Pulmonary embolism or thrombosis in ARDS COVID-19 patients: A French monocenter retrospective study
Pulmonary embolism or thrombosis in ARDS COVID-19 patients: A French monocenter retrospective study
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DOI：
10.1371/journal.pone.0238413
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发表时间：
2020-08-27
期刊：
影响因子：
3.7
通讯作者：
Plantefeve, Gaetan
中科院分区：
文献类型：
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作者：
Contou, Damien;Pajot, Olivier;Plantefeve, Gaetan
据报道，2019年冠状病毒病(新冠肺炎)患者的高凝状态和内皮病变，再加上深度镇静和神经肌肉阻滞剂治疗急性呼吸窘迫综合征(ARDS)所固有的严格和长时间的制动，可能会使新冠肺炎危重患者面临静脉血栓形成和肺栓塞(PE)的风险增加。我们旨在评估在ICU期间诊断为PE的ARDS新冠肺炎患者的发生率，并描述其临床特征和转归。自2020年3月13日至4月24日，共有92例患者(中位年龄：61岁，第1-3四分位数[55-70]；男性：73/92，79%；基线SOFA：4[3-7]，SAPS II：31[21-40]；有创机械通气：83/92，90%；重症监护病房病死率：45/92，49%)因新冠肺炎急性呼吸窘迫综合征而进入我们的41张床位重症监护室。其中26例患者(n=26/92，28%)行CT肺血管造影，发现PE者16例(n=16/26，62%)，占队列总数的17%(n=16/92)。3例(19%)为双侧PE，13例(81%)为单侧PE。最近端血栓位于主动脉(n=4，25%)、叶动脉(n=2，12%)和节段动脉(n=10，63%)。血栓多位于实质性凝固区(n=13/16，81%)。16例患者中只有3例(19%)在多普勒超声检查中出现了下肢静脉血栓形成。阿替普酶联合抗凝治疗3例(19%)，单纯抗凝治疗13例(81%)。发生PE患者的ICU病死率高于无PE患者(n=11/16，69%比n=2/10，20%；p=0.04)。下肢静脉血栓的低发生率和远端肺血栓的高发生率证明了与经典的栓塞术相关的局部免疫血栓形成过程。还需要进一步的更大规模的研究来评估肺栓塞/血栓形成的真实患病率和危险因素及其对新冠肺炎危重患者预后的影响。
Hypercoagulability and endotheliopathy reported in patients with coronavirus disease 2019 (COVID-19) combined with strict and prolonged immobilization inherent to deep sedation and administration of neuromuscular blockers for Acute Respiratory Distress Syndrome (ARDS) may expose critically ill COVID-19 patients to an increased risk of venous thrombosis and pulmonary embolism (PE). We aimed to assess the rate and to describe the clinical features and the outcomes of ARDS COVID-19 patients diagnosed with PE during ICU stay. From March 13(th)to April 24(th)2020, a total of 92 patients (median age: 61 years, 1st-3rd quartiles [55-70]; males: n = 73/92, 79%; baseline SOFA: 4 [3-7] and SAPS II: 31 [21-40]; invasive mechanical ventilation: n = 83/92, 90%; ICU mortality: n = 45/92, 49%) were admitted to our 41-bed COVID-19 ICU for ARDS due to COVID-19. Among them, 26 patients (n = 26/92, 28%) underwent a Computed Tomography Pulmonary Angiography which revealed PE in 16 (n = 16/26, 62%) of them, accounting for 17% (n = 16/92) of the whole cohort. PE was bilateral in 3 (19%) patients and unilateral in 13 (81%) patients. The most proximal thrombus was localized in main (n = 4, 25%), lobar (n = 2, 12%) or segmental (n = 10, 63%) pulmonary artery. Most of the thrombi (n = 13/16, 81%) were located in a parenchymatous condensation. Only three of the 16 patients (19%) had lower limb venous thrombosis on Doppler ultrasound. Three patients were treated with alteplase and anticoagulation (n = 3/16, 19%) while the 13 others (n = 13/16, 81%) were treated with anticoagulation alone. ICU mortality was higher in patients with PE compared to that of patients without PE (n = 11/16, 69% vs. n = 2/10, 20%; p = 0.04). The low rate of lower limb venous thrombosis together with the high rate of distal pulmonary thrombus argue for a local immuno-thrombotic process associated with the classic embolic process. Further larger studies are needed to assess the real prevalence and the risk factors of pulmonary embolism/thrombosis together with its prognostic impact on critically ill patients with COVID-19.