Point of care ultrasound screening for deep vein thrombosis in critically ill COVID-19 patients, an observational study

Sarah Galien, Michael Hultström, Miklós Lipcsey, Karl Stattin, Robert Frithiof, Jacob Rosén, Uppsala Intensive Care COVID-19 Research Group, Tomas Luther, Sara Bülow Anderberg, Anna Gradin, Sten Rubertsson, Katja Hanslin, Sarah Galien, Michael Hultström, Miklós Lipcsey, Karl Stattin, Robert Frithiof, Jacob Rosén, Uppsala Intensive Care COVID-19 Research Group, Tomas Luther, Sara Bülow Anderberg, Anna Gradin, Sten Rubertsson, Katja Hanslin

Abstract

Background: Deep vein thrombosis (DVT) is common in critically ill patients with Coronavirus disease 2019 (COVID-19) and may cause fatal pulmonary embolism (PE) prior to diagnosis due to subtle clinical symptoms. The aim of this study was to explore the feasibility of bedside screening for DVT in critically ill COVID-19 patients performed by physicians with limited experience of venous ultrasound. We further aimed to compare inflammation, coagulation and organ dysfunction in patients with and without venous thromboembolism (VTE).

Methods: This observational study included patients with COVID-19 admitted to the intensive care unit (ICU) of a tertiary hospital in Sweden and screened for DVT with proximal compression ultrasound of the lower extremities between April and July 2020. Screening was performed by ICU residents having received a short online education and one hands-on-session. Pathological screening ultrasound was confirmed by formal ultrasound whereas patients with negative screening underwent formal ultrasound on clinical suspicion. Clinical data, laboratory findings and follow-up were extracted from medical records.

Results: Of 90 eligible patients, 56 were screened by seven ICU residents with no (n = 5) or limited (n = 2) previous experience of DVT ultrasound who performed a median of 4 (IQR 2-19) examinations. Four (7.1%) patients had pathological screening ultrasound of which three (5.6%) were confirmed by formal ultrasound. None of the 52 patients with negative screening ultrasound were diagnosed with DVT during follow-up. Six patients were diagnosed with PE of which four prior to negative screening and two following negative and positive screening respectively. Patients with VTE (n = 8) had higher median peak D-dimer (24.0 (IQR 14.2-50.5) vs. 2.8 (IQR 1.7-7.2) mg/L, p = 0.004), mean peak C-reactive protein (363 (SD 80) vs. 285 (SD 108) mg/L, p = 0.033) and median peak plasma creatinine (288 (IQR 131-328) vs. 94 (IQR 78-131) μmol/L, p = 0.009) compared to patients without VTE (n = 48). Five patients (63%) with VTE received continuous renal replacement therapy compared to six patients (13%) without VTE (p = 0.005).

Conclusion: ICU residents with no or limited experience could detect DVT with ultrasound in critically ill COVID-19 patients following a short education. VTE was associated with kidney dysfunction and features of hyperinflammation and hypercoagulation.

Trial registration: ClinicalTrials ID: NCT04316884 . Registered 20 March 2020.

Keywords: COVID-19; Deep vein thrombosis; ICU; Point of care ultrasound; Screening.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Screening ultrasound. The images display the bifurcation of the popliteal vein into the calf veins. The thrombus, marked with an asterisk (*), can be distinguished even without compression in the left vein (a). The left vein cannot be fully compressed, which is diagnostic of thrombosis, whereas the right vein demonstrates normal compression with full collapsibility (b). This pathological screening ultrasound was later confirmed by formal ultrasound

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