, Manish Pandey⁵, Louise Aaron³, Charlotte A Bradbury⁶, Simon J Stanworth^{7

8}, Raza Alikhan⁹, Stephen Von Kier¹⁰, Keith Maher¹⁰, Nicola Curry^{8

11}, Susan Shapiro^{8

11}, Matthew J Rowland^{3

12}, Matt Thomas⁴, Richard Mason⁴, Matthew Holland⁴, Tom Holmes⁵, Michael Ware⁵, Stefan Gurney¹³, Stuart R McKechnie³

Affiliations

¹ Radcliffe Department of Medicine, Level 4 Academic Block, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. akshay.shah@linacre.ox.ac.uk.
² Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. akshay.shah@linacre.ox.ac.uk.
³ Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁴ Intensive Care Unit, North Bristol NHS Trust, Bristol, UK.
⁵ Adult Intensive Care Unit, University Hospital of Wales, Cardiff, Wales, UK.
⁶ Faculty of Health Sciences, University of Bristol, Bristol, UK.
⁷ Radcliffe Department of Medicine, Level 4 Academic Block, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
⁸ Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK.
⁹ Haemostasis and Thrombosis, Department of Haematology, University Hospital of Wales, Cardiff, UK.
¹⁰ Blood Management and Conservation Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
¹¹ Oxford Haemophilia & Thrombosis Centre, Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation, Oxford, UK.
¹² Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
¹³ Intensive Care Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK.

PMID: 32948243
PMCID: PMC7499016
DOI: 10.1186/s13054-020-03260-3

Free PMC article

Observational Study

Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

Akshay Shah et al. Crit Care. 2020.

Free PMC article

. 2020 Sep 18;24(1):561.

doi: 10.1186/s13054-020-03260-3.

Authors

Affiliations

¹ Radcliffe Department of Medicine, Level 4 Academic Block, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. akshay.shah@linacre.ox.ac.uk.
² Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. akshay.shah@linacre.ox.ac.uk.
³ Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁴ Intensive Care Unit, North Bristol NHS Trust, Bristol, UK.
⁵ Adult Intensive Care Unit, University Hospital of Wales, Cardiff, Wales, UK.
⁶ Faculty of Health Sciences, University of Bristol, Bristol, UK.
⁷ Radcliffe Department of Medicine, Level 4 Academic Block, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
⁸ Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK.
⁹ Haemostasis and Thrombosis, Department of Haematology, University Hospital of Wales, Cardiff, UK.
¹⁰ Blood Management and Conservation Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
¹¹ Oxford Haemophilia & Thrombosis Centre, Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation, Oxford, UK.
¹² Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
¹³ Intensive Care Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK.

PMID: 32948243
PMCID: PMC7499016
DOI: 10.1186/s13054-020-03260-3

Abstract

Background: Optimal prophylactic and therapeutic management of thromboembolic disease in patients with COVID-19 remains a major challenge for clinicians. The aim of this study was to define the incidence of thrombotic and haemorrhagic complications in critically ill patients with COVID-19. In addition, we sought to characterise coagulation profiles using thromboelastography and explore possible biological differences between patients with and without thrombotic complications.

Methods: We conducted a multicentre retrospective observational study evaluating all the COVID-19 patients received in four intensive care units (ICUs) of four tertiary hospitals in the UK between March 15, 2020, and May 05, 2020. Clinical characteristics, laboratory data, thromboelastography profiles and clinical outcome data were evaluated between patients with and without thrombotic complications.

Results: A total of 187 patients were included. Their median (interquartile (IQR)) age was 57 (49-64) years and 124 (66.3%) patients were male. Eighty-one (43.3%) patients experienced one or more clinically relevant thrombotic complications, which were mainly pulmonary emboli (n = 42 (22.5%)). Arterial embolic complications were reported in 25 (13.3%) patients. ICU length of stay was longer in patients with thrombotic complications when compared with those without. Fifteen (8.0%) patients experienced haemorrhagic complications, of which nine (4.8%) were classified as major bleeding. Thromboelastography demonstrated a hypercoagulable profile in patients tested but lacked discriminatory value between those with and without thrombotic complications. Patients who experienced thrombotic complications had higher D-dimer, ferritin, troponin and white cell count levels at ICU admission compared with those that did not.

Conclusion: Critically ill patients with COVID-19 experience high rates of venous and arterial thrombotic complications. The rates of bleeding may be higher than previously reported and re-iterate the need for randomised trials to better understand the risk-benefit ratio of different anticoagulation strategies.

Keywords: COVID-19; Haemorrhage; Heparin; Thrombosis.

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Conflict of interest statement

None.

Figures

**Fig. 1**
Description of thrombotic and haemorrhagic complications

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References

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[1] Joly BS, Siguret V, Veyradier A. Understanding pathophysiology of hemostasis disorders in critically ill patients with COVID-19. Intensive Care Med. 2020. 10.1007/s00134-020-06088-1. - PMC - PubMed

[2] Joly BS, Siguret V, Veyradier A. Understanding pathophysiology of hemostasis disorders in critically ill patients with COVID-19. Intensive Care Med. 2020. 10.1007/s00134-020-06088-1. - PMC - PubMed

[3] Mojoli F, Mongodi S, Orlando A, Arisi E, Pozzi M, Civardi L, et al. Our recommendations for acute management of COVID-19. Crit Care. 2020;24:207. doi: 10.1186/s13054-020-02930-6. - DOI - PMC - PubMed

[4] Mojoli F, Mongodi S, Orlando A, Arisi E, Pozzi M, Civardi L, et al. Our recommendations for acute management of COVID-19. Crit Care. 2020;24:207. doi: 10.1186/s13054-020-02930-6. - DOI - PMC - PubMed

[5] Murthy S, Gomersall CD, Fowler RA. Care for critically ill patients with COVID-19. JAMA. 2020;323:1499–1500. doi: 10.1001/jama.2020.3633. - DOI - PubMed

[6] Murthy S, Gomersall CD, Fowler RA. Care for critically ill patients with COVID-19. JAMA. 2020;323:1499–1500. doi: 10.1001/jama.2020.3633. - DOI - PubMed

[7] Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19. N Engl J Med. 2020. 10.1056/NEJMoa2015432. - PMC - PubMed

[8] Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19. N Engl J Med. 2020. 10.1056/NEJMoa2015432. - PMC - PubMed

[9] Wang Y, Lu X, Chen H, Chen T, Su N, Huang F, et al. Clinical course and outcomes of 344 intensive care patients with COVID-19. Am J Respir Crit Care Med. 2020;201:1430–1434. doi: 10.1164/rccm.202003-0736LE. - DOI - PMC - PubMed

[10] Wang Y, Lu X, Chen H, Chen T, Su N, Huang F, et al. Clinical course and outcomes of 344 intensive care patients with COVID-19. Am J Respir Crit Care Med. 2020;201:1430–1434. doi: 10.1164/rccm.202003-0736LE. - DOI - PMC - PubMed

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Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

Affiliations

Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

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Abstract

Conflict of interest statement

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