Obstrucción intestinal por hematoma intraabdominal: una complicación de la heparina de bajo peso molecular en el paciente pediátrico / Intestinal obstruction as a result of intra-abdominal hematoma: a complication of low molecular weight heparin in pediatric patients

Introducción: Los hematomas son una causa poco frecuente deobstrucción intestinal. La heparina subcutánea tiene riesgo de producirla punción directa de un asa intestinal, provocando un hematoma trau-mático que genere una obstrucción intestinal. Casos clínicos: Se describen tres casos de pacientes pediátricos conclínica de obstrucción intestinal en tratamiento con heparina subcutánea.Dos casos presentaron elevación de reactantes de fase aguda y signosradiológicos de sufrimiento intestinal por lo que se optó por tratamientoquirúrgico, con el hallazgo intraoperatorio de hematoma intramural. Eltercer caso fue manejado de manera conservadora con supresión de laanticoagulación y reposo intestinal, dado el adecuado estado generaly ausencia de hallazgos compatibles con isquemia o necrosis en laspruebas complementarias. Comentarios: La administración de heparina subcutánea puedeprovocar la aparición de hematomas de pared intestinal, tanto por suefecto anticoagulante, como por el riesgo de punción inadvertida deun asa intestinal.(AU)

Introduction: Hematomas are a rare cause of intestinal obstruc-tion. Subcutaneous heparin can bring about direct punctures on smallbowel loops, potentially leading to traumatic hematoma and intestinalobstruction. Case reports: We present three cases of pediatric patients withclinical signs of intestinal obstruction treated with subcutaneous heparin. Two cases had increased acute-phase reactants and radiological signsof intestinal suffering, so surgical treatment was decided upon, withintramural hematoma emerging as an intraoperative finding. The thirdcase was conservatively managed with anticoagulant discontinuationand gut rest, since the patient had an adequate general condition andno findings compatible with ischemia or necrosis were noted in thecomplementary tests. Discussion: The administration of subcutaneous heparin may causeintestinal wall hematomas due to its anticoagulating effect and to therisk of inadvertent punctures on small bowel loops.(AU)

Tromboprofilaxis en COVID-19. Nuevas evidencias / COVID-19 thromboprophylaxis: New evidences

Recientes publicaciones han puesto en duda la eficacia de la utilización de dosis terapéuticas o intermedias de heparina de bajo peso molecular (HBPM) en pacientes COVID-19, especialmente en los pacientes más graves. Con el objetivo de actualizar estas recomendaciones se ha realizado una revisión no sistemática en las principales bases de datos médicas. Se seleccionaron un total de 14 ensayos clínicos aleatorizados, 14 metaanálisis y las recomendaciones de 12 sociedades científicas, estratificadas según el tipo de paciente (ambulatorio, hospitalizado, ingresado en cuidados críticos o post-alta). Se ha analizado la eficacia de HBPM y también de otras aproximaciones terapéuticas (rivaroxabán, apixabán, sulodexida, ácido acetilsalicílico e inhibidores P2Y12). Los hallazgos recomiendan utilizar dosis estándar de HBPM como tromboprofilaxis en los pacientes COVID-19 hospitalizados críticos y dosis terapéutica en hospitalizados no críticos si el riesgo de sangrado es bajo. En los pacientes ambulatorios y dados de alta del hospital podría utilizarse HBPM a dosis profiláctica si existen factores de riesgo trombótico y el riesgo hemorrágico es bajo. No se recomienda asociar antiagregantes plaquetarios a la HBPM salvo indicación previa.(AU)

Recent publications have questioned the efficacy of using therapeutic or intermediate doses of low molecular weight heparin (LMWH) in COVID-19 patients, especially in the most severe patients. In order to update these recommendations, a non-systematic review has been carried out in the main medical databases. A total of 14 randomized clinical trials, 14 meta-analyses and the recommendations of 12 scientific societies were selected, stratified according to the type of patient (outpatient, hospitalized, admitted to critical care or post-discharge). The efficacy of LMWH and other therapeutic approaches (rivaroxaban, apixaban, sulodexide, acetylsalicylic acid and P2Y12 inhibitors) has been analyzed. The findings recommend using standard doses of LMWH as thromboprophylaxis in critically hospitalized COVID-19 patients and therapeutic doses in non-critically hospitalized patients with low bleeding risk. In outpatients and those discharged from the hospital, LMWH could be used at a prophylactic dose if there are thrombotic risk factors, and the bleeding risk is low. It is not recommended to associate antiplatelet agents with LMWH unless previously indicated.(AU)

COVID-19 thromboprophylaxis. New evidence.

Recent publications have questioned the efficacy of using therapeutic or intermediate doses of low molecular weight heparin (LMWH) in COVID-19 patients, especially in the most severe patients. In order to update these recommendations, a non-systematic review has been carried out in the main medical databases. A total of 14 randomized clinical trials, 14 meta-analyses and the recommendations of 12 scientific societies were selected, stratified according to the type of patient (outpatient, hospitalized, admitted to critical care or post-discharge). The efficacy of LMWH and other therapeutic approaches (rivaroxaban, apixaban, sulodexide, acetylsalicylic acid and P2Y12 inhibitors) has been analyzed. The findings recommend using standard doses of LMWH as thromboprophylaxis in critically hospitalized COVID-19 patients and therapeutic doses in non-critically hospitalized patients if the risk of bleeding is low. In outpatients and those discharged from the hospital, LMWH could be used at a prophylactic dose if there are thrombotic risk factors, and the bleeding risk is low. It is not recommended to associate antiplatelet agents with LMWH unless previously indicated.

Eficacia de la tromboprofilaxis con heparina de bajo peso molecular en pacientes críticos con COVID-19: estudio observacional, prospectivo y multicéntrico / Effectiveness of thromboprophylaxis with low molecular weight heparin in critically ill patients with COVID-19. An observational prospective, multicenter study

Introducción: Los pacientes COVID-19 presentan una coagulopatía caracterizada por una elevada incidencia de complicaciones tromboembólicas. Ante la controversia existente sobre el manejo de la tromboprofilaxis, se llevó a cabo un estudio con el objetivo de analizar el efecto de las diferentes dosis de heparina de bajo peso molecular (HBPM) utilizadas en los pacientes críticos con COVID-19. Material y métodos: Se evaluaron datos del Reg-COVID-19. Se compararon 2 grupos de pacientes según la dosis de HBPM administrada: profilaxis y tratamiento. El objetivo primario fue determinar si había relación de la dosis de HBPM con la mortalidad. Los objetivos secundarios incluyeron la incidencia de eventos trombóticos y hemorrágicos, la duración de la estancia en la UCI, la ventilación mecánica invasiva y los parámetros trombóticos e inflamatorios. Resultados: Se analizaron datos de 720 pacientes, 258 en el grupo de profilaxis y 462 en el de tratamiento. La proteína C reactiva, la ventilación mecánica invasiva y el tratamiento con tocilizumab o corticosteroides se relacionaron con la elección de la dosis de HBPM. La incidencia de complicaciones hemorrágicas (66/720, 9,2%) y trombóticas (69/720, 9,6%) fue similar en ambos grupos, al igual que el curso temporal de los eventos trombóticos, que ocurrieron antes que los hemorrágicos (9 [3-18] y 12 [6-19] días, respectivamente). La mortalidad fue menor en el grupo de profilaxis (25,2 frente al 35,1%), pero al aplicar un modelo de ponderación de probabilidad inversa, no se encontraron diferencias entre los grupos. Conclusión: No se encontraron efectos beneficiosos ni perjudiciales relacionados con la administración de dosis profilácticas o terapéuticas de HBPM en pacientes críticos COVID-19, con una tasa similar de complicaciones hemorrágicas o trombóticas. A partir de estos resultados, consideramos que son necesarios más estudios para determinar el protocolo óptimo de tromboprofilaxis en estos pacientes.(AU)

Introduction: COVID-19 induces coagulopathy associated with an increase of thromboembolic events. Due to the lack of agreement on recommendations for thromboprophylactic management, the aim of this study was to study the dosages of LMWH used in critically ill COVID-19 patients assessing the effect on their outcome. Metohds: We evaluated data of the Reg-COVID19. According to LMWH dose two groups were analyzed: prophylaxis and treatment. Primary outcome was the relationship of LMWH dosage with mortality. Secondary outcomes included the incidence of thrombotic and bleeding events, length of ICU stay, invasive mechanical ventilation, and thrombotic and inflammatory parameters. Results: Data of 720 patients were analyzed, 258 in the prophylaxis group and 462 in the treatment group. C Reactive Protein, invasive mechanical ventilation, tocilizumab and corticosteroid treatments were related with the choice of LMWH dose. Hemorrhagic events (66/720, 9.2%) and thrombotic complications (69/720, 9.6%) were similar in both groups (P=.819 and P=.265), as was the time course of the thrombotic events, earlier than hemorrhagic ones (9 [3-18] and 12 [6-19] days respectively). Mortality was lower in prophylaxis group (25.2% versus 35.1%), but once an inverse probability weighting model was applied, we found no effect of LMWH dose. Conclusion: We found no benefit or harm with the administration of therapeutic or prophylactic LMWH dose in COVID19 critically ill patients. With a similar rate of hemorrhagic or thrombotic events, the LMWH dose had no influence on mortality. More studies are needed to determine the optimal thromboprophylaxis protocol for critically ill patients.(AU)

Efficacy and safety of direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism: A systematic review and Bayesian network meta-analysis / Eficacia y seguridad de los anticoagulantes orales directos para el tratamiento de la tromboembolia venosa asociada al cáncer: una revisión sistemática y un metaanálisis en red bayesiana

Introduction: Direct oral anticoagulants (DOACs) could effectively prevent the occurrence of cancer-associated venous thromboembolism (CAVTE), which incidence rate was estimated to be 4–20%. But the efficacy and safety remain controversial between DOACs and low molecular weight heparin (LMWH).Materials and methodsPubMed, Cochrane Library, Embase, ClinicalTrials.gov databases for randomized controlled trials (RCTs) were systematically searched from inception to March 15, 2022. A random-effects model was used to report the odds ratio (OR) and 95% confidence interval (CI) for both direct and network meta-analyses.ResultsSeven studies were included totaling 3242 patients. A lower rate of recurrence VTE was noted in the DOACs compared with LMWH (OR 0.62, 95% CI 0.47–0.82, I2=0.0%). The aspect of major bleeding (MB) was similar (OR 1.30, 95% CI 0.77–2.18, I2=34.9%). When assessing clinically relevant nonmajor bleeding (CRNMB) (OR 1.61, 95% CI 1.17–2.22, I2=20.7%) and clinically relevant bleeding (CRB) (OR 1.39, 95% CI 1.11–1.74, I2=0.0%), a higher risk of events was observed in DOACs. In subgroup analyses, the MB of gastrointestinal and genitourinary malignancies had a higher rate in the DOACs. For ranking, apixaban ranked the first in prevention of VTE and reducing MB events. Edoxaban had the highest risk drug in MB. In terms of CRNMB and CRB, LMWH showed the lowest risk.ConclusionsCompared with LMWH, DOACs seemed to have a decreased risk of recurrence VTE while increasing CRNMB and CRB. DOACs and LMWH were equivalent to the aspect of MB, but DOACs had a higher MB risk in patients with gastrointestinal and genitourinary malignancies. Apixaban may be the lowest risk compared to the other DOACs in precaution of VTE and reducing bleeding events. (AU)

Introducción: Los anticoagulantes orales directos (ACOD) son eficaces en la prevención de la tromboembolia venosa (TEV) relacionada con el cáncer, cuya tasa de incidencia se estima en 4-20%. Sin embargo, la eficacia y seguridad de ACOD y heparina de bajo peso molecular (HBPM) siguen siendo controvertidas.Materiales y métodosDesde el inicio hasta el 15 de marzo de 2022 se realizaron búsquedas sistemáticas en las bases de datos de ensayos controlados aleatorios (ECA) en PubMed, The Cochrane Library, Embase, ClinicalTrials.gov. Se utilizó el modelo de efectos aleatorios para informar la razón de probabilidades (RP) y los intervalos de confianza (IC) de 95% para los metaanálisis directos y de red.ResultadosSe incluyeron siete estudios con un total de 3.242 pacientes. En comparación con HBPM, los ACOD tienen una tasa más baja de recurrencia de TEV (OR 0,62, IC 95%: 0,47 a 0,82, I2 = 0,0%). La frecuencia de hemorragias mayores fue similar (OR 1,30, IC 95% 0,77 a 2,18, I2 = 34,9%). Se observó un mayor riesgo de eventos en los ACOD. Cuando se evaluaron las hemorragias no mayores clínicamente relevantes (CRNMB) (OR 1,61, IC 95%: 1,17 a 2,22, I2 = 20,7%) y las hemorragias clínicamente relevantes (OR 1,39, IC 95%: 1,11 a 1,74, I2 = 0,0%), En los análisis de subgrupos, las hemorragias mayores en las neoplasias malignas gastrointestinales y genitourinarias fueron más frecuentes con los ACOD. Apixabán ocupó el primer lugar en la prevención de TEV y la reducción de eventos hemorrágicos mayores. Edoxabán tuvo el mayor riesgo de hemorragias mayores. Las HBPM demostraron tener menor riesgo de hemorragias mayores clínicamente relevantes y hemorragias clínicamente relevantes. (AU)

Effectiveness of thromboprophylaxis with low molecular weight heparin in critically ill patients with COVID-19. An observational prospective, multicenter study.

INTRODUCTION: COVID-19 induces coagulopathy associated with an increase of thromboembolic events. Due to the lack of agreement on recommendations for thromboprophylactic management, the aim of this study was to study the dosages of LMWH used in critically ill COVID-19 patients assessing the effect on their outcome. METHODS: We evaluated data of the Reg-COVID19. According to LMWH dose two groups were analyzed: prophylaxis and treatment. Primary outcome was the relationship of LMWH dosage with mortality. Secondary outcomes included the incidence of thrombotic and bleeding events, length of ICU stay, invasive mechanical ventilation, and thrombotic and inflammatory parameters. RESULTS: Data of 720 patients were analyzed, 258 in the prophylaxis group and 462 in the treatment group. C Reactive Protein, invasive mechanical ventilation, tocilizumab and corticosteroid treatments were related with the choice of LMWH dose. Hemorrhagic events (66/720, 9.2%) and thrombotic complications (69/720, 9.6%) were similar in both groups (p = .819 and p = .265), as was the time course of the thrombotic events, earlier than hemorrhagic ones (9 [3-18] and 12 [6-19] days respectively). Mortality was lower in prophylaxis group (25.2% versus 35.1%), but once an inverse probability weighting model was applied, we found no effect of LMWH dose. CONCLUSION: We found no benefit or harm with the administration of therapeutic or prophylactic LMWH dose in COVID19 critically ill patients. With a similar rate of hemorrhagic or thrombotic events, the LMWH dose had no influence on mortality. More studies are needed to determine the optimal thromboprophylaxis protocol for critically ill patients.

Efficacy and safety of direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism: A systematic review and Bayesian network meta-analysis.

INTRODUCTION: Direct oral anticoagulants (DOACs) could effectively prevent the occurrence of cancer-associated venous thromboembolism (CAVTE), which incidence rate was estimated to be 4-20%. But the efficacy and safety remain controversial between DOACs and low molecular weight heparin (LMWH). MATERIALS AND METHODS: PubMed, Cochrane Library, Embase, ClinicalTrials.gov databases for randomized controlled trials (RCTs) were systematically searched from inception to March 15, 2022. A random-effects model was used to report the odds ratio (OR) and 95% confidence interval (CI) for both direct and network meta-analyses. RESULTS: Seven studies were included totaling 3242 patients. A lower rate of recurrence VTE was noted in the DOACs compared with LMWH (OR 0.62, 95% CI 0.47-0.82, I2=0.0%). The aspect of major bleeding (MB) was similar (OR 1.30, 95% CI 0.77-2.18, I2=34.9%). When assessing clinically relevant nonmajor bleeding (CRNMB) (OR 1.61, 95% CI 1.17-2.22, I2=20.7%) and clinically relevant bleeding (CRB) (OR 1.39, 95% CI 1.11-1.74, I2=0.0%), a higher risk of events was observed in DOACs. In subgroup analyses, the MB of gastrointestinal and genitourinary malignancies had a higher rate in the DOACs. For ranking, apixaban ranked the first in prevention of VTE and reducing MB events. Edoxaban had the highest risk drug in MB. In terms of CRNMB and CRB, LMWH showed the lowest risk. CONCLUSIONS: Compared with LMWH, DOACs seemed to have a decreased risk of recurrence VTE while increasing CRNMB and CRB. DOACs and LMWH were equivalent to the aspect of MB, but DOACs had a higher MB risk in patients with gastrointestinal and genitourinary malignancies. Apixaban may be the lowest risk compared to the other DOACs in precaution of VTE and reducing bleeding events.

Actualización sobre trombofilias y gestación / Update on thrombophilia and pregnancy

El embarazo constituye un factor de riesgo independiente de eventos tromboembólicos, provocado por los cambios en la hemostasia que se producen durante la gestación. Las trombofilias son trastornos de la hemostasia que predisponen a eventos trombóticos. La creciente evidencia sugiere que las trombofilias se asocian a enfermedad tromboembólica y resultados obstétricos desfavorables. Sin embargo, las limitaciones metodológicas han dificultado la obtención de una visión general clara de los riesgos que suponen durante la gestación. El objetivo del presente artículo es realizar una revisión bibliográfica exhaustiva sobre el uso de tromboprofilaxis durante la gestación, con especial interés en esclarecer qué trombofilias tienen indicación de anticoagulación durante el embarazo basada en una mejora de los resultados obstétricos demostrados en la literatura científica.(AU)

Pregnancy is an independent risk factor for thromboembolic events, caused by changes in haemostasis that occur during pregnancy. Thrombophilia comprises disorders of haemostasis that predispose to thrombotic events. Increasing evidence suggests that thrombophilia is associated with thromboembolic disease and poor obstetric outcomes. However, methodological limitations have made it difficult to obtain a clear overview of the risk they pose during pregnancy. The objective of this article is to carry out an exhaustive bibliographic review on the use of thromboprophylaxis during pregnancy, with special interest in clarifying the thrombophilia for which anticoagulation is indicated during pregnancy based on an improvement in obstetric results demonstrated in the scientific literature.(AU)

Incidencia de trombosis venosa profunda en pacientes con síndrome de distrés respiratorio agudo secundario a COVID-19, bajo tromboprofilaxis con dosis intermedia de heparina de bajo peso molecular / Deep venous thrombosis incidence in patients with COVID-19 acute respiratory distress syndrome, under intermediate dose of chemical thromboprophylaxis

Resumen A pesar de la tromboprofilaxis estándar, el diagnóstico de trombosis es común en pacientes críticos con COVID-19. El objetivo del presente estudio fue evaluar la incidencia de trombosis venosa profunda (TVP) en pacientes con neumonía grave por COVID-19 con requerimientos de asistencia respiratoria mecánica, bajo tromboprofilaxis química con dosis intermedia (1 mg/kg/día) de heparina de bajo peso molecular (enoxaparina). Se trató de un estudio unicéntrico, descriptivo y de corte transversal de datos recopilados en forma prospectiva. Se realizó búsqueda activa y sistemática de TVP en miembros inferiores (o en confluente yúgulosubclavio en su defecto) mediante doppler venoso cada 7 días. Se continuó con la evaluación por doppler semanal hasta la finalización de la ventilación mecánica, el cum plimiento de los 28 días de internación en unidad de cuidados intensivos, el fallecimiento o la suspensión de la tromboprofilaxis con enoxaparina por cualquier causa. Se incluyeron 46 pacientes. Se realizó diagnóstico de TVP en 5 (3 en miembros inferiores y 2 en con fluente yúgulosubclavio). Tres diagnósticos de TVP fueron asociados a la presencia de catéter venoso central (2 en miembros inferiores y 1 en el confluente yúgulosubclavio), dos fallecieron durante el seguimiento por causas vinculadas al síndrome de distrés respiratorio agudo (SDRA) pero no por eventos trombóticos o de sangrado mayor. En todos los casos, los eventos trombóticos fueron asintomáticos. En nuestra serie de pacientes con SDRA moderado/grave secundario a neumonía por COVID-19, la incidencia de TVP fue del 10.9% en aquellos bajo tromboprofilaxis con dosis intermedia (1 mg/kg/día) de enoxaparina.

Abstract Despite standard thrombo prophylaxis, venous thrombosis is common in critically ill patients with COVID-19. The objective of this study was to evaluate deep venous thrombosis (DVT) incidence in patients with severe COVID-19 pneumonia with mechanical ventilation requirements under intermediate dose of chemical thromboprophylaxis (1 mg/kg/day of enoxaparin). This was a single-center, descriptive, cross-sectional study of prospectively collected data. An active and systematic protocol with venous doppler was carried out for DVT diagnosis in lower limbs (or in jugulo-subclavian venous confluence) every 7 days. Weekly doppler evaluation was continued until the end of mechanical ventilation, up to 28 days of intensive care unit admission, until death or until the thromboprophylaxis suspension for any cause. Forty-six patients were included. DVT was diagnosed in 5 (3 in lower limbs and 2 in jugulo-subclavian conflu ent). In 3 cases, DVT was catheter-related (2 in lower limbs and 1 in jugulo-subclavian confluent), 2 died during follow-up due to acute respiratory distress syndrome (ARDS) complications without thrombotic events or major bleeding. All thrombotic events were asymptomatic. In our series of patients with moderate/severe COVID-19 ARDS, DVT incidence was 10.9% under thromboprophylaxis with intermediate dose (1 mg/kg/ day) of enoxaparin.

Trombocitopenia inducida por heparina de bajo peso molecular en un paciente con COVID-19

RESUMEN Aunque el sistema respiratorio resulta el más afectado por la COVID-19, hoy conocemos que también predispone a la enfermedad tromboembólica, debido a la excesiva inflamación, activación plaquetaria, disfunción endotelial y estasis que suele ocasionar. La aplicación profiláctica de heparinas de bajo peso molecular ha sido una de las principales recomendaciones en pacientes hospitalizados por esta emergencia sanitaria, práctica no exenta de eventos secundarios, y que tiene entre sus complicaciones más graves la trombocitopenia. Con el propósito de alertar sobre la aparición de esta entidad y evitar mayores complicaciones, se expone un caso en el cual se constató trombocitopenia luego de recibir siete dosis de enoxaparina, y que luego de 48 horas de suspenderse esta, comenzó el ascenso progresivo del número de plaquetas, hasta alcanzar sus niveles de normalidad.

ABSTRACT Although the respiratory system is the most affected by COVID-19, today we know that it also predisposes to thromboembolic disease, due to the excessive inflammation, platelet activation, endothelial dysfunction and stasis that it usually causes. The prophylactic application of low molecular weight heparins has been one of the main recommendations in patients hospitalized for this health emergency, a practice that is not exempt from secondary events, and which has thrombocytopenia among its most serious complications. In order to alert about the appearance of this entity and avoid further complications, a case is presented in which thrombocytopenia was found after receiving seven doses of enoxaparin, and after 48 hours of suspending this, the progressive rise of platelets in number began, until they reach their normal levels.

Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight-heparin.

We present the case of an 81-year-old woman who developed a bilateral spontaneous suprachoroidal hemorrhage while under treatment with sodium enoxaparin. Temporal suspension of anticoagulant therapy led to an improvement of the choroidal hemorrhage. After three months follow-up, there was a complete reabsorption of the choroidal detachments, but there was a persistent vitreous hemorrhage in the right eye, which had been more severely affected. Pars plana vitrectomy with air tamponade was successfully performed in the right eye. Vision improved to 20/50 in the right eye and 20/20 in the left eye. Suprachoroidal hemorrhage is a rare condition with a poor visual prognosis. Reports on the development of suprachoroidal hemorrhage in patients with no predisposing ocular conditions are scarce, and in none were both eyes affected. The case reported herein is, to the best of our knowledge, the first case of bilateral, simultaneous suprachoroidal hemorrhage without predisposing ocular factors due to treatment with anticoagulants, with a favourable visual outcome.

Hemorragia supracoroidea espontánea bilateral en un paciente en tratamiento con heparina de bajo peso molecular / Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight heparin

Presentamos el caso de una paciente de 81 años en tratamiento con enoxaparina sódica, que desarrolló una hemorragia supracoroidea espontánea bilateral. Tras suspender el tratamiento anticoagulante se produjo una mejoría clínica, que se mantuvo incluso tras reiniciar la anticoagulación. Tras 3 meses de seguimiento, la hemorragia coroidea se resolvió completamente en ambos ojos, pero se decidió realizar una vitrectomía pars plana en el ojo derecho de la paciente, el más afectado inicialmente, debido a un hemovítreo persistente. La agudeza visual alcanzada fue de 20/50 en el ojo derecho y 20/20 en el ojo izquierdo. La hemorragia supracoroidea es una entidad poco frecuente, asociada habitualmente a un mal pronóstico visual. Se han descrito pocos casos en la literatura de hemorragia supracoroidea en pacientes sin factores de riesgo oculares, ninguno de ellos bilateral. Este podría ser el primer caso descrito en la literatura de hemorragia supracoroidea bilateral simultánea sin factores oculares predisponentes relacionado con anticoagulantes, resuelto con un buen resultado visual (AU)

We present the case of an 81-year-old woman who developed a bilateral spontaneous suprachoroidal hemorrhage while under treatment with sodium enoxaparin. Temporal suspension of anticoagulant therapy led to an improvement of the choroidal hemorrhage. After three months follow-up, there was a complete reabsorption of the choroidal detachments, but there was a persistent vitreous hemorrhage in the right eye, which had been more severely affected. Pars plana vitrectomy with air tamponade was successfully performed in the right eye. Vision improved to 20/50 in the right eye and 20/20 in the left eye. Suprachoroidal hemorrhage is a rare condition with a poor visual prognosis. Reports on the development of suprachoroidal hemorrhage in patients with no predisposing ocular conditions are scarce, and in none were both eyes affected. The case reported herein is, to the best of our knowledge, the first case of bilateral, simultaneous suprachoroidal hemorrhage without predisposing ocular factors due to treatment with anticoagulants, with a favourable visual outcome (AU)

Point of care ultrasound (POCUS) in diagnosis of proximal deep vein thrombosis among COVID-19 hospitalized patients with a high rate of low molecular weight heparin prophylaxis

Antecedentes: La trombosis venosa profunda (TVP) y la embolia pulmonar (EP) son complicaciones relacionadas con la COVID-19. La ecografía clínica en el punto de atención (POCUS) de las extremidades inferiores podría detectar coágulos ocultos, ayudando a decidir a quién tratar con anticoagulación.ObjetivosDeterminar la prevalencia de la TVP proximal con el cribado mediante POCUS entre los pacientes hospitalizados por COVID-19.Pacientes/métodosSe realizó una POCUS de miembros inferiores a todos los pacientes ingresados en planta o en la Unidad de Cuidados Intensivos (UCI) entre el 22 y el 30 de abril de 2020. Se evaluaron las características clínicas y de laboratorio, las prescripciones, las complicaciones trombóticas y los resultados.ResultadosSe examinaron 87 pacientes, de los cuales 26 (29,8%) habían sido dados de alta de la UCI (19,5%) o seguían en estado crítico (10,3%). Se detectó una TVP en cuatro pacientes (tres femoral, uno poplítea), de los cuales uno no había recibido profilaxis con heparina de bajo peso molecular (HBPM). Se realizaron 21 angiografías pulmonares por TC, siendo positivas para EP en cinco casos (23,8%); solo dos de estos pacientes sufrieron TVP. (AU)

Background: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are both complications linked with COVID-19. Lower limb point-of-care clinical ultrasound (POCUS) could detect occult clots, helping decide whom to treat with anticoagulation.ObjectivesTo determine proximal DVT prevalence with POCUS screening among hospitalized COVID-19 patients.Patients/MethodsLower limb POCUS was performed in all patients admitted either to the ward or intensive care unit (ICU) between April 22nd and 30th 2020. Clinical and laboratory features, prescriptions, thrombotic complications and outcomes were assessed.Results87 patients were screened, of which 26 (29.8%) either had been discharged from ICU (19.5%) or were still in critical condition (10.3%). DVT was found in 4 patients (3 femoral, 1 popliteal), of which 1 had not received low molecular weight heparin (LMWH) prophylaxis. 21 CT pulmonary angiograms were performed, being positive for PE in 5 cases (23.8%); only 2 of these patients suffered DVT. (AU)

Point of care ultrasound (POCUS) in diagnosis of proximal deep vein thrombosis among COVID-19 hospitalized patients with a high rate of low molecular weight heparin prophylaxis.

BACKGROUND: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are both complications linked with COVID-19. Lower limb point-of-care clinical ultrasound (POCUS) could detect occult clots, helping decide whom to treat with anticoagulation. OBJECTIVES: To determine proximal DVT prevalence with POCUS screening among hospitalized COVID-19 patients. PATIENTS/METHODS: Lower limb POCUS was performed in all patients admitted either to the ward or intensive care unit (ICU) between April 22nd and 30th 2020. Clinical and laboratory features, prescriptions, thrombotic complications and outcomes were assessed. RESULTS: 87 patients were screened, of which 26 (29.8%) either had been discharged from ICU (19.5%) or were still in critical condition (10.3%). DVT was found in 4 patients (3 femoral, 1 popliteal), of which 1 had not received low molecular weight heparin (LMWH) prophylaxis. 21 CT pulmonary angiograms were performed, being positive for PE in 5 cases (23.8%); only 2 of these patients suffered DVT. CONCLUSIONS: Screening lower extremities with POCUS did not find a high rate of DVT among patients receiving LMWH-prophylaxis. However, there was a noteworthy amount of PE without DVT.

Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight heparin. / Hemorragia supracoroidea espontánea bilateral en un paciente en tratamiento con heparina de bajo peso molecular.

We present the case of an 81-year-old woman who developed a bilateral spontaneous suprachoroidal hemorrhage while under treatment with sodium enoxaparin. Temporal suspension of anticoagulant therapy led to an improvement of the choroidal hemorrhage. After three months follow-up, there was a complete reabsorption of the choroidal detachments, but there was a persistent vitreous hemorrhage in the right eye, which had been more severely affected. Pars plana vitrectomy with air tamponade was successfully performed in the right eye. Vision improved to 20/50 in the right eye and 20/20 in the left eye. Suprachoroidal hemorrhage is a rare condition with a poor visual prognosis. Reports on the development of suprachoroidal hemorrhage in patients with no predisposing ocular conditions are scarce, and in none were both eyes affected. The case reported herein is, to the best of our knowledge, the first case of bilateral, simultaneous suprachoroidal hemorrhage without predisposing ocular factors due to treatment with anticoagulants, with a favourable visual outcome.

The effect of the transition to Electronic Patient Records on adherence to venous thromboembolism prophylaxis guidelines in general surgical patients.

INTRODUCTION AND OBJECTIVES: Surgical patients are at risk of hospital-acquired venous thromboembolisms (VTEs), and preventative measures such as thromboembolism deterrent stockings (TEDs) and low molecular weight heparin (LMWH) are proven to be beneficial. The National Quality Requirement in the NHS Standard Contract 2017/19 in England mandates that 95% of inpatients undergo VTE risk assessments. As hospitals transition to Electronic Patient Records (EPR), it is important to observe the impact on vital safety indicators such as VTE risk. The aim of this study is to observe the effect of implementing EPR in a tertiary centre on adherence to national guidelines, including VTE assessment rates and prophylaxis administration in surgical patients. MATERIALS AND METHODS: Using consecutive sampling, all acute surgical admissions at the hospital from 26/02/2018 to 18/03/2018 (n=154) pre-EPR and 31/10/2018 to 25/11/2018 (n=151) post-EPR were observed for VTE risk assessment, 24-h re-assessment, prophylaxis prescriptions, administration, and patient compliance. Data was compared using a two-tailed Z-test. RESULTS: Pre-EPR, 96% of patients had completed VTE assessments, which increased after EPR implementation to 97% (p=0.39). LWMH prescription rates decreased from 82% to 77% following EPR (p=0.14). Moreover, TED prescriptions decreased from 84% to 64% post-EPR (p<0.01). Administration rates of prophylaxis generally improved post-EPR. The 24-h re-assessment rate decreased from 62% to 54% of patients (p=0.08). CONCLUSION: The study demonstrated that EPR is non-inferior to paper records. Transitioning to an EPR system did not interfere with the completion of VTE risk assessments, hence did not negatively impact the ability to achieve national targets.

Alteraciones de la coagulación en la COVID-19.

Infection with the SARS-CoV-2 virus and the development of all manifestations of COVID-19, predisposes to arterial and venous thromboembolic disease. The coagulation system can be activated by various viruses, including SARS-CoV-2. Vascular endothelial damage, added to the development of disseminated intravascular coagulation, affects the prognosis and mortality from this disease. Treatment is aimed at the prevention, early detection and timely interventions of all coagulation disorders generated by COVID-19. The recommended anticoagulant is low molecular weight heparin, taking into account creatinine clearance, and if major invasive procedures will be performed, unfractionated heparin is a safe option.

La infección por el virus SARS-CoV-2 y el desarrollo de todas las manifestaciones de COVID-19 predisponen a la enfermedad tromboembólica arterial y venosa. El sistema de coagulación puede ser activado por diversos virus, entre ellos el SARS-CoV-2. El daño endotelial vascular, sumado al desarrollo de coagulación intravascular diseminada, afecta el pronóstico y la mortalidad de esta enfermedad. El tratamiento está dirigido a la prevención, la detección temprana y las intervenciones oportunas de todas las alteraciones de la coagulación generadas por la COVID-19. El anticoagulante recomendado es la heparina de bajo peso molecular, tomando en cuenta el aclaramiento de creatinina, y si se realizarán procedimientos invasivos mayores, la heparina no fraccionada es una opción segura.

SEDAR-SEMICYUC consensus recommendations on the management of haemostasis disorders in severely ill patients with COVID-19 infection. / Recomendaciones de consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes graves con infección por COVID-19.

The infection by the coronavirus SARS-CoV-2, which causes the disease called COVID-19, mainly causes alterations in the respiratory system. In severely ill patients, the disease often evolves into an acute respiratory distress syndrome that can predispose patients to a state of hypercoagulability, with thrombosis at both venous and arterial levels. This predisposition presents a multifactorial physiopathology, related to hypoxia as well as to the severe inflammatory process linked to this pathology, including the additional thrombotic factors present in many of the patients. In view of the need to optimise the management of hypercoagulability, the working groups of the Scientific Societies of Anaesthesiology-Resuscitation and Pain Therapy (SEDAR) and of Intensive, Critical Care Medicine and Coronary Units (SEMICYUC) have developed a consensus to establish guidelines for actions to be taken against alterations in haemostasis observed in severely ill patients with COVID-19. These recommendations include prophylaxis of venous thromboembolic disease in these patients, and in the peripartum, management of patients on long-term antiplatelet or anticoagulant treatment, bleeding complications in the course of the disease, and the interpretation of general alterations in haemostasis.

Anticoagulación sostenible en COVID-19: Revisión de predicción de gravedad y razonamiento clínico / Sustainable anticoagulation in COVID-19: Review of severity prediction and clinical reasoning

RESUMEN Objetivo Identificar el fenómeno procoagulante en pacientes SARS-CoV- 2 y proponer orientación terapéutica sostenible para países de bajos ingresos. Método Se realizó una revisión sistemática que identificó cinco estudios observacionales de un escrutinio a partir de 78 resultados. Se examinaron 712 pacientes y los resultados fueron agrupados según mortalidad y severidad. La comparación de los grupos se interpretó mediante estadística descriptiva. Resultado Los valores del dímero D se asociaron significativamente en todas las observaciones a mayor severidad y mortalidad. La protrombina se asoció, en algunas observaciones, a mayor mortalidad; en cuanto a severidad, los resultados fueron inconclusos. Conclusión El COVID-19 tiene importante actividad procoagulante y su tratamiento oportuno puede alterar el pronóstico. La evidencia explorada avala métodos sostenibles. Se necesita más evidencia para mejorar el manejo. Se recomienda un abordaje sistemático temprano de los pacientes con medidas terapéuticas sostenibles a la medida del sistema de salud.

ABSTRACT Objective To identify the procoagulant phenomenon in SARS-CoV-2 patients and propose sustainable therapeutic guidance for low-income countries. Methods A systematic review was conducted. It identified 5 observational studies from a scrutiny from 78 results. 712 patients were examined and the results were grouped according to mortality and severity. The comparison of the groups was interpreted using descriptive statistics. Results D-dimer values were significantly associated with greater severity and mortality. Prothrombin was associated in some observations with higher mortality, but in terms of severity it was inconclusive. Conclusion COVID-19 disease has significant procoagulant activity and its timely treatment can alter the prognosis. The explored evidence supports sustainable methods. More evidence is needed to improve management. An early systematic approach to patients with sustainable therapeutic measures tailored to the health system is recommended.