Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, NY.
Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, NY.
Crit Care Med. 2020 Dec;48(12):e1322-e1326. doi: 10.1097/CCM.0000000000004614.
To describe the predictive utility of the D-dimer assay among patients with the coronavirus disease 2019 syndrome for unprovoked lower extremity deep venous thrombosis.
Prospective observational study with retrospective data analysis.
Academic medical center surgical ICU.
Seventy-two intubated patients with critical illness from coronavirus disease 2019.
Therapeutic anticoagulation after imaging diagnosis of the first three deep venous thrombosis cases was confirmed; therapeutic anticoagulation as prophylaxis thereafter to all subsequent ICU admissions.
Seventy-two patients with severe coronavirus disease 2019 were screened for deep venous thrombosis after ICU admission with 102 duplex ultrasound examinations, with 12 cases (16.7%) of lower extremity deep venous thrombosis identified. There were no differences between groups with respect to age, renal function, or biomarkers except for D-dimer (median, 12,858 ng/mL [interquartile range, 3,176-30,770 ng/mL] for lower extremity deep venous thrombosis vs 2,087 ng/mL [interquartile range, 638-3,735 ng/mL] for no evidence of deep venous thrombosis; p < 0.0001). Clinical screening tools (Wells score and Dutch Primary Care Rule) had no utility. The C-statistic for D-dimer concentration was 0.874 ± 0.065. At the model-predicted cutoff value of 3,000 ng/mL, sensitivity was 100%, specificity was 51.1%, positive predictive value was 21.8%, and negative predictive value was 100%.
Lower extremity deep venous thrombosis is prevalent in coronavirus disease 2019 disease and can be present on ICU admission. Screening has been recommended in the context of the pro-inflammatory, hypercoagulable background milieu. D-dimer concentrations are elevated in nearly all coronavirus disease 2019 patients, and the test appears reliable for screening for lower extremity deep venous thrombosis at or above a concentration of 3,000 ng/mL (more than 13-fold above the normal range). Full anticoagulation is indicated if the diagnosis is confirmed, and therapeutic anticoagulation should be considered for prophylaxis, as all coronavirus disease 2019 patients are at increased risk.
描述 2019 年冠状病毒病患者的 D-二聚体检测对无诱因下肢深静脉血栓形成的预测价值。
前瞻性观察研究，回顾性数据分析。
学术医疗中心外科重症监护病房。
72 例因 2019 年冠状病毒病而病情危重的插管患者。
对前 3 例深静脉血栓形成病例进行影像学诊断后，给予抗凝治疗；此后，对所有后续入住 ICU 的患者均进行抗凝治疗作为预防措施。
在 ICU 入住后，对 72 例严重 2019 年冠状病毒病患者进行深静脉血栓形成筛查，共进行 102 次双功超声检查，发现 12 例（16.7%）下肢深静脉血栓形成。两组患者在年龄、肾功能或生物标志物方面均无差异，除 D-二聚体（中位数，12858ng/ml[四分位距，3176-30770ng/ml]，下肢深静脉血栓形成组；2087ng/ml[四分位距，638-3735ng/ml]，无深静脉血栓形成证据；p<0.0001）。临床筛查工具（Wells 评分和荷兰初级保健规则）没有效果。D-二聚体浓度的 C 统计量为 0.874±0.065。在预测模型截点值为 3000ng/ml 时，灵敏度为 100%，特异性为 51.1%，阳性预测值为 21.8%，阴性预测值为 100%。
2019 年冠状病毒病患者下肢深静脉血栓形成的发病率较高，且可在 ICU 入住时出现。鉴于炎症反应、高凝状态背景，建议进行筛查。几乎所有 2019 年冠状病毒病患者的 D-二聚体浓度均升高，该检测对于浓度在 3000ng/ml（高于正常值 13 倍以上）或以上的下肢深静脉血栓形成的筛查较为可靠。如果确诊，应给予充分抗凝治疗；所有 2019 年冠状病毒病患者均有较高的血栓形成风险，应考虑进行抗凝治疗作为预防措施。
