Marvi Tanya K, Stubblefield William B, Tillman Benjamin F, Tenforde Mark W, Patel Manish M, Lindsell Christopher J, Self Wesley H, Grijalva Carlos G, Rice Todd W
Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.
Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
Crit Care Explor. 2022 Jan 18;4(1):e0618. doi: 10.1097/CCE.0000000000000618. eCollection 2022 Jan.
To test the hypothesis that relatively lower clot strength on thromboelastography maximum amplitude (MA) is associated with development of venous thromboembolism (VTE) in critically ill patients with COVID-19.
Prospective, observational cohort study.
Tertiary care, academic medical center in Nashville, TN.
Patients with acute respiratory failure from COVID-19 pneumonia admitted to the adult medical ICU without known VTE at enrollment.
None.
Ninety-eight consecutive critically ill adults with laboratory-confirmed COVID-19 were enrolled. Thromboelastography parameters and conventional coagulation parameters were measured on days 0 (within 48 hr of ICU admission), 3, 5, and 7 after enrollment. The primary outcome was diagnosis of VTE with confirmed deep venous thrombosis and/or pulmonary embolism by clinical imaging or autopsy. Twenty-six patients developed a VTE. Multivariable regression controlling for antiplatelet exposure and anticoagulation dose with death as a competing risk found that lower MA was associated with increased risk of VTE. Each 1 mm increase in enrollment and peak MA was associated with an 8% and 14% decrease in the risk of VTE, respectively (enrollment MA: subdistribution hazard ratio [SHR], 0.92; 95% CI, 0.87-0.97; = 0.003 and peak MA: SHR, 0.86; 95% CI, 0.81-0.91; < 0.001). Lower enrollment platelet counts and fibrinogen levels were also associated with increased risk of VTE ( = 0.002 and = 0.01, respectively). Platelet count and fibrinogen level were positively associated with MA (multivariable model: adjusted = 0.51; < 0.001).
When controlling for the competing risk of death, lower enrollment and peak MA were associated with increased risk of VTE. Lower platelet counts and fibrinogen levels at enrollment were associated with increased risk of VTE. The association of diminished MA, platelet counts, and fibrinogen with VTE may suggest a relative consumptive coagulopathy in critically ill patients with COVID-19.
为验证以下假设，即对于患有新型冠状病毒肺炎（COVID-19）的重症患者，血栓弹力图最大振幅（MA）相对较低与静脉血栓栓塞症（VTE）的发生有关。
前瞻性观察队列研究。
田纳西州纳什维尔的三级医疗学术医学中心。
因COVID-19肺炎导致急性呼吸衰竭且入院时无已知VTE的成年医学重症监护病房患者。
无。
连续纳入98例实验室确诊的COVID-19重症成年患者。在入组后第0天（重症监护病房入院后48小时内）、第3天、第5天和第7天测量血栓弹力图参数和传统凝血参数。主要结局是通过临床影像或尸检确诊深静脉血栓形成和/或肺栓塞的VTE诊断。26例患者发生了VTE。以死亡作为竞争风险，对血小板暴露和抗凝剂量进行多变量回归分析发现，较低的MA与VTE风险增加相关。入组时MA每增加1毫米和峰值MA每增加1毫米，VTE风险分别降低8%和14%（入组时MA：亚分布风险比[SHR]，0.92；95%置信区间，0.87 - 0.97；P = 0.003；峰值MA：SHR，0.86；95%置信区间，0.81 - 0.91；P < 0.001）。入组时较低的血小板计数和纤维蛋白原水平也与VTE风险增加相关（分别为P = 0.002和P = 0.01）。血小板计数和纤维蛋白原水平与MA呈正相关（多变量模型：调整后R² = 0.51；P < 0.001）。
在控制死亡的竞争风险时，较低的入组时和峰值MA与VTE风险增加相关。入组时较低的血小板计数和纤维蛋白原水平与VTE风险增加相关。MA降低、血小板计数和纤维蛋白原与VTE的关联可能提示COVID-19重症患者存在相对消耗性凝血病。
