• Jonathon P Fanning, Natasha Weaver, Robert B Fanning, Matthew J Griffee, Sung-Min Cho, Mauro Panigada, Nchafatso G Obonyo, Akram M Zaaqoq, Hannah Rando, Yew Woon Chia, Bingwen Eugene Fan, Declan Sela, Davide Chiumello, Silvia Coppola, Ahmed Labib, WhitmanGlenn J RGJRDivision of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD., Rakesh C Arora, Bo S Kim, Anna Motos, Antoni Torres, Ferran Barbé, Giacomo Grasselli, Alberto Zanella, Eric Etchill, Asad Ali Usman, Maximilian Feth, Nicole M White, Jacky Y Suen, Gianluigi Li Bassi, Giles J Peek, John F Fraser, Heidi Dalton, and COVID-19 Critical Care Consortium.
• Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.
• Crit. Care Med. 2023 May 1; 51 (5): 619631619-631.

ObjectivesTo determine the prevalence and outcomes associated with hemorrhage, disseminated intravascular coagulopathy, and thrombosis (HECTOR) complications in ICU patients with COVID-19.DesignProspective, observational study.SettingTwo hundred twenty-nine ICUs across 32 countries.PatientsAdult patients (≥ 16 yr) admitted to participating ICUs for severe COVID-19 from January 1, 2020, to December 31, 2021.InterventionsNone.Measurements And Main ResultsHECTOR complications occurred in 1,732 of 11,969 study eligible patients (14%). Acute thrombosis occurred in 1,249 patients (10%), including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial ischemia, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic strokes. Hemorrhagic complications were reported in 579 patients (4.8%), including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, 77 (13%) with pulmonary hemorrhage, and 68 (12%) with hemorrhage associated with extracorporeal membrane oxygenation (ECMO) cannula site. Disseminated intravascular coagulation occurred in 11 patients (0.09%). Univariate analysis showed that diabetes, cardiac and kidney diseases, and ECMO use were risk factors for HECTOR. Among survivors, ICU stay was longer (median days 19 vs 12; p < 0.001) for patients with versus without HECTOR, but the hazard of ICU mortality was similar (hazard ratio [HR] 1.01; 95% CI 0.92-1.12; p = 0.784) overall, although this hazard was identified when non-ECMO patients were considered (HR 1.13; 95% CI 1.02-1.25; p = 0.015). Hemorrhagic complications were associated with an increased hazard of ICU mortality compared to patients without HECTOR complications (HR 1.26; 95% CI 1.09-1.45; p = 0.002), whereas thrombosis complications were associated with reduced hazard (HR 0.88; 95% CI 0.79-0.99, p = 0.03).ConclusionsHECTOR events are frequent complications of severe COVID-19 in ICU patients. Patients receiving ECMO are at particular risk of hemorrhagic complications. Hemorrhagic, but not thrombotic complications, are associated with increased ICU mortality.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.

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