CHEST Guidelines-Response_chest

Response_chest_29

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In response to a study on the use of high-dose prophylactic anticoagulation (HPA) in critically ill COVID-19 patients, Charles Tacquard and colleagues address concerns raised by Paez et al. regarding the incidence of thrombotic complications and the bleeding risks associated with HPA. Tacquard et al. maintain that their reported incidence aligns with existing studies, but they caution that such data can vary due to differing local screening protocols and ICU admission criteria. They point out that COVID-19 patient profiles and treatments have evolved, with more co-morbidities and medications at play, including early use of corticosteroids and immunomodulators. These changes may affect the thrombotic risk, potentially reducing HPA's benefits due to inflammation's role in thrombosis.<br /><br />The authors also highlight that the timing of HPA is critical; benefits observed during early inflammation may not be sustained as inflammation subsides, potentially increasing bleeding risks. They acknowledge a lack of studies reporting the timing of thrombotic versus bleeding events. Additionally, the effectiveness of HPA on micro-thrombosis remains uncertain due to the complex involvement of coagulation, endothelium, and immune responses, possibly explaining why mortality reduction wasn't significant in their findings despite reduced thrombotic complications.<br /><br />Tacquard and colleagues emphasize that studies should be contextualized in a rapidly evolving situation to avoid misleading conclusions. They acknowledge various affiliations and potential conflicts of interest pertaining to their study.<br /><br />In a separate letter, intensivists express interest in the ethical discussions by Bishop and Eberl on life-sustaining treatment withdrawal during care crises, highlighting the necessity for clear ethical guidance in resource-limited situations.

Keywords

high-dose prophylactic anticoagulation

critically ill COVID-19

thrombotic complications

bleeding risks

corticosteroids

immunomodulators

inflammation

micro-thrombosis

mortality reduction

ethical guidance