Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
J Vasc Surg Venous Lymphat Disord. 2019 May;7(3):317-324. doi: 10.1016/j.jvsv.2018.08.010. Epub 2018 Nov 23.
An association between increased venous thromboembolism (VTE) events and influenza A H1N1 (H1N1) was noted in the first 10 patients with severe acute respiratory distress syndrome (ARDS). An empirical systemic anticoagulation protocol (heparin intravenous infusion) was initiated when autopsy of patients with severe hypoxemia confirmed multiple primary pulmonary thrombi and emboli. The purpose of this study was to examine the relationship between H1N1 and VTE events and to assess the efficacy of empirical systemic heparin anticoagulation in preventing VTE and death in H1N1 severe ARDS patients.
An observational cohort study of critically ill severe ARDS patients with possible H1N1 viral pneumonia was performed in a surgical intensive care unit in a single 990-bed academic tertiary care center. Early empirical systemic heparin anticoagulation for all severe ARDS patients with possible H1N1 viral pneumonia was initiated as a VTE preventive strategy.
Univariate comparisons and multivariate logistic regression were used to identify risk factors for VTE. Independent risk factors for VTE included H1N1, culture-positive bacterial pneumonia, and vasopressor requirement. Independent risk factors for pulmonary embolism included H1N1, culture-positive bacterial pneumonia, and male sex. H1N1 ARDS patients had 23.3-fold higher risk for pulmonary embolism and 17.9-fold increased risk for VTE. Kaplan-Meier analysis and log-rank test confirmed that empirical systemic heparin anticoagulation provided significant protection from thrombotic events in the H1N1-positive but not in the H1N1-negative critically ill ARDs patients. In multivariate analysis, adjusting for H1N1 status, patients without empirical systemic anticoagulation were 33 times more likely to have any VTE compared with those treated with empirical systemic heparin anticoagulation (P = .01).
Critically ill patients with H1N1 ARDS have increased risk of venous thrombotic complications, particularly pulmonary thromboembolism. Empirical systemic heparin anticoagulation in this cohort of patients significantly reduced VTE incidence without increased hemorrhagic complications.
在最初的 10 例严重急性呼吸窘迫综合征（ARDS）患者中，发现甲型 H1N1 流感（H1N1）与静脉血栓栓塞（VTE）事件之间存在关联。当对严重低氧血症患者的尸检证实存在多发性原发性肺血栓和栓塞时，启动了经验性全身抗凝方案（静脉内肝素输注）。本研究旨在探讨 H1N1 与 VTE 事件之间的关系，并评估经验性全身肝素抗凝在预防 H1N1 严重 ARDS 患者的 VTE 和死亡中的效果。
在一家拥有 990 张床位的学术性三级保健中心的外科重症监护病房中，对患有疑似 H1N1 病毒性肺炎的危重症 ARDS 患者进行了一项观察性队列研究。对所有疑似患有 H1N1 病毒性肺炎的严重 ARDS 患者，均早期启动经验性全身肝素抗凝，作为预防 VTE 的策略。
采用单变量比较和多变量逻辑回归来确定 VTE 的危险因素。VTE 的独立危险因素包括 H1N1、培养阳性细菌性肺炎和血管加压素需求。肺栓塞的独立危险因素包括 H1N1、培养阳性细菌性肺炎和男性。H1N1 ARDS 患者发生肺栓塞的风险增加 23.3 倍，VTE 的风险增加 17.9 倍。Kaplan-Meier 分析和对数秩检验证实，经验性全身肝素抗凝可显著预防 H1N1 阳性但不能预防 H1N1 阴性的危重症 ARDS 患者的血栓事件。在多变量分析中，调整 H1N1 状态后，与接受经验性全身抗凝治疗的患者相比，未接受经验性全身抗凝治疗的患者发生任何 VTE 的可能性高 33 倍（P =.01）。
患有 H1N1 ARDS 的危重症患者发生静脉血栓并发症的风险增加，尤其是肺血栓栓塞症。在本研究队列中，经验性全身肝素抗凝可显著降低 VTE 的发生率，且不增加出血并发症。
