Department of Surgery, Ascension St. John Hospital, Detroit, Mich.
Department of Surgery, Ascension St. John Hospital, Detroit, Mich.
J Vasc Surg. 2021 Jun;73(6):1881-1888.e3. doi: 10.1016/j.jvs.2020.11.033. Epub 2020 Dec 5.
The hypercoagulability seen in patients with novel coronavirus disease 2019 (COVID-19) likely contributes to the high temporary hemodialysis catheter (THDC) malfunction rate. We aim to evaluate prophylactic measures and their association with THDC patency.
A retrospective chart review of our institutions COVID-19 positive patients who required placement of a THDC between February 1 to April 30, 2020, was performed. The association between heparin locking, increased dosing of venous thromboembolism (VTE) prophylaxis and systemic anticoagulation on THDC patency was assessed. Proportional hazards modeling was used to perform a survival analysis to estimate the likelihood and timing of THDC malfunction with the three different prophylactic measures. We also determined the mortality, rate of THDC malfunction and its association with d-dimer levels.
A total of 48 patients with a mortality rate of 71% were identified. THDC malfunction occurred in 31.3% of patients. Thirty-seven patients (77.1%) received heparin locking, 22 (45.8%) received systemic anticoagulation, and 38 (79.1%) received VTE prophylaxis. Overall, the rate of THDC malfunction was lower at a trend level of significance, with heparin vs saline locking (24.3% vs 54.6%; P = .058). The likelihood of THDC malfunction in the heparin locked group is lower than all other groups (hazard ratio [HR], 0.07; 95% confidence interval [CI], 0.01-0.45]; P = .005). The rate of malfunction in patients with subcutaneous heparin (SQH) 7500 U three times daily is significantly lower than of the rate for patients receiving none (HR, 0.03; 95% CI, 0.001-0.74; P = .032). A trend level significant association was found for SQH 5000 U vs none (P = .417) and SQH 7500 vs 5000 U (P = .059). Systemic anticoagulation did not affect the THDC malfunction rate (P = .240). Higher d-dimer levels were related to greater mortality (HR, 3.28; 95% CI, 1.16-9.28; P = .025), but were not significantly associated with THDC malfunction (HR, 1.79; 95% CI, 0.42, 7.71; P = .434).
Locking THDCs with heparin is associated with a lower malfunction rate. Prospective randomized studies will be needed to confirm these findings to recommend locking THDC with heparin in patients with COVID-19. Increased VTE prophylaxis suggested a possible association with improved THDC patency, although the comparison lacked sufficient statistical power.
新型冠状病毒病 2019（COVID-19）患者的高凝状态可能导致临时血液透析导管（THDC）故障的高发生率。我们旨在评估预防性措施及其与 THDC 通畅性的关系。
对 2020 年 2 月 1 日至 4 月 30 日期间在我们机构中 COVID-19 阳性患者中需要放置 THDC 的患者进行回顾性图表审查。评估肝素锁定、增加静脉血栓栓塞症（VTE）预防剂量和全身抗凝治疗与 THDC 通畅性的关系。使用比例风险模型进行生存分析，以估计三种不同预防措施下 THDC 故障的可能性和时间。我们还确定了死亡率、THDC 故障率及其与 D-二聚体水平的关系。
共确定了 48 例死亡率为 71%的患者。31.3%的患者出现 THDC 故障。37 例（77.1%）患者接受肝素锁定，22 例（45.8%）患者接受全身抗凝治疗，38 例（79.1%）患者接受 VTE 预防。总体而言，肝素与生理盐水锁定相比，THDC 故障的发生率呈趋势性显著降低（24.3%比 54.6%；P=0.058）。肝素锁定组的 THDC 故障可能性低于其他所有组（风险比[HR]，0.07；95%置信区间[CI]，0.01-0.45；P=0.005）。接受皮下肝素（SQH）7500U 每日三次的患者的故障发生率明显低于未接受治疗的患者（HR，0.03；95%CI，0.001-0.74；P=0.032）。SQH 5000U 与无治疗组（P=0.417）和 SQH 7500U 与 5000U 组（P=0.059）之间存在显著趋势关联。全身抗凝治疗并不影响 THDC 故障发生率（P=0.240）。较高的 D-二聚体水平与更高的死亡率相关（HR，3.28；95%CI，1.16-9.28；P=0.025），但与 THDC 故障无显著相关性（HR，1.79；95%CI，0.42，7.71；P=0.434）。
肝素锁定 THDC 与较低的故障发生率相关。需要进行前瞻性随机研究来证实这些发现，以便在 COVID-19 患者中推荐使用肝素锁定 THDC。增加 VTE 预防措施可能与改善 THDC 通畅性有关，尽管比较缺乏足够的统计学效力。
