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Anticoagulation in Hospitalized Patients with Covid-19

Continue intermediate-dose anticoagulation and anticoagulation after hospital discharge

Jean M. Connors, MD

Medical practice has been hurt by the Kovid-19 epidemic. With approximately 20 million cases worldwide, Kovid-19 presents both logistic challenges, due to the sheer number of patients infected during local surges and therapeutic management challenges, particularly high-quality clinical care Due to lack of data. Are seriously ill. The published observational data since the onset of the epidemic have limitations but may provide some direction as we deal with a number of issues related to the care of patients infected with SARS-CoV-2.

Mr. Jackson’s clinical condition has worsened, with progressive hypoxemia, elevated inflammatory markers, and an increase in DA level more than 3 times the upper limit of the normal level, a level that is associated with increased mortality,8 But there is no evidence of VTE on imaging. Although anticoagulation to prevent thrombotic events is now undisputed in hospitalized patients with Kovid-19, the proper dose to prevent thrombosis and, possibly, pulmonary microvascular thrombosis is not known. Thromboinflammation associated with Kovid-19 results in hybridagulability with elevated levels of procoagulant proteins, including fibrinogen, von Willebrand factor, and factor VIII; Activation of coagulation; Endothelialitis due to viral infection of endothelial cells with loss of protective antithrombotic activity; And pulmonary micro-vascular thrombosis.4,9 Data from Wuhan in China showed that anticoagulation decreased mortality in severe cases of Kovid-19.10 Reports from Europe and the United States have shown that the incidence of VTE was three to four times higher in critically ill ICU patients with CTEid-19 than ICF patients despite standard prophylactic-dose anticoagulants. Even in patients admitted to the ICU, a higher incidence of VTE has been found in people with Kovid-19 than in critically ill patients or in patients with ICU with a distinct viral disease.4,11-13

Anticoagulation has been increased for Mr. Jackson; The sharp increase in oxygen requirement reflects ICU penetration. Although the use of therapeutic-dose anticoagulation is controversial, “intermediate” intensity anticoagulation, such as enoxaparin at twice the dose of 0.5 mg per kg of body weight daily, is required in critically ill patients with covid-19 to prevent thrombosis appears to be. About half of the experts who write the Society’s guidelines for critically ill patients suggest or give consideration for its use (eg, data notwithstanding the guidelines of the International Society of Thrombosis and Hemostasis, Royal College of Physicians and the Anticoagulation Forum Despite the lack of) randomized controlled trials. Some centers use a weight-based dose, acknowledging that 40 mg of enoxaparin or equivalent is insufficient for many patients. A review of previous data on VTE prophylaxis in critically ill patients suggests that we are treating these patients. Heparin should be used in critically ill patients instead of direct oral anticoagulants, due to prognostic factors including short half-lives, the fact that the dose can be adjusted in patients with severe renal injury, and drug-medication. Absence of conversation of. Bleeding rates have generally been low, but the need for prolonged invasive mechanical ventilation suggests problems associated with common ICUs. The risks and benefits of anticoagulation should be assessed for any critically ill patient.4,12 Analyzes from large health systems databases suggest that therapeutic-dose anticoagulation is associated with improved outcomes; However, these retrospective analyzes have limitations. Mr. Jackson will be enrolled in a randomized clinical trial registered at ClinicalTirales.GO to assess the efficacy and safety of increased doses of anticoagulants in patients with Kovid-19.

Although critically ill patients with Covid-19 have an increased risk of VTE, a recent observational study has shown that the incidence of VTE decreased after hospital discharge14; Short length of stay (including first patient discharge due to lack of hospital bed), treatment with antiinflammatory and antiviral agents, and the use of intermediate-dose anticoagulation in ICU patients may reduce postnatal risk. Previous trials of postdischarge VTE prophylaxis in medically ill patients have shown significant reductions in VTE; However, major bleeding was tested with most anticoagulants, resulting in little change in behavior. Unless data from randomized clinical trials that show no clinical clinical benefit are available, postdischarge VTE prophylaxis should be strongly considered for patients who are discharged early from the hospital because of lack of bed, rehabilitation facilities Risk factors for VTE with discharged patients, or known additional patients, such as obesity, thrombophilia, advanced age, and history of VTE. Mr. Jackson, by virtue of his age, possibly resides in the ICU, and is elevated D-Dimer levels, a randomized clinical trial in which he can enroll, are not available if a standard-dose postdischarge VTE for 14 to 35 days is a candidate for prophylaxis.

Disclosure forms The full text of this article is available at provided by the author.

Author Affiliations

From Brigham and Women’s Hospital, Boston.

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