Coronavirus disease-19 (COVID-19) includes a thromboinflammatory syndrome that may manifest with microvascular and macrovascular thrombosis. Patients with COVID-19 have a higher incidence of venous ...thromboembolism than other hospitalized patients. Three randomized control trials suggesting benefit of therapeutic heparin in hospitalized noncritically ill patients with COVID-19 have led to conditional guideline recommendations for this treatment. By contrast, prophylactic-dose heparin is recommended for critically ill patients. Unprecedented collaboration and rapidly funded research have improved care of hospitalized patients with COVID-19.
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In this narrative review, the epidemiology, diagnosis, prevention strategies, and management of catheter-related thrombosis are outlined. Central venous catheters have significantly improved the ...quality of life of patients requiring chemotherapy, parenteral nutrition, and chronic transfusions. Catheter-related thrombosis (CRT) complicates between 1–5% of inserted catheters, with incidence varying between patient population, catheter type, and vein cannulated. Strategies to prevent CRT, including anticoagulation and locking solutions, have largely been ineffective. Using clinical decision tools and D-dimer testing can limit radiographic testing for patients with suspected CRT. Although most patients with CRT are treated with anticoagulation, the most effective type and duration of treatment have not been established for adults or children. Many unanswered questions remain concerning risk stratification, prevention, and management of CRT. National and international collaborative research networks could be harnessed to perform these much needed studies.
•Catheter-related thrombosis (CRT) occurs in 1–5% of inserted catheters.•The Constans score is a clinical prediction rule for upper extremity thrombosis.•The most effective type and duration of therapy for CRT has not been established.•Treatment of CRT in children is based upon studies in adults.
This is the 2nd update to the 9th edition of these guidelines. We provide recommendations on 17 PICO (Population, Intervention, Comparator, Outcome) questions, four of which have not been addressed ...previously.
We generate strong and weak recommendations based on high-, moderate-, and low-certainty evidence, using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.
The panel generated 29 guidance statements, 13 of which are graded as strong recommendations, covering aspects of antithrombotic management of VTE from initial management through secondary prevention and risk reduction of postthrombotic syndrome. Four new guidance statements have been added that did not appear in the 9th edition (2012) or 1st update (2016). Eight statements have been substantially modified from the 1st update.
New evidence has emerged since 2016 that further informs the standard of care for patients with VTE. Substantial uncertainty remains regarding important management questions, particularly in limited disease and special patient populations.
Background
COVID‐19 vaccinations in the United States are effective in preventing illness and hospitalization yet concern over post‐vaccination venous thromboembolism (VTE) risk has led to vaccine ...hesitancy.
Methods
The aim of this study was to compare VTE rates before and after COVID‐19 vaccination. COVID‐19 vaccinated patients ≥18 years between November 1, 2020 through November 1, 2021 were analyzed using electronic medical records across the Mayo Clinic enterprise. The primary outcome was imaging confirmed acute VTE (upper or lower deep vein thrombosis or pulmonary embolism) occurring 90 days before and after the date of first vaccine dose.
Results
A total of 792 010 patients with at least one COVID‐19 vaccination were identified (Pfizer, n = 452 950, Moderna, n = 290 607, and Janssen Johnson & Johnson, n = 48 453). A total of 1565 VTE events occurred in the 90 days before (n = 772) and after (n = 793) COVID‐19 vaccination. VTE post‐vaccination occurred in 326 patients receiving Moderna (0.11%, incidence rate IR 4.58 per 1000p‐years), 425 patients receiving Pfizer (0.09%, IR 3.84 per 1000p‐years), and 42 receiving Janssen (0.09%, IR 3.56 per 1000p‐years). Compared to the pre‐vaccination timeframe, the adjusted hazard ratio (aHR) for VTE after the Janssen vaccination was 0.97 (95% confidence interval CI 0.63–1.50), aHR 1.02 (95% CI 0.87–1.19) for Moderna, and aHR 1.00 (95% CI 0.87–1.15) for Pfizer.
Conclusion
In this large cohort of COVID‐19 vaccinated patients, no increased risk for acute VTE post‐vaccination was identified for the authorized vaccines in the United States.
Background
The Recipient Epidemiology and Donor Evaluation Study‐IV‐Pediatric (REDS‐IV‐P) is a new iteration of prior National Heart, Lung, and Blood Institute (NHLBI) REDS programs that focus on ...improving transfusion recipient outcomes across the lifespan as well as the safety and availability of the blood supply.
Study Design and Methods
The US program includes blood centers and hospitals (22 including 6 free‐standing Children's hospitals) in four geographic regions. The Brazilian program has 5 participating hemocenters. A Center for Transfusion Laboratory Studies (CTLS) and a Data Coordinating Center (DCC) support synergistic studies and activities over the 7‐year REDS‐IV‐P program.
Results
The US is building a centralized, vein‐to‐vein (V2V) database, linking information collected from blood donors, their donations, the resulting manufactured components, and data extracts from hospital electronic medical records of transfused and non‐transfused patients. Simultaneously, the Brazilian program is building a donor, donation, and component database. The databases will serve as the backbone for retrospective and prospective observational studies in transfusion epidemiology, transfusion recipient outcomes, blood component quality, and emerging blood safety issues. Special focus will be on preterm infants, patients with sickle cell disease, thalassemia or cancer, and the effect of donor biologic variability and component manufacturing on recipient outcomes. A rapid response capability to emerging safety threats has resulted in timely studies related to Severe Acute Respiratory Syndrome Corona Virus‐2 (SARS‐CoV‐2).
Conclusions
The REDS‐IV‐P program endeavors to improve donor‐recipient‐linked research with a focus on children and special populations while also maintaining the flexibility to address emerging blood safety issues.
Background: Excessive bleeding and surgical reexploration are common complications that increase the risk of multi-organ failure and prolonged hospitalization after cardiac surgery. Off-label use of ...recombinant activated factor VII (rFVIIa) is a recommended treatment for refractory bleeding. Objective: The objective of the study is to determine if the adequacy of hemostatic resuscitation enhances the efficacy of rFVIIa. Methods: This retrospective, observational, cohort study included patients who received rFVIIa for refractory postoperative bleeding after cardiac surgery. Patients were divided into two groups based on the presence or absence of adequate coagulation resuscitation before rFVIIa administration, defined as international ratio (INR) ≤1.5, platelet count ≥100 K/mL, and fibrinogen ≥200 mg/dL. The failure of rFVIIa treatment was defined as surgical reexploration within 24 h, thoracostomy drainage >400 mL/h within 6 h or transfusion of additional blood products or another rFVIIa dose within 6 h after initial rFVIIa dose. Results: Of the 3833 patients, screened who underwent cardiothoracic surgery procedures, 58 patients received rFVIIa for refractory postoperative bleeding. Successful hemostasis with rFVIIa was more likely in patients who were adequately resuscitated compared with those who were not (20 71.4% vs. 10 33.3%, respectively; P = 0.0046). Multiple logistic regression analysis indicated that patients who were adequately resuscitated before rFVIIa were less likely to fail treatment (odds ratio, 0.16; 95% confidence interval 0.04-0.62; P = 0.007). Conclusions: The therapeutic efficacy of rFVIIa is dependent on the adequacy of hemostatic resuscitation; restoration of normal serum fibrinogen, INR, and platelet counts >100 K/mL may provide an adequate substrate for rFVIIa to be effective in managing refractory postoperative cardiac surgical bleeding.
•ICD-10 coding for identification of VTE in electronic health record is imprecise.•Natural Language Processing (NLP) tools potentially offer a rapid and accurate method to identify VTE.•VTE NLP ...algorithms were validated at 3 distinct institutions.•Identification of VTE with a combined >98 % sensitivity and >99 % specificity
Left ventricular assist devices (LVADs) have increased the survival of patients with advanced heart failure fourfold. Despite these advances, significant bleeding and thrombotic complications occur. ...Hemorrhage requiring surgery has been reported in up to 30 % of adults and 50 % of children after LVAD placement. LVAD thrombosis and embolic stroke lead to significant long-term morbidity. Adults are treated with antithrombotic therapy to prevent thrombotic complications, but the amount and intensity of treatment differs between institutions. The goal international normalized ratio for warfarin therapy varies from 1.5 to 3.0. Some physicians manage adult LVAD patients without antiplatelet medication, whereas other adults are treated with aspirin as a single agent or combined with dipyridamole. In contrast, physicians typically manage children with LVADs using the Edmonton Anticoagulation and Platelet Inhibition Protocol, a detailed algorithm for anticoagulation and antiplatelet treatment modified based on thromboelastography results. LVAD implantation causes consumption of coagulation proteins, activation of fibrinolysis, and loss of high molecular weight von Willebrand protein multimers. How these changes in the coagulation system influence the risk of hemorrhage and initiation of thrombosis is unknown. Prospective, controlled studies are needed to determine the antithrombotic regimen that most effectively balances bleeding and thrombosis in LVAD patients.
Background:
Temporary mechanical circulatory support (tMCS) devices are used for patients with severe cardiac or respiratory failure; however, these patients are at high risk for clotting and ...bleeding. The best method to monitor heparin in these patients has not been established.
Objective:
To determine the risks for bleeding and clotting while monitoring heparin with either anti-Xa or activated clotting time (ACT) in tMCS patients.
Methods:
A retrospective cohort study was conducted on tMCS patients who received heparin adjusted according to an anti-Xa or ACT protocol. The primary outcome was incidence of major bleeding. Pertinent secondary outcomes were individual components of the primary outcome, clotting events, and time to therapeutic range.
Results:
There were 103 patients included in the study: 53 in the ACT group and 50 in the anti-Xa group. Overall, there were 30 (56.6%) patients with major bleeding in the ACT group, compared with 16 (32%) patients in the anti-Xa group (P = 0.017). An anti-Xa–based protocol was associated with a decreased hazard of major bleeding (hazard ratio = 0.388 0.215-0.701; P = 0.002) in the univariate analysis. In the multivariable analysis, an anti-Xa protocol remained associated with a significantly lower hazard of bleeding. Findings were similar when broken down into more discrete subgroups of the entire cohort, extracorporeal membrane oxygenation life support (ECMO), and non-ECMO groups.
Conclusion and Relevance:
Anti-Xa monitoring was associated with a lower hazard of bleeding during tMCS compared to an ACT-based protocol. Further studies should evaluate if anti-Xa monitoring should be preferentially used in tMCS.
Background
Appropriate timing of central venous catheter (CVC) removal, in relation to start of anticoagulation, in children after the diagnosis of a CVC‐related thrombosis (CRT) is not well ...established.
Objectives
This retrospective cohort study evaluated the incidence of symptomatic pulmonary embolism (PE) after CVC removal using data from the multi‐institutional Children’s Hospital‐Acquired Thrombosis (CHAT) Consortium Registry.
Patients/Methods
The CHAT Registry consists of data from children aged 0–21 years with a hospital‐acquired venous thromboembolism. Eligible subjects were those with CRT diagnosed <3 days after CVC removal. Subjects were excluded if the CRT was due to a failed CVC insertion. Subjects were divided into three groups: those with CVC removal without anticoagulation, those with CVC removal <48 h after starting anticoagulation, and those with CVC removal ≥48 h after starting anticoagulation.
Results
A total of 687 CRT events from 663 subjects were included. A majority of CRT events were in subjects with peripherally inserted central catheters (62.3%, n = 428). For the 611 CRT events in which the CVC was removed, there was only one case of symptomatic PE (0.16%), which occurred <48 h after initiation of anticoagulation.
Conclusions
While current guidelines suggest anticoagulation before CVC removal in the setting of a CRT to prevent embolization, CVC removal is not associated with symptomatic PE regardless of duration of anticoagulation before CVC removal.
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