Point of care ultrasound screening for deep vein thrombosis in critically ill COVID-19 patients, an observational study

Abstract

Background Deep vein thrombosis (DVT) is common in critically ill patients with Coronavirus disease 2019 (COVID-19) and may cause fatal pulmonary embolism (PE) prior to diagnosis due to subtle clinical symptoms. The aim of this study was to explore the feasibility of bedside screening for DVT in critically ill COVID-19 patients performed by physicians with limited experience of venous ultrasound. We further aimed to compare inflammation, coagulation and organ dysfunction in patients with and without venous thromboembolism (VTE). Methods This observational study included patients with COVID-19 admitted to the intensive care unit (ICU) of a tertiary hospital in Sweden and screened for DVT with proximal compression ultrasound of the lower extremities between April and July 2020. Screening was performed by ICU residents having received a short online education and one hands-on-session. Pathological screening ultrasound was confirmed by formal ultrasound whereas patients with negative screening underwent formal ultrasound on clinical suspicion. Clinical data, laboratory findings and follow-up were extracted from medical records. Results Of 90 eligible patients, 56 were screened by seven ICU residents with no (n = 5) or limited (n = 2) previous experience of DVT ultrasound who performed a median of 4 (IQR 2–19) examinations. Four (7.1%) patients had pathological screening ultrasound of which three (5.6%) were confirmed by formal ultrasound. None of the 52 patients with negative screening ultrasound were diagnosed with DVT during follow-up. Six patients were diagnosed with PE of which four prior to negative screening and two following negative and positive screening respectively. Patients with VTE (n = 8) had higher median peak D-dimer (24.0 (IQR 14.2–50.5) vs. 2.8 (IQR 1.7–7.2) mg/L, p = 0.004), mean peak C-reactive protein (363 (SD 80) vs. 285 (SD 108) mg/L, p = 0.033) and median peak plasma creatinine (288 (IQR 131–328) vs. 94 (IQR 78–131) μmol/L, p = 0.009) compared to patients without VTE (n = 48). Five patients (63%) with VTE received continuous renal replacement therapy compared to six patients (13%) without VTE (p = 0.005). Conclusion ICU residents with no or limited experience could detect DVT with ultrasound in critically ill COVID-19 patients following a short education. VTE was associated with kidney dysfunction and features of hyperinflammation and hypercoagulation. Trial registration ClinicalTrials ID: NCT04316884. Registered 20 March 2020.

Therapeutic anticoagulation to prevent thrombosis, coagulopathy, and mortality in severe COVID‐19: The Swiss COVID‐HEP randomized clinical trial

“…This is in agreement with previous prospective studies, the HEP‐COVID, and X‐COVID‐19 trials showing a low prevalence of asymptomatic proximal DVT of 0% to 2.9% among acutely ill medical patients 14,17,30‐32 . In the ICU, we did not find the elevated (5%–23%) risks found by previous prospective studies 33‐37 …”

“…14,17,[30][31][32] In the ICU, we did not find the elevated (5%-23%) risks found by previous prospective studies. [33][34][35][36][37] Our trial has several strengths. We conducted active follow-up after hospital discharge, until 1 month.…”

Association of interleukin-6, ferritin, and lactate dehydrogenase with venous thromboembolism in COVID-19: a systematic review and meta-analysis

“…1, a total of 208 studies were obtained with our search strategy, after excluding repeated articles and screening title and abstract, we retained 51 eligible studies. Further, 34 studies were excluded after full-text screening, and we finally had 17 literatures [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] for meta-analysis, including 12 retrospective cohort studies and 5 prospective cohort studies. The main characteristics of these studies were displayed in Table 1.…”

HOCUS POCUS: ultrasound beyond regional anesthesia in the ambulatory setting

“…Though both two-point and three-point compression scans seem to have high specificity and sensitivity, recent recommendations favor a three-point scan for a complete screening [2 ▪▪ ,22,25 ▪▪ ]. It was shown that a group of ICU residents after a basic education were able to detect DVT with ultrasound [26]. DVT POCUS is easy to perform and takes only a few minutes for those already skilled in ultrasound guided peripheral nerve blocks.…”