November 30, 2020 - a podcast by COVID19LST

In today's episode we discuss:

—Epidemiology: There is higher prevalence of pulmonary macrothrombi in SARS-CoV-2 than in influenza A. A comparative analysis by pathologists at University Hospital Zurich in Switzerland assessed pulmonary macrothrombi autopsy findings in 411 patients who died from the Influenza A pandemic in 1918/1919, 12 from Influenza A in 2009-2020, and 75 for COVID-19. They found COVID-19 patients had significantly higher occurrences of grossly visible pulmonary thrombosis despite empiric thrombophylaxis due to in situ clot formation associated with SARS-CoV-2. Authors suggest a specific COVID-19 coagulopathy may be linked to higher mortality rate seen in COVID-19 compared to the seasonal flu.

—Understanding the Pathology: In vivo demonstration of microvascular thrombosis in severe COVID-19 was found in one study where researchers in the Department of Internal Medicine, Ribeirão Preto School of Medicine in Brazil conducted imaging via video capillaroscopy of 13 severe COVID-19 positive patients requiring mechanical ventilation to assess sublingual microcirculation for evidence of microthrombi. They found microthrombi in 11/13 (85%) of patients and acute thromboembolic occlusion in 5/13 (38%) of patients. This evidence suggests that microvascular thrombosis could be considered a hallmark of COVID-19 and that these microvascular thrombotic events occur systemically, affecting many organ systems.  

—Management: Dosing of thromboprophylaxis and mortality in critically ill COVID-19 patients were explored by investigators in Stockholm, Sweden. They analyzed thromboprophylaxis and 28-day mortality among 156 patients with COVID-19-associated respiratory failure admitted to 2 local ICUs. Dosing was dependent on changes in regional guidelines over time and not patient severity. Results illustrated the following:  - 67 patients on low-dose thromboprophylaxis had a mortality rate of 38.8%  - 48 patients on medium-dose thromboprophylaxis had a mortality rate of 25%  - 37 patients on high-dose thromboprophylaxis had the lowest mortality rate of 13.5%  These findings suggest that starting critically ill patients on high-dose thromboprophylaxis maybe a beneficial strategy in reducing thromboembolic events and mortality.

· Point-of-Care Ultrasound (POCUS) can be useful in managing ICU Patients with COVID-19. 

—Adjusting Practice During COVID-19: ewer motor vehicle collisions and higher alcohol involvement were seen in COVID-19 Pandemic trauma presentations in one trauma center. Medical students and physicians from the Medical College of Georgia compared trauma activations at their level 1 trauma center between March 1 and June 15, 2020 to trauma activations from the same time frame in the previous 5 years (2015-2019). While there was no difference in the number and distribution of trauma cases, they found fewer motor vehicle collisions (MVCs)(p=0.009704), higher incidence of alcohol involvement in traumas (p=2.26 × 10^-7), and longer average length of hospital stay (3.87 vs 5.39; p=8.488 × 10^-6) in 2020 compared to pre-pandemic years. Authors suggest the decreased number of MVCs is attributable to fewer drivers during pandemic-related lockdowns but recommend further investigation into factors influencing the observed increase in alcohol related trauma and longer hospital stays to better identify areas of potential preventative interventions.

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