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Observational Study
. 2021 Jul 1;49(7):e663-e672.
doi: 10.1097/CCM.0000000000004971.

A Comparison of Thrombosis and Hemorrhage Rates in Patients With Severe Respiratory Failure Due to Coronavirus Disease 2019 and Influenza Requiring Extracorporeal Membrane Oxygenation

Andrew J Doyle  1 , Beverley J Hunt  1 , Barnaby Sanderson  2 , Joseph Zhang  2 , Sze M Mak  3 , Guilia Benedetti  3 , Karen A Breen  1 , Luigi Camporota  2 , Nicholas A Barrett  2   4 , Andrew Retter  2
Affiliations
Observational Study

A Comparison of Thrombosis and Hemorrhage Rates in Patients With Severe Respiratory Failure Due to Coronavirus Disease 2019 and Influenza Requiring Extracorporeal Membrane Oxygenation

Andrew J Doyle et al. Crit Care Med. .

Abstract

Objectives: Extracorporeal membrane oxygenation is a lifesaving therapy for patients with severe acute respiratory distress syndrome refractory to conventional mechanical ventilation. It is frequently complicated by both thrombosis and hemorrhage. A markedly prothrombotic state associated with high rates of venous thromboembolism has been described in patients with severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) infection. These rates have currently not been described during extracorporeal membrane oxygenation in comparison to other viral pneumonias.

Design: Retrospective observational study.

Setting: Single high-volume tertiary critical care department at a university hospital.

Patients: Patients 16 years old or greater receiving venovenous extracorporeal membrane oxygenation between March 1, 2020, and May 31, 2020, with coronavirus disease 2019 were compared with a cohort of patients with influenza pneumonia between June 1, 2012, and May 31, 2020.

Interventions: None.

Measurements and main results: The rates of venous thromboembolism and hemorrhage were compared in patients with coronavirus disease 2019 against a historic population of patients with influenza pneumonia who required extracorporeal membrane oxygenation. There were 51 patients who received extracorporeal membrane oxygenation due to coronavirus disease 2019 and 80 patients with influenza. At cannulation for extracorporeal membrane oxygenation, 37% of patients with coronavirus disease 2019 compared with 8% of patients with influenza had filling defects on CT pulmonary angiography (p = 0.0001). Catheter-associated deep vein thrombosis shown on ultrasound Doppler after decannulation was present in 53% with coronavirus disease 2019 versus 25% with influenza (p = 0.01). The rates of intracranial hemorrhage at the time of cannulation were 16% with coronavirus disease 2019 and 14% with influenza (p = 0.8). Elevated d-dimer levels were seen in both conditions and were significantly higher in those with pulmonary thromboembolism than those without in coronavirus disease 2019 (p = 0.02). Fibrinogen and C-reactive protein levels were significantly higher in those with coronavirus disease 2019 than influenza (p < 0.01).

Conclusions: Significant rates of pulmonary thromboembolism and of catheter-associated deep vein thrombosis were seen in both viral infections but were greater in those requiring the use of extracorporeal membrane oxygenation in coronavirus disease 2019 than for influenza.

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Conflict of interest statement

Dr. Hunt disclosed that she is the Medical Director of Thrombosis UK. Dr. Barrett received research and educational support from Maquet and ALung Incorporated. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Comment in

  • The Janus Face of Coronavirus Disease 2019-Associated Coagulopathy.
    Stahl K, Seeliger B, Hofmaenner DA, Doebler M, Bode C, David S. Stahl K, et al. Crit Care Med. 2021 Oct 1;49(10):e1049-e1050. doi: 10.1097/CCM.0000000000005128. Crit Care Med. 2021. PMID: 34048369 Free PMC article. No abstract available.
  • The authors reply.
    Doyle AJ, Retter A. Doyle AJ, et al. Crit Care Med. 2021 Oct 1;49(10):e1050-e1051. doi: 10.1097/CCM.0000000000005199. Crit Care Med. 2021. PMID: 34166291 Free PMC article. No abstract available.

References

    1. Desborough MJR, Doyle AJ, Griffiths A, et al. Image-proven thromboembolism in patients with severe COVID-19 in a tertiary critical care unit in the United Kingdom. Thromb Res. 2020; 193:1–4
    1. Klok FA, Kruip MJHA, van der Meer NJM, et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis. Thromb Res. 2020; 191:148–150
    1. Thomas W, Varley J, Johnston A, et al. Thrombotic complications of patients admitted to intensive care with COVID-19 at a teaching hospital in the United Kingdom. Thromb Res. 2020; 191:76–77
    1. Nopp S, Moik F, Jilma B, et al. Risk of venous thromboembolism in patients with COVID-19: A systematic review and meta-analysis. Res Pract Thromb Haemost. 2020; 4:1178–1191
    1. Tomashefski JF Jr, Davies P, Boggis C, et al. The pulmonary vascular lesions of the adult respiratory distress syndrome. Am J Pathol. 1983; 112:112–126

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