Thrombo-inflammatory response in hospitalised patients with COVID-19: a single institution experience.

BACKGROUND: Severe COVID-19 causes acute inflammation, which is complicated by venous thromboembolism events (VTE). However, it is unclear if VTE risk has evolved over time since the COVID-19 outbreak. AIMS: To determine markers of thrombo-inflammation and rates of symptomatic VTE in patients hospitalised for COVID-19 in a metropolitan hospital in Sydney, Australia. METHODS: A retrospective, single-centre, cohort study was performed by reviewing electronic medical records of consecutive patients admitted to Royal Prince Alfred Hospital between March 2020 and September 2021. This period included three waves of COVID-19 outbreaks in Australia with the ancestral, alpha and delta variants. Standard coagulation assays and inflammatory markers were recorded over 4 weeks. RESULTS: A total of 205 patients were consecutively admitted during the study period. Activated partial thromboplastin time, neutrophil count and C-reactive protein (CRP) were significantly increased in patients hospitalised in the intensive care unit (ICU) compared with non-ICU patients. The use of anti-inflammatory medication increased in 2021 compared with 2020. The mortality rate was 7.3% in our cohort. Ninety-four per cent of patients received anticoagulation with 6.3% of patients developing VTE. CONCLUSION: We observed lower rates of VTE compared to the internationally reported rate for the same period. We conclude that in the setting of controlled hospital admission rate and standard anticoagulation guidelines, COVID-19 resulted in similar thrombo-inflammatory response and VTE rates over the first 1.5 years of the pandemic.

Preventability of venous thromboembolism in hospitalised patients.

BACKGROUND: Hospital-acquired venous thromboembolism (VTE) is a major cause of morbidity and mortality. AIMS: To determine the proportion of patients with hospital-acquired VTE that are preventable. METHODS: This was a retrospective study of patients in two tertiary care hospitals in Sydney, Australia. Data were collected for patients with hospital-acquired VTE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) coding from January 2018 to May 2020. Patients were classified as low, moderate or high risk of developing a VTE during hospitalisation based on demographic and clinical factors. A hospital-acquired VTE was considered to be potentially preventable if there was suboptimal prophylaxis in the absence of contraindications. Suboptimal therapy included at least one of the following related to VTE prophylaxis: low dose, missed dose (prior to developing a VTE), suboptimal drug and delayed start (>24 h from admission). RESULTS: There were 229 patients identified with VTE based on ICD-10-AM coding. A subset of 135 patients were determined to have actual hospital-acquired VTE. Of these, there were no patients at low risk, 64% (87/135) at moderate risk and 44% (48/135) at high risk of developing a VTE. Most (65%; n = 88/135) patients had one or more contraindications to receive recommended prophylaxis. Overall, the proportion of patients who received suboptimal prophylaxis was 11% (15/135). CONCLUSION: Approximately one out of 10 hospital-acquired VTE are preventable. Hospitals should focus on measuring and reporting VTE that are preventable to provide a more accurate measure of the burden of VTE that can be reduced by improving care.

Development and implementation of venous thromboembolism stewardship across a hospital network.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of preventable death in hospital. Ensuring all hospitalized patients are assessed for VTE risk and given appropriate prophylaxis can reduce the burden of VTE on patients and the healthcare system. This is the first study to explore the effectiveness of a VTE stewardship program using electronic clinical decision support (eCDS) to provide oversight of hospital initiatives to prevent VTE. AIM: To determine if a VTE stewardship program can increase risk-appropriate VTE prophylaxis, VTE risk assessment using eCDS, any documented risk assessment and risk assessment within 24 h of admission, plus reduce the incidence of hospital acquired VTE (HA-VTE). METHODS: Education, daily medication chart auditing, weekly clinician performance feedback, health promotion and gamification were deployed over 6 months by two multidisciplinary VTE stewardship teams across four hospitals. Service impact was assessed through cross-sectional audits of electronic medical records every 3 months and review of HA-VTE events pre- and post-intervention. Implementation costs were calculated. RESULTS: A total of 1622 patients were audited in separate cohorts at baseline, 3, 6 and 9 months. There was significant improvement in the prescription of appropriate prophylaxis (78%, 83%, 84%, and 88%, p = 0.004), VTE risk assessment using the eCDS tool (20%, 50%, 81% and 87%, p < 0.001), any documented risk assessment (71%, 82%, 95% and 93%, p < 0.001) and any documented risk assessment within 24 h of admission (54%, 56%, 65% and 63%, p = 0.001). Use of eCDS was associated with prescription of risk-appropriate VTE prophylaxis (p < 0.001). Annual incidence of HA-VTE decreased from 7.88 to 6.99 events per 10,000 discharges pre- to post-intervention (Odds Ratio (OR) 0.89, 95 %CI 0.66-1.18, p = 0.43). The cost of implementing the program across 133,078 episodes of care during the study period was AUD$108,167 (mean cost of $0.82 per patient).

Large aortic arch mural thrombus in non-atherosclerotic thoracic aorta--a rare cause of stroke in the young.

A 43-year-old Indian woman was admitted to the intensive care unit, with large cerebellar infarction. A brain CT scan showed a large non-haemorrhagic infarct involving the vermis and cerebellar hemispheres. Transesophageal echocardiography and CT angiography demonstrated a large mural aortic thrombus. No evidence of cardiac or vascular pathology was present. The patient had a high risk for surgical intervention and was treated with anticoagulation. Follow-up imaging 2 weeks later showed complete resolution of the thoracic aortic thrombus. This case report emphasises that imaging of the great vessels of the neck and transesophageal echocardiography should be included in ischaemic stroke work up. A thoracic aortic thrombus should always be considered in young patients with unexplained stroke or peripheral embolism; the condition can be treated effectively with anticoagulation.