Thrombosis-Related Loss of Arterial Lines in the First Wave of COVID-19 and Non-COVID-19 Intensive Care Unit Patients

Abstract

Background: Patients with coronavirus disease 2019 (COVID-19) can present with severe respiratory distress requiring intensive care unit (ICU)-level care. Such care often requires placement of an arterial line for monitoring of pulmonary disease progression, hemodynamics, and laboratory tests. During the first wave of the COVID-19 pandemic in March 2020, experienced physicians anecdotally reported multiple attempts, decreased insertion durations, and greater need for replacement of arterial lines in patients with COVID-19 due to persistent thrombosis. Because invasive procedures in patients with COVID-19 may increase the risk for caregiver infection, better defining difficulties in maintaining arterial lines in COVID-19 patients is important. We sought to explore the association between COVID-19 infection and arterial line thrombosis in critically ill patients.

Methods: In this primary exploratory analysis, a multivariable Fine-Gray subdistribution hazard model was used to retrospectively estimate the association between critically ill COVID-19 (versus sepsis/acute respiratory distress syndrome [ARDS]) patients and the risk of arterial line removal for thrombosis (with arterial line removal for any other reason treated as a competing risk). As a sensitivity analysis, we compared the number of arterial line clots per 1000 arterial line days between critically ill COVID-19 and sepsis/ARDS patients using multivariable negative binomial regression.

Results: We retrospectively identified 119 patients and 200 arterial line insertions in patients with COVID-19 and 54 patients and 68 arterial line insertions with non-COVID ARDS. Using a Fine-Gray subdistribution hazard model, we found the adjusted subdistribution hazard ratio (95% confidence interval [CI]) for arterial line clot to be 2.18 (1.06-4.46) for arterial lines placed in COVID-19 patients versus non-COVID-19 sepsis/ARDS patients ( P = .034). Patients with COVID-19 had 36.3 arterial line clots per 1000 arterial line days compared to 19.1 arterial line clots per 1000 arterial line days in patients without COVID-19 (adjusted incidence rate ratio [IRR] [95% CI], 1.78 [0.94-3.39]; P = .078).

Conclusions: Our study suggests that arterial line complications due to thrombosis are more likely in COVID-19 patients and supports the need for further research on the association between COVID-19 and arterial line dysfunction requiring replacement.

Figure 1.

Flow diagram of COVID-19 and non–COVID-19 sepsis/ARDS ICU patient selection. ARDS indicates acute respiratory distress syndrome; COVID-19‚ coronavirus disease 2019; ICU, intensive care unit; RoCI, registry of critical illness database.

Figure 2.

Plot of cause-specific cumulative incidence of removal of arterial lines due to clot formation for COVID-19 ICU and non–COVID-19 sepsis/ARDS ICU patients. Arterial line removal for reason besides clot was treated as a competing risk. ARDS indicates acute respiratory distress syndrome; COVID-19‚ coronavirus disease 2019; ICU, intensive care unit.

Figure 3.

Plot of cause-specific cumulative incidence of removal of arterial lines for clot for COVID-19 ICU patients stratified by maximum anticoagulation strategy used. Arterial line removal for reason besides clot was treated as a competing risk. COVID-19 indicates coronavirus disease 2019; ICU‚ intensive care unit.