Epidemiology
· There is higher prevalence of pulmonary macrothrombi in SARS-CoV-2 than in influenza A. A comparative analysis by pathologists at University Hospital Zurich in Switzerland assessed pulmonary macrothrombi autopsy findings in 411 patients who died from the Influenza A pandemic in 1918/1919, 12 from Influenza A in 2009-2020, and 75 for COVID-19. They found COVID-19 patients had significantly higher occurrences of grossly visible pulmonary thrombosis despite empiric thrombophylaxis due to in situ clot formation associated with SARS-CoV-2. Authors suggest a specific COVID-19 coagulopathy may be linked to higher mortality rate seen in COVID-19 compared to the seasonal flu.
Understanding the Pathology
· In vivo demonstration of microvascular thrombosis in severe COVID-19 was found in one study where researchers in the Department of Internal Medicine, Ribeirão Preto School of Medicine in Brazil conducted imaging via video capillaroscopy of 13 severe COVID-19 positive patients requiring mechanical ventilation to assess sublingual microcirculation for evidence of microthrombi. They found microthrombi in 11/13 (85%) of patients and acute thromboembolic occlusion in 5/13 (38%) of patients. This evidence suggests that microvascular thrombosis could be considered a hallmark of COVID-19 and that these microvascular thrombotic events occur systemically, affecting many organ systems. Management
· Dosing of thromboprophylaxis and mortality in critically ill COVID-19 patients were explored by investigators in Stockholm, Sweden. They analyzed thromboprophylaxis and 28-day mortality among 156 patients with COVID-19-associated respiratory failure admitted to 2 local ICUs. Dosing was dependent on changes in regional guidelines over time and not patient severity. Results illustrated the following: - 67 patients on low-dose thromboprophylaxis had a mortality rate of 38.8% - 48 patients on medium-dose thromboprophylaxis had a mortality rate of 25% - 37 patients on high-dose thromboprophylaxis had the lowest mortality rate of 13.5% These findings suggest that starting critically ill patients on high-dose thromboprophylaxis maybe a beneficial strategy in reducing thromboembolic events and mortality.
· Point-of-Care Ultrasound (POCUS) can be useful in managing ICU Patients with COVID-19. In a guideline article, physicians at Prisma Health USC Medical Group in Charleston, South Carolina provide benefits of using POCUS on critically-ill COVID-19 patients at various diagnostic stages, in order to provide accurate and efficient care, while also attempting to decrease contamination of additional instrumentation and reduce viral transmission to hospital staff. They advocate for POCUS as a safe and valuable imaging modality to manage patients throughout the entire ICU course and suggest that it may provide benefits over other modalities for various diagnostic protocols. Adjusting Practice During COVID-19
· Fewer motor vehicle collisions and higher alcohol involvement were seen in COVID-19 Pandemic trauma presentations in one trauma center. Medical students and physicians from the Medical College of Georgia compared trauma activations at their level 1 trauma center between March 1 and June 15, 2020 to trauma activations from the same time frame in the previous 5 years (2015-2019). While there was no difference in the number and distribution of trauma cases, they found fewer motor vehicle collisions (MVCs)(p=0.009704), higher incidence of alcohol involvement in traumas (p=2.26 × 10^-7), and longer average length of hospital stay (3.87 vs 5.39; p=8.488 × 10^-6) in 2020 compared to pre-pandemic years. Authors suggest the decreased number of MVCs is attributable to fewer drivers during pandemic-related lockdowns but recommend further investigation into factors influencing the observed increase in alcohol related trauma and longer hospital stays to better identify areas of potential preventative interventions.
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