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

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.

Venous Thromboembolism in COVID-19 Compared to Non-COVID-19 Cohorts: A Systematic Review with Meta-Analysis

“…Characteristics of the selected studies: We identified 5792 citations, of which 113 were retained for full-text evaluation. Twelve articles [12,[17][18][19][20][21][22][23][24][25][26][27], reporting data on 7011 COVID-19 patients and 1,006,484 non-COVID-19 patients, were finally included (Figure 1). The characteristics of the studies are reported in (Table 1).…”

“…The characteristics of the studies are reported in (Table 1). Eight studies were retrospective [12,17,18,20,22,[24][25][26], three were prospective [19,21,23], and one was an autoptic evaluation [27].…”

“…Six studies included patients admitted into the ICU [12,19,21,22,24,25], while two studies were performed in emergency departments [18,23]. Six studies compared COVID-19 patients with influenza patients [12,17,22,24,25,27], and two studies included community and viral pneumonia [20,26].…”

The Janus Face of Coronavirus Disease 2019–Associated Coagulopathy

“…We congratulate Doyle et al ( 1 ) on their exciting and clinically relevant report published in a recent issue of Critical Care Medicine comparing thromboembolic complications and bleeding events in coronavirus disease (COVID)–19 acute respiratory distress syndrome (ARDS) with influenza A patients on veno-venous extracorporeal membrane oxygenation (ECMO). The key finding that COVID-19–induced ARDS is associated with higher thromboembolic events despite therapeutic anticoagulation is of high relevance to the community of intensivists.…”

A comprehensive review of vascular complications in COVID-19

“…Anticoagulation strategy in COVID-19 patients on ECMO is further complicated by the co-existence of thrombocytopenia and thromboembolism [ 65 , 66 ]. Therefore, the innate thrombotic potential of ECMO within the emerging evidence of higher thrombotic complications seen in COVID-19 makes it challenging, necessitating a large scale study to establish its clinical utility [ 67 , 68 ].…”