thrombosis in 50% NL-ICU cases

[url]https://nos.nl/nieuwsuur/artikel/2332229-helft-coronapatienten-op-ic-heeft-stollingen-in-longen-of-hersenen.html[/url]

via google translate

It is becoming increasingly clear that the coronavirus causes other life-threatening complications in addition to infections. A study of 184 patients in intensive care shows that half have thrombosis symptoms. People with such complications are more likely to die. Timely treatment is vital.

The research was conducted in three Dutch hospitals: the Leiden University Medical Center (LUMC), the Amphia Hospital in Breda and the Rotterdam Erasmus Medical Center. Doctors worldwide have already noticed that patients with covid-19 also have thrombosis symptoms, this study now shows how big the problem really is.


"We did not know that so many corona patients had a thrombosis complication," says Internal Medicine professor Menno Huisman (LUMC), who led the study together with internist Rik Endeman (Erasmus MC). "The results have been received with surprise worldwide. Until now, the main focus has been on infections in the lungs and their consequences, but not on thrombosis complications."

That is precisely why the findings of the study are very important, says Huisman. "We can also try to do something about it. By giving IC patients an increased dose of blood thinners, you can reduce the risk of thrombosis complications and, if possible, improve their condition."

Pulmonary embolism or stroke
In thrombosis, the blood and blood clots that form, block the veins or arteries. Clots can develop in corona patients due to an interplay of factors, the professor explains. "One of the factors is the high rate of inflammation of the coronavirus, which activates blood clotting."

Another factor is that corona patients who are ventilated in intensive care are put to sleep for a longer period of time. "They lie motionless in bed for days. This makes it easy for blood clots to form in the legs," says Huisman.

The blood clots can enter the lungs, or develop in the heart or head, resulting in a pulmonary embolism, heart or cerebral infarction. The researchers found a pulmonary embolism in most patients. To a lesser extent, cerebral infarctions were involved, but that number was also seven to ten times higher than normal.

It is quite remarkable that the cerebral infarctions also affect people who previously had no risk factors at all, such as high blood pressure, arteriosclerosis, high cholesterol or tobacco addiction. The patients with a cerebral infarction were also quite young, and the researchers are concerned.

The first results of the study were already published in mid-April. Then a third of the patients appeared to have clotting problems. As a result, the guidelines have already been amended. It was recommended to double the amount of the anticoagulant heparin, which corona patients in the IC are already receiving as a precaution.

"We do not quite honestly know whether that is enough. Of course we hope so and there is reason to assume that. But we still have to find out," says Huisman. "We do that by looking at new ICU patients who have received a double dose of heparin from the start."

Two hours per patient
The research of the three Dutch hospitals is the first research into large-scale thrombosis complications in corona patients. The professor explains that such extensive research is difficult to realize. The patients must be examined with a CT scan.


"It takes a lot of effort to bring the ICU patients on respiratory equipment there. Two to three nurses per patient take about two hours to get that done," says Huisman.

I agree DJ. Good they are learning all the time about the virus and they are adapting treatment protocols.

Most scientific literature and press now reporting strokes and cardiac arrests including in the young.   Some report the removal of clots, just for them to reform in front of surgeons eyes which is unheard of.  So major vascular coagulation dysfunction in some patients.

 They think that the virus is causing  mass destruction of ACE2 receptor when it enters the cell ( many viruses enter cells but dont initially destroy the receptor they use, however this virus does).   

ACE2 is a receptor but importantly it is also an enzyme on endothelium cells ( blood vessels).  It  acts as a vasodilator to lower blood pressure.

ACE2 enzyme probably also has antithrombotic effects ( via the bradykinin-dependent release of t-PA).  So widespread viral destruction of ACE2 could lead to loss of control of clotting within the blood vessels.

Combine these 2 together in an already inflammatory environment is adding to an already severe pathology.

So the thinking is 

1)  In severe Covid19 the virus has disseminated onward out from the local lung infection, and entered into the full body ( systemic blood vessels.

2) It enters  via ACE2 ( just as it had done in the lungs).  In doing this it is now destroying ACE2 on  blood vessel walls but now on a body wide scale.

3) Depleting ACE2 means the blood vessels all start to constrict  as ACE is left unchecked ( vessels become narrow).    

3) Loss of ACE2 on blood vessels may  ALSO causes  widespread systemic blood clotting as control of an anticoagulation pathway is lost.

4)  Blood clots in lungs ( breathing) in brain ( strokes) in heart ( cardiac arrest) and have been seen in feet and hands as rash/bruises as clots travel to periphery.

5) The proinflammatory cytokines abundant in systemic system are also interplaying with the pathology.

 Above is just the basics of the blood vessel system and how it relates to COVID19 but you can look more in depth if interested.

I think the treatment that they are adding in to ICU Covid19 patients is  heparin and increased tracking of coagulation factors over course of disease.

As an aside point.  If viral loss of ACE2  inhibiting ACE  is causing vasoconstriction and high BP,  could this mimics an underlying health condition so possibly wrongly profiling previously healthy COVID19 patients as having undiagnosed high BP.  Skew statistics that most people in ICU have underlying when maybe they dont.

This information is pooled from various sources but you can read, see and watch opinions on this all over the science journals and medical websites just now so dont want to include an extensive list.   Publications from experiences in Chine, Italy, UK, US and from article listed by DJ. The following link goes into much more detail because there are even more complex interactions in the cascade for anyone that is interested.

Hz x

https://www.youtube.com/watch?v=22Bn8jsGI54&feature=youtu.be

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Another article from today

https://www.statnews.com/2020/05/06/giving-blood-thinners-to-severely-ill-covid19-patients-gaining-ground/