Anticoagulation and Antiplatelet Therapy for Prevention of Venous and Arterial Thrombotic Events in Critically Ill Patients With COVID-19: COVID-PACT.

BACKGROUND: The efficacy and safety of prophylactic full-dose anticoagulation and antiplatelet therapy in critically ill COVID-19 patients remain uncertain. METHODS: COVID-PACT (Prevention of Arteriovenous Thrombotic Events in Critically-ill COVID-19 Patients Trial) was a multicenter, 2×2 factorial, open-label, randomized-controlled trial with blinded end point adjudication in intensive care unit-level patients with COVID-19. Patients were randomly assigned to a strategy of full-dose anticoagulation or standard-dose prophylactic anticoagulation. Absent an indication for antiplatelet therapy, patients were additionally randomly assigned to either clopidogrel or no antiplatelet therapy. The primary efficacy outcome was the hierarchical composite of death attributable to venous or arterial thrombosis, pulmonary embolism, clinically evident deep venous thrombosis, type 1 myocardial infarction, ischemic stroke, systemic embolic event or acute limb ischemia, or clinically silent deep venous thrombosis, through hospital discharge or 28 days. The primary efficacy analyses included an unmatched win ratio and time-to-first event analysis while patients were on treatment. The primary safety outcome was fatal or life-threatening bleeding. The secondary safety outcome was moderate to severe bleeding. Recruitment was stopped early in March 2022 (≈50% planned recruitment) because of waning intensive care unit-level COVID-19 rates. RESULTS: At 34 centers in the United States, 390 patients were randomly assigned between anticoagulation strategies and 292 between antiplatelet strategies (382 and 290 in the on-treatment analyses). At randomization, 99% of patients required advanced respiratory therapy, including 15% requiring invasive mechanical ventilation; 40% required invasive ventilation during hospitalization. Comparing anticoagulation strategies, a greater proportion of wins occurred with full-dose anticoagulation (12.3%) versus standard-dose prophylactic anticoagulation (6.4%; win ratio, 1.95 [95% CI, 1.08-3.55]; P=0.028). Results were consistent in time-to-event analysis for the primary efficacy end point (full-dose versus standard-dose incidence 19/191 [9.9%] versus 29/191 [15.2%]; hazard ratio, 0.56 [95% CI, 0.32-0.99]; P=0.046). The primary safety end point occurred in 4 (2.1%) on full dose and in 1 (0.5%) on standard dose (P=0.19); the secondary safety end point occurred in 15 (7.9%) versus 1 (0.5%; P=0.002). There was no difference in all-cause mortality (hazard ratio, 0.91 [95% CI, 0.56-1.48]; P=0.70). There were no differences in the primary efficacy or safety end points with clopidogrel versus no antiplatelet therapy. CONCLUSIONS: In critically ill patients with COVID-19, full-dose anticoagulation, but not clopidogrel, reduced thrombotic complications with an increase in bleeding, driven primarily by transfusions in hemodynamically stable patients, and no apparent excess in mortality. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04409834.

COVID-19 in a Mississippi Community Hospital.

OBJECTIVES: Mississippi recorded the first case of coronavirus disease 2019 (COVID-19) on March 11, 2020. This report describes the initial COVID-19 experience of the single healthcare system serving Jackson County, Mississippi. The intent of this retrospective review of COVID-19 hospitalized patients was to identify any characteristics or interventions amenable to improving care management and clinical outcomes for patients within our community hospital. METHODS: All hospitalized patients 18 years of age and older in our health system with positive tests for COVID-19 (severe acute respiratory syndrome-coronavirus-2 [SARS CoV-2]) by reverse transcriptase-polymerase chain reaction between March 15 and April 10, 2020 are included in this retrospective observational report. RESULTS: During the study period, 158 patients of the 1384 tested (11.4%) were positive for COVID-19 infection. Of the 158 patients, 41 (26%) were hospitalized, with 17 (41%) admitted to the intensive care unit (ICU). The remaining 24 patients did not require ICU admission. The mean age of the 158 COVID-19-positive patients was 55 years (range 2-103). Obesity was noted in 68% of the hospitalized patients, including 13 (54%) of the non-ICU patients and 15 (88%) of the ICU patients. All 9 deceased patients were obese. Twelve of 17 patients received invasive mechanical ventilation (IMV) and 3 patients received only high-flow nasal cannula oxygen. Only 25% (3 of 12) of the IMV patients were successfully extubated during the study period. The median duration on IMV was 17 days (range 4-35). The mortality in the 158 COVID-19-positive patients was 5.7% (9 of 158). None of the 24 non-ICU patients died. The ICU mortality rate was 53% (9 of 17). CONCLUSIONS: This report describes a community hospital experience with COVID-19. Patient outcome was comparable to that reported at larger centers. Obesity was a major comorbidity and correlated with adverse outcomes. Amidst the initial wave of COVID-19 with high demand for inpatient treatment, it is reassuring that appropriate care can be provided in a community health system.

Direct patient care during an acute disaster: chasing the will-o'-the-wisp.

Well developed disaster plans are essential in today's atmosphere of natural and man-made disasters. We describe the problems faced by a community hospital on the Mississippi Gulf Coast during and in the wake of Hurricane Katrina. Because of significant damage to surrounding health care facilities, this hospital was called upon to provide care to a large section of the affected population. In spite of a previously successful disaster plan, a number of unforeseen difficulties were encountered. These included staff shortages due to inability of relief personnel to re-enter the affected area, insufficient power generation by hospital generators, breakdown in communication, fuel shortage, limited mortuary space, and stretching of emergency room resources. These unexpected developments emphasize the importance of contingency planning as part of disaster preparedness.