Evaluation of Coagulation Disorders in Intubated and Non-Intubated Patients with Covid-19 Diagnosis in The Intensive Care unit

Abstract

Objective: It is known that the need for invasive mechanical ventilation due to severe respiratory failure develops in COVID-19 patients followed in the intensive care unit. It has been reported in the literature that coagulopathy seen during COVID-19 disease is an important cause of mortality and morbidity. Our aim in our study was to evaluate coagulation disorders developing between intubated and non-intubated patients. Method: The data of 812 patients diagnosed with COVID-19 in the Intensive Care Unit, between March 2020 and September 2021 were retrospectively analyzed. The patients were divided into two groups according to the need for invasive mechanical ventilation. Demographic characteristics, laboratory values at the time of diagnosis, coagulopathy development status and survival of the patients were investigated. Results: Of the 812 patients included in the study, 459 (56.5%) were male. The mean age was 66,4 ± 15,2. 257 (31.7%) of the patients received invasive mechanical ventilation support. Coagulopathy was detected in 146 (56.8%) of these patients. Distribution of coagulopathy in intubated patients; 26% Disseminated Intravascular Coagulation, 17.9% Acute Coronary Syndrome, 10.5% Hemorrhage (inside or outside the body), 5.4% Pulmonary Embolism, 5% Heparin-Induced Thrombocytopenia, 3.5% Ischemic Stroke, 1.9% Hemorrhagic Stroke and 0.8% found as Deep Vein Thrombosis. We found that 32% of the patients who were not intubated developed coagulopathy, and this difference was statistically significant (p<0.001). We found the mortality rate to be 97.7% in intubated patients. Mortality in non-intubated patients was 38.4%. In our study, coagulopathy development rate was found to be higher in patients with at least one comorbidity (p=0,006). Relationship between the laboratory findings at the time of hospitalization and the rate of coagulopathy development were analyzed and a statistically significant differences was found between the hemoglobin, thrombocyte, fibrinogen, d-dimer and INR levels of the patients and development of coagulopathy (p=0.026, p<0.001, p<0.001, p<0.001, p<0.001, p<0.001). It was seen that 49.8% of the patients who died had at least one coagulopathy condition. This rate was found to be 26.7% in the surviving patients, and this difference was statistically significant (p<0.001). Conclusion: It was determined that approximately one third of the COVID-19 patients hospitalized in the intensive care unit required mechanical ventilation. A coagulation disorder was detected in 56.8% of the patients. A significant correlation was found between intubation and the development of coagulopathy. In addition a significant difference was found between high d-dimer, fibrinogen, INR levels, low hemoglobin and thrombocyte levels and the development of coagulopathy. Comorbidities were also found to be associated with coagulopathy and mortality. It was observed that 97.7% of the intubated patients died.

Keywords

• Covid-19
• Coagulopathy
• Intubation

References

1. 1.WHO Director-General’s remarks at the mediabriefing on 2019-nCoV on 11 February 2020. (2020,February 11). https://www.who.int/director-general/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020
2. 2.Olmez H, Tosun M, Unver E, Dogan M, Işik NA.COVID-19 and hypercoagulability. The EuropeanResearch Journal. 2021;7(2), 209–217.
3. 3.Hanff TC, Mohareb AM, Giri J, Cohen JB, ChirinosJA. Thrombosis in COVID-19. Am J Hematol.2020;95(12):1578–89.
4. 4.Gupta N, Zhao Y-Y, Evans CE. The stimulation ofthrombosis by hypoxia. Thromb Res. 2019;181:77–83.
5. 5.Klok FA, Kruip MJHA, van der Meer NJM, et al.Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res.2020;191:145–7.
6. 6.Helms J, Tacquard C, Severac F, et al. High risk ofthrombosis in patients with severe SARS-CoV-2infection: a multicenter prospective cohort study.Intensive Care Med. 2020;46(6):1089–98.
7. 7.Zhang Y, Xiao M, Zhang S, et al. Coagulopathy andAntiphospholipid Antibodies in Patients with Covid-19.N Engl J Med. 2020;382(17):e38.
8. 8. Merkler AE, Parikh NS, Mir S, et al. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019(COVID-19) vs Patients With Influenza. JAMANeurol. 2020;

9. 9.Bayrak V, Durukan NS, Aydemir FD, et al. Riskfactors associated with mortality in intensive careCOVID-19 patients: the importance of chest CT score and intubation timing as risk factors. Turk J Med Sci.2021;51(4):1665–74.
10. 10.Dursun R, Mermutluoglu C, Aktar F, et al. WhichCOVID-19 patients die in intensive care unit (ICU) in Turkey. Dicle TIP Dergisi, 2022;49(1):85–91.
11. 11.Azoulay E, Zafrani L, Mirouse A, et al. Clinicalphenotypes of critically ill COVID-19 patients.Intensive Care Med. 2020;46(8):1651–2.
12. 12.Elhadi M, Alsoufi A, Abusalama A, et al.Epidemiology, outcomes, and utilization of intensivecare unit resources for critically ill COVID-19patients in Libya: A prospective multi-center cohortstudy. PLOS ONE. 2021;16(4):e0251085.
13. 13.Ayaz A, Arshad A, Malik H, et al. Risk factors forintensive care unit admission and mortality inhospitalized COVID-19 patients. Acute Crit Care.2020 Nov;35(4):249–54.
14. 14.Jenner WJ, Kanji R, Mirsadraee S, et al.Thrombotic complications in 2928 patients withCOVID-19 treated in intensive care: a systematicreview. J Thromb Thrombolysis. 2021;51(3):595–607.
15. 15.Lodigiani C, Iapichino G, Carenzo L, et al. Venousand arterial thromboembolic complications inCOVID-19 patients admitted to an academic hospitalin Milan, Italy. Thromb Res. 2020;191:9–14.
16. 16.Daughety MM, Morgan A, Frost E, et al. COVID-19associated coagulopathy: Thrombosis, hemorrhageand mortality rates with an escalated-dosethromboprophylaxis strategy. Thromb Res.2020;196:483–5.
17. 17.Long X, Zhang Z, Zou W, et al. Coagulopathy ofPatients with COVID-19 is Associated withInfectious and Inflammatory Markers. Risk ManagHealthc Policy. 2020;13:1965–75.
18. 18.Iba T, Levy JH, Connors JM, et al. The uniquecharacteristics of COVID-19 coagulopathy. Crit Care.2020;24(1):360.
19. 19.Chi G, Lee JJ, Jamil A, et al. VenousThromboembolism among Hospitalized Patientswith COVID-19 Undergoing Thromboprophylaxis: ASystematic Review and Meta-Analysis. J Clin Med.2020;9(8):2489.